Beruflich Dokumente
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EMERGENCY
MEDICINE
EDUCATION
PROJECT
iem-student.org
Emergency
Medicine
Clerkship
Students
Editors
Arif Alper Cevik
Lit Sin Quek
Abdel Noureldin
Elif Dilek Cakal
i
Copyright ©2018 International Emergency Medicine (iEM) Education Project
Copyright Resources shared by iEM Education Project through website, book content,
image and video archive are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 International License,
which permits unrestricted use, distribution in any non-commercial medium.
You give appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were made.
Edited by
Arif Alper Cevik, Lit Sin Quek, Abdel Noureldin, and Elif Dilek Cakal
Cover design
Arif Alper Cevik
Published by
iEM Education Project, iem-student.org
INTERNATIONAL
EMERGENCY
MEDICINE
EDUCATION
PROJECT
iem-student.org
ii
What is iEM? International Emergency Medicine (iEM) Education Project is an
international, non-profit project, endorsed by International Federation for
Emergency Medicine (IFEM) and supported by Emergency Medicine
professionals from all around the world. Currently, there are 146
contributors from 21 countries in the project. It aims to promote
Emergency Medicine and provide free, reusable educational content for
undergraduate medical trainees and educators.
The book "iEmergency Medicine for Medical Students and Interns" is a part
of the project content and service. It was created by 133 international
contributors. At the publication time, the book content provided in the iem-
student.org has been visited by more than 20,000 visitors from 150
countries.
iEM education project is run by volunteers, and you can join us. Please visit
“how to contribute” page to share your Emergency Medicine experience and
message with future colleagues from all around the world.
iii
Preface “if you want to go fast go alone,
if you want to go far go together”
African Proverb
Today, there are few countries in the world that have appropriately designed
UEME programs in their medical schools. The majority of the countries (even
some developed ones) have no guidelines, curricula, or enough educational
resources. In addition, there are limited resources (textbooks, websites) for
medical students/interns which covers their educational needs based on current
UEME recommendations.
This is just a start to build up better Emergency Medicine resources for medical
students and interns, especially for developing countries. It is a continuous
process, and there are a lot of areas that we need to improve in this book.
Therefore, we are looking forward to your feedback and collaboration.
We also believe that international UEME will reach the minimum required
standards in all countries based on the endless collaboration of emergency
medicine professionals.
iv
Terms of Use This book aims to provide general Emergency Medicine information and dis-
cussion to medical students and interns.The content and discussions found
on this electronic book are not individualized medical advice and can not be
used for this purpose. If you think you need emergency care or any type of
medical care, please contact your doctor or call local/national emergency
number.
Notification The iEM is a global project and may contain various opinions and
approaches. The information and opinions expressed in this book have no
relation to those of any academic, hospital, practice, institution, or worldview
Some images in this book may be disturbing. Some of with which the authors or editors are affiliated, and does not represent
the topics may contain medical-related information institutional policies.
that is sexually explicit. If you find this information The content of this book has been prepared by international authors to
offensive, you may not want to use the book. This provide this content to medical students and interns. The content, informa-
tion, opinions, references, and links to other knowledge resources provided
book includes medical content, particularly emergency
by Editors and authors are only for medical students and interns’
medicine related, for medical students and interns. educational purposes. This book is not intended or advised for public use.
Some of the content in this book may contain elements
The iEM project, its’ Editors, contributors and its’ team do not intend to
that are not suitable for some readers. Accordingly,
establish any physician-patient relationship through the contents of this
viewer discretion is advised. book, nor does it replace the services of a trained physician or health care
professional, or otherwise to be a substitute for professional medical advice,
The book content is not suitable for persons under 18 diagnosis, or treatment. Again, this is an educational book for medical
years of age. Persons under the age of eighteen (18) students and interns, and it is not medical care platform. Therefore, you shall
should not access, use and browse the book. not make any medical or health-related decision based in whole or in part on
anything contained in this book. If you need medical care or advice, you
should consult a licensed physician in your community healthcare office or
hospitals.
Although their main interest is emergency medicine, the content of the book
was prepared by international contributors from different backgrounds.
Medicine itself is changing very fast. Therefore, we can not guarantee
v
providing complete, correct, timely, current or up-to-date our best to get functioning these links, but they may stop
information in the book. Similar to any printed material, the con- functioning any other reason.
tent may become out-of-date and may be changed without
notice. The Editors and authors have no obligation to update any The iEM project Director, Editors, and authors are not responsible
content in the book. The Editors may update the content at any for the content of any linked or otherwise connected websites.
time without notice, based on their absolute discretion. The iEM The iEM project Director, Editors, and authors do not make any
project Director and Editors reserve the right to make alterations representations or guarantees regarding the privacy practices of,
or deletions to the content at any time without notice. or the content or accuracy of materials included in, any linked or
third party websites or resources. The inclusion of third-party
Opinions expressed in the book are not necessarily those of the links in the book does not constitute an endorsement, guarantee,
Editors, authors and iEM project team. These opinions cannot be or recommendation.
applied to an individual case or particular circumstance. The con-
tent should not be used or relied upon for any other purpose, The book content is not suitable for persons under 18 years of
including, but not limited to, use in or in connection with any legal age. Persons under the age of eighteen (18) should not access,
proceeding. Some images in this book may be disturbing. Some use and browse the book.
of the topics may contain medical-related information that is sexu-
Although the Editors and authors have made every effort to
ally explicit. If you find this information offensive, you may not
assure that the information in this book is correct at publication
want to use the book. This book includes medical content,
time, the Editors and authors do not assume and hereby disclaim
particularly emergency medicine related, for medical students and
any liability to any party for any loss, damage, or disruption
interns. Some of the content in this book may contain elements
caused by errors or omissions, whether such errors or omissions
that are not suitable for some readers. Accordingly, viewer
result from negligence, accident, or any other cause.
discretion is advised.
For more information regarding terms of use, please visit website.
This project aims to expand medical students interest in and
knowledge of Emergency Medicine. Therefore, iEM Editors and
team continuously search for valuable third party links. The book
may contain links to other (“third party”) websites, videos, etc.
These links are provided solely as a convenience and not as a
guarantee or recommendation by the Editors or authors for the
services, information, opinion or any other content on such third
party websites or as an indication of any affiliation, sponsorship
or endorsement of such third party resources. If you decide to
access a given link, you do so at your own risk. Your use of other
websites is subject to the terms of use for these sites. We tried
vi
Publishing Process There is continuous work for the iEM book process. We applied multiple
editing and reviewing steps. We continue this process for many chapters
with the feedback from our readers and contributors.
The Editors and authors have made every effort to assure that the
information in this book is correct and appropriate for medical students and
interns. The Editors and authors do not assume and hereby disclaim any
liability to any party for any loss, damage, or disruption caused by errors or
omissions, whether such errors or omissions result from negligence,
accident, or any other cause.
vii
Acknowledgement We thank the institutions and organizations which helped this project to see
the light. The United Arab Emirates University, College of Medicine and
Health Sciences supported funding the expenses of iEM Education Project.
The International Federation for Emergency Medicine (IFEM) supported the
project since beginning and officially endorsed on October 2018.
We thank our Editors, authors, and collaborators for their time and fantastic
work during the production of this book.
We would like to thank Prof.Dr. Fikri Abu-Zidan for his wise advise and
continuous encouragement during the hardship of delivering the book and
its content.
viii
Editors Editors
Arif Alper Cevik, UAE
Lit Sin Quek, Singapore
Abdel Noureldin, USA
Elif Dilek Cakal, Turkey
Section Editors
Toh Hong Chuen, Singapore
Veronica Tucci, USA
Silvio Aguilera, Argentina
Funda Karbek Akarca, Turkey
Rahul Goswami, Singapore
Mary J.O., USA
Ziad Kazzi, USA
Jesus Daniel Lopez Tapia, Spanish Section Editor, Mexico
Olinda Giselle G. Saenz, Spanish Section Editor, Mexico
Language Editor
Sarah Elizabeth Noureldin, USA
ix
Contributors Abdel Noureldin, USA David Wood, USA
Abdulaziz Al Mulaik, KSA Diana V. Yepes, USA
Aldo E.M. Salinas, Mexico Dejvid Ahmetovic, Slovenia
Alja Pareznik, Slovenia Donna Venezia, USA
Ana Podlesnik, Slovenia David F. Toro, USA
Ana Spehonja, Slovenia Ebru Unal Akoglu, Turkey
Amila Punyadasa, Singapore Eisa AlKaabi – UAE
Arif Alper Cevik, UAE-Turkey Elif Dilek Cakal, Turkey
Arwa Alburaiki. UAE Elizabeth Bassett, USA
Assad Suliman Shujaa, Qatar Emilie J. Calvello Hynes, USA
Ashley Bean, USA Eman Al Mulla, UAE
Aya Dodin, UAE Falak Sayed, UAE
Ayse Ece Akceylan, Turkey Fathiya Al Naqbi, UAE
x
Jesus Daniel Lopez Tapia, Mexico Meltem Songur Kodik, Turkey Sadiye Yolcu, Turkey
Joe Lex, USA Michael Butterfield, USA Sarah Attwa, UAE
Jorge Luis Garcia Macias, Mexico Michelle Chan, USA Sara Nikolic, Slovenia
Josepph Pinero, USA Moira Carrol, USA Selene Larrazolo Carrasco, Mexico
Justin Brooten, USA Muneer Al Marzouqi, UAE Sercan Yalcinli, Turkey
Kaja Cankar, Slovenia Murat Cetin, Turkey Serpil Yaylaci, Turkey
Kamil Kayayurt, Turkey Mustafa Emin Canakci, Turkey Shabana Walia, USA
Katja Zalman, Slovenia Nidal Moukaddam, USA Shaza Karrar, UAE
Keith A Reymond, Austria Nik A.S.N. Him, Malaysia Shanaz Sajeed, USA
Kemal Gunaydin, Turkey Nik Rahman, Malaysia Shirley Ooi, Singapore
Khuloud Alqaran, UAE Nur-Ain Nadir, USA Stacey Chamberlain, USA
Khalid Mohammed Ali, Singapore Olinda Giselle Garza Saenz, Mexico Sujata Kirtikant Sheth, Singapore
Kuan Win Sen, Singapore Ozge Can, Turkey Suzanne Bentley, USA
Lamiess Osman, UAE Ozlem Dikme Akinci, Turkey Tanju Tasyurek, Turkey
Linda Katirji, USA Ozlem Koksal, Turkey Tiffany Abramson, USA
Lindsay Davis, USA Pia Jerot, Slovenia Timothy Snow, USA
Lit Sin Quek, Singapore Puneet Sharma, UK Tjasa Banovic, Slovenia
Mahmoud Aljufaili, Oman Qais Abuagla, UAE Toh Hong Chuen, Singapore
Mary J O, USA Rabind Anthony Charles, Singapore Tomislav Jelic, Canada
Maryam AlBadwawi, UAE Ramin Tabatabai, USA Veronica Tucci, USA
Maryam Darwish, UAE Rahul Goswami, Singapore Vigor Arva, Slovenia
Marwan Galal, UAE Rasha Buhumaid, UAE Vijay Nagpal, USA
Matevz Privsek, Slovenia Reza Akhavan, Iran Walid Hammad, USA
Matija Ambooz, Slovenia Rob Rogers, USA Will Sanderson, USA
Matthew Lisankie, Canada Rok Petrovcic, Slovenia Yadira Rubio Azuara, Mexico
Matthew Smetana, USA Rouda Salem Alnuaimi, UAE Yusuf Ali Altunci, Turkey
Mehmet Ali Aslaner, Turkey Ryan H. Holzhauer, USA Ziad Kazzi, USA
xi
Content 1. The Facts of Emergency Medicine
Emergency Medicine: A Unique Specialty
Will Sanderson, Danny Cuevas, Rob Rogers
Choosing The Emergency Medicine As A Career
C. James Holliman
Thinking Like An Emergency Physician
Joe Lex
xii
3. General Approach to Emergency Patients Acute Heart Failure
Walid Hammad
The ABC Approach to Critically Ill Patient
Donna Venezia Aortic Dissection
Shanaz Sajeed
Abdominal Pain
Shaza Karrar Deep Venous Thrombosis
Elif Dilek Cakal
Altered Mental Status
Murat Cetin, Begum Oktem, Mustafa Emin Canakci Hypertensive Emergencies
Sadiye Yolcu
Cardiac Arrest
Abdel Noureldin, Falak Sayed Pulmonary Embolism
Elif Dilek Cakal
Chest Pain
Assad Suliman Shujaa
A Child With Fever
Jabeen Fayyaz
5. Selected Endocrine, Electrolyte
Gastrointestinal Bleeding Emergencies
Moira Carrol, Gurpreet Mudan, Suzanne Bentley Acid-Base Disturbance
Headache Lamiess Osman, Qais Abuagla
Matevz Privsek, Gregor Prosen Hyperglycaemia
Multiple Trauma Hong Chuen
Pia Jerot, Gregor Prosen Hypernatremia
Poisoning Vigor Arva, Gregor Prosen
Harajeshwar Kohli, Ziad Kazzi Hyponatremia
Respiratory Distress Vigor Arva, Gregor Prosen
Ebru Unal Akoglu Hypoglycaemia
Shock Rok Petrovcic
Maryam AlBadwawi Thyroid Storm
Shabana Walia
4. Selected Cardiovascular Emergencies
Abdominal Aortic Aneurysm
Lit Sin Quek
Acute Coronary Syndrome
Khalid Mohammed Ali, Shirley Ooi
xiii
6. Selected Environmental Emergencies 9. Selected Neurological Emergencies
Burns Approach to Patients With Stroke
Rahul Goswami Matevz Privsek, Gregor Prosen
Drowning Acute Ischemic Stroke
Ana Spehonja Fatih Buyukcam
Heat Illness Intracranial Hemorrhage
Abdulaziz Al Mulaik Nur-Ain Nadir, Matthew Smetana
Hyperthermia Seizure
Puneet Sharma Feriyde Caliskan Tur
xiv
12. Selected Orthopaedic Problems and 16. Selected Procedures
Injuries Automatic External Defibrillator (AED) Use
Back Pain Mehmet Ali Aslaner
Funda Karbek Akarca Arterial Blood Gas Sampling
Lower Extremity Injuries Matija Ambooz and Gregor Prosen
Ayse Ece Akceylan Arthrocentesis
Pelvic Injuries Tanju Tasyurek
Sercan Yalcinli Basics of Bleeding Control
Spine Injuries Ana Spehonja, Gregor Prosen
Ozge Can Cardiac Monitoring
Upper Extremity Injuries Stacey Chamberlain
Meltem Songur Kodik Gastric Lavage and Activated Charcoal Application
Elif Dilek Cakal
13. Selected Infectious Problems Intravenous Line Access
Epiglottitis Keith A Reymond
KuanWin Sen Intraosseous (IO) Line Access
Meningitis Keith A Reymond
Alja Pareznik Emergency Delivery
Sinusitis David F. Toro, Diana V. Yepes, Ryan H. Holzhauer
Katja Zalman, Gregor Prosen Pericardiocentesis
Sepsis David Wald, Lindsay Davis
Emilie J. Calvello Hynes Lumbar Puncture
Khuloud Alqaran
14. Selected Toxicologic Problems Nasogastric Tube Placement
Opioid Overdose Sara Nikolic, Gregor Prosen
Aldo E. B. Salinas, Jesus Daniel Lopez Tapia Procedural Sedation and Analgesia
Nik Rahman
15. Selected Eye Problems Rapid Sequence Intubation
Eye Trauma Qais Abuagla
Serpil Yaylaci, Kamil Kayayurt
Reduction of Common Dislocations and Fractures
Red Eye Dejvid Ahmetović, Gregor Prosen
David Wood
xv
Splinting and Casting 19. Selected Emergency Drugs
Joseph Pinero, Timothy Snow, Suzanne Bentley
Antidotes
Urinary Catheter Placement Hamidreza Reihani, Elham Pishbin
Gul Pamucu Gunaydin
Drugs for Pain Relief
Nik Ahmad Shaiffudin Nik Him, Azizul Fadzi
17. Selected Diagnostic Tests
Paralyzing Agents
Arterial and Venous Blood Gases Analyses
Qais Abuagla
Kemal Gunaydin
Cerebrospinal Fluid Analysis 20. Selected Clinical Rules, Scores,
Arwa Alburaiki, Rouda Salem Alnuaimi
Urine Analysis
Mnemonics
Jan Zajc Clinical Decision Rules
Stacey Chamberlain
Whole Blood Cell Count – CBC
Kaja Cankar Mnemonics
Ozlem Dikme
18. Selected Imaging Modalities Classifications and Scores
EFAST - Extended Focused Sonography for Trauma Sarah Attwa, Marwan Galal
Ashley Bean, Brian Hohertz, Gregory R. Snead
POCUS in Patients with Undifferentiated Hypotension
Rasha Buhumaid
BLUE Protocol
Toh Hong Chuen
How to Read C-Spine X-Rays
Dejvid Ahmetovic, Gregor Prosen
How to Read Chest X-Rays
Ozlem Koksal
How to Read Head CT
Reza Akhavan, Bita Abbasi
How to Read Pelvic X-ray
Sara Nikolic, Gregor Prosen
xvi
Chapter 1
The Facts of
Emergency
Medicine
Section 1
Imagine walking into the hospital to start your day – ambulances are blaring, the
by Will Sanderson, Danny Cuevas, Rob Rogers waiting room is clamoring, babies are crying. You stroll through this sea of
humanity and eventually arrive at your workstation. After setting your bag down,
you prepare the basic tools of your trade: a stethoscope, a fresh cup of coffee,
and a sharp mind. Taking a deep breath, you prepare for the routine of yet another
shift. But there is no “routine.” There is only the excitement and variety of what is
about to come through those sliding double doors. That flimsy piece of metal and
glass is the only barrier that separates you from the thousands of people with a
multitude of medical ailments, any one of which could bring them to your
doorstep. With a low hum and an almost silent whoosh, these doors part to reveal
your next patient. To them, it is probably the worst day of their life. For you, it’s
another Tuesday.
Who will be your next patient? Is it the 4-year-old boy with the asthma attack
gasping for that next breath? Will it be the 78-year-old widower who fell at home
while fixing himself a sandwich? Maybe it’s the 31-year-old female who just rear-
ended another vehicle at highway speed; oh, did they also mention she’s 28 weeks
pregnant? You look over and see new patients filling the critical examination rooms
and the trauma bay. No matter what walks through that door, you’ll be ready. You
sit down. You grab a chart. It’s time to get to work. Today is going to be another
Audio is available here routinely awesome day.
18
Why choose a career in emergency medicine? Before discussing d e e p e r l o o k i n t o t h e practice and lifestyle of the modern
where the field is going, it’s important to know a little background emergency medicine physician.
on where it has been. And if you’re reading this and considering a
career in EM, do yourself a favor – take the time to watch this Why EM?
documentary from the Emergency Medicine Residents’ Emergency medicine is a fast paced, team oriented, dynamic
Association (EMRA). As you’ll see, the specialty of emergency specialty that focuses on the rapid evaluation and treatment of a
medicine has evolved drastically over the last several decades diversified patient population consisting of both pediatric and
and continues to be an increasingly popular choice among adult patients. As the initial provider for many of their patients, the
graduating medical students. Only a few decades ago, emergency medicine physician is charged with the rapid
emergency departments around the country were staffed by assessment and data gathering needed to launch the initial
physicians with a variety of training backgrounds. The vast workup and management of a wide variety of complaints that
majority of these physicians had little to no emergency medicine bring patients to the ED. Their work has an incredible influence in
training at all. General surgeons, family physicians, neurologists, the patients’ care as it generates the driving force for further
and even psychiatrists were among those that staffed emergency medical evaluation; whether the patient is admitted to the hospital
departments around the country and throughout the world. But or discharged home, the emergency physician plays a huge role
since the establishment of the first emergency medicine residency in directing both short and long term care well after their stay in
programs in the 1970’s and the subsequent establishment of the the emergency department. Here’s a look inside the lives of
American Board of Emergency Medicine in 1979, the specialty several emergency physicians from Rob Orman of ERcast.
has continued its rapid development in defining its place in the Variety is the spice of the EM life. There is no set routine or
house of medicine. Walk into anything other than the smallest of expected patient list for the day. In the short span of a shift, you
EDs these days and you’re likely to encounter an emergency may diagnose strep pharyngitis, intubate an unresponsive patient
medicine residency trained physician. A study published in 2008 who overdosed on heroin, reveal a cancer diagnosis to a young
demonstrated that in its relatively short history as a recognized patient with flu-like symptoms, reduce a dislocated hip, place a
medical specialty, the number of physicians staffing departments chest tube in a patient with a hemothorax, and resuscitate a
across the country who had received emergency medicine patient undergoing a cardiac arrest. Your next patient could be a
training soared from 0% to 70%. Why the dramatic shift? To six-year-old or a 75-year-old, both with abdominal pain. In a
understand the answer to this question, you need to take a setting where some may see chaos, EM physicians find order. It’s
19
exciting. It’s energizing. This diversity is a uniquely challenging t h e s h i f t w o r k i n t h e emergency department affords a
aspect of the medicine practiced in the emergency department. level of flexibility not seen in other medical specialties. Emergency
physicians manage the hustle and bustle of their department for a
EM physicians pull from a knowledge base that spans all medical
set number of hours, after which a fresh physician team arrives to
specialties including pulmonology, cardiology, gastroenterology,
take over. After his shift, the previous doctor hands over the care
trauma surgery, nephrology, ophthalmology, psychiatry, and
of his patients to the oncoming team to continue with the
neurology. Jack of all trades? Sure. Master of none? Not even
diagnostic and therapeutic management of the patient. In this
close. The gap between the medical and surgical specialties is
regard, one can wrap up, sign out, and head home without
bridged within the practice of emergency medicine. The
bringing any of his work with him. The nature of shift work also
combination of a broad knowledge base with the need to develop
allows for trading of shifts amongst the physicians staffing the
a focused procedural skill set makes the EM physician a veritable
department. Want a week off in April to spend some time at the
Swiss Army Knife within the house of medicine. From
beach? As long as you plan in advance, you shouldn’t have any
endotracheal intubation, cricothyroidotomy, fracture reduction,
trouble getting there. With enough planning, it’s quite possible to
and central line placement to pericardiocentesis, thoracotomy,
be at nearly every important life/family event you choose.
chest tube placement, and lateral canthotomy, even the most
enthusiastic proceduralist will find his hands full working in the Within the field of emergency medicine, physicians are employed
ED. in several settings. These settings range from hospital-based
and freestanding emergency departments, urgent care facilities,
Variety is a word that not only defines the practice of emergency
observation medicine units, emergency medical response
medicine but also the lifestyle it affords. Are you a morning
services, and even telemedicine locations. Patient volumes, even
person who is up at the break of dawn and thinks best with a
at facilities in close proximity to one another, can vary greatly.
fresh mind after breakfast? Or are you a night owl who gets a
Some facilities are designated trauma centers while others are
burst of energy in the wee hours of the night when most others
not. There are facilities teamed up with a strong academic center
are sound asleep? Are you a weekend warrior who prefers to
to provide numerous subspecialty support and others are
keep your schedule open on those days? Or would you rather
resource-limited community hospitals. No matter what your
work during the day to finish in time to pick up your children after
preference, there are a variety of settings to fit your needs. But
they finish their day at school? Irrespective of your preference,
let’s get to the real question at hand: are emergency medicine
20
physicians satisfied with their career? This is really the crux of any
discussion regarding career choice. How devastating would it be
to realize after spending over a decade in college, medical
school, and residency that working in the emergency department
isn’t for you? Well, in 2015, emergency medicine physicians came
in 4th in overall career satisfaction compared to other medical
specialties. 60% of all emergency physicians surveyed were
satisfied with their income. Emergency physicians typically work
more intensely for fewer total hours compared with other
physicians and enjoy above-average compensation per hour.
Below, Dr. Kevin King of the University of Texas Health Science
Center San Antonio discusses the Pros and Cons of a Career in
Emergency Medicine: Pros and Cons of a Career in Emergency
Medicine. As you can see, the life of an emergency medicine
physician is not a perfect fit for everyone. EM physicians suffer
from relatively high rates of burnout. However, as the field evolves
and physician wellness becomes a priority for all physicians
within medicine, this will surely improve. If the characteristics
outlined above are consistent with the qualities you are looking
for in a specialty, emergency medicine may well be the perfect fit
for you.
21
Section 2
The specialty of Emergency Medicine (EM) is a great career choice for medical
by C. James Holliman students and interns. In August 2013, I celebrated my 30th year in full-time EM
clinical practice, and I remain very happy and satisfied with my career choice. I
have served as a career advisor to medical students and interns for over 30 years
now and am very interested in encouraging people to undertake EM as a career.
Why is EM a great career? The main summary reason is that it is challenging and
very personally rewarding. You can directly and quickly see the benefits and
positive results of your diagnosis and treatment of patients who have emergent
medical conditions. You have the satisfaction of knowing you have made a big
positive difference in patients’ lives and well-being. EM encompasses a very wide
variety of patients and medical and surgical problems. EM deals with patients of
both genders and all ages. The variety of cases seen by EM is probably greater
than that of any other specialty, and this aspect is part of what makes EM so
interesting and stimulating. The practice of EM encompasses a nice mix of
diagnostic medicine and of performing diagnostic and therapeutic procedures.
The EM practitioner sees patients with undifferentiated symptoms and so must
make the initial diagnosis of many conditions. EM interacts with all the other
medical specialties, and at most hospitals accounts for the majority of hospital
A video is available here admissions.
Audio is available here
22
Unique subjects routinely taught in EM include: cost-effective intensive care, pediatrics, o b s t e t r i c s , i n t e r n a l m e d i c i n e ,
ancillary test ordering, efficiency in patient flow, managing cardiology, trauma, etc.), and this direct exposure to other
multiple simultaneous patients, coordinating Prehospital and multiple specialties makes EM residencies more interesting. Of
Emergency Department (ED) care, focusing the approach to course, the majority of time in most EM residencies is spent in the
medical problems, speed and efficiency of patient evaluations, hospital ED. Most EM residencies also offer opportunities to
efficient use of ancillary personnel, efficient recording and participate in prehospital care and EM research. One validation
transmittal of clinical data, and injury and violence prevention. EM of the strength of EM as a career is that in the U.S. each year it is
is also a young, vibrant specialty with a lot of enthusiastic the first or second most popular choice for residency by medical
practitioners, most of whom have extended interests and talents students, and the overall residency program “fill” rate in the
outside of medical practice, and who serve as role models and National Residency Matching Program is over 99%. For more
mentors. information on EM residencies from the perspective of EM
residents, check the website www.emra.org.
EM also encompasses the supervision of and interactions with
prehospital care. EM receives patients brought to the hospital ED EM has also developed a number of sub-specialties which
by ambulance. EM is responsible for training the prehospital enhance the career options in EM. Each sub-specialty offers
personnel, and in some countries, EM practitioners may find post-residency fellowship training programs of one to three years
themselves directly staff ambulances, both ground and duration. In the U.S.A., the following EM subspecialties are
aeromedical. EM also is the main specialty involved in the officially recognized and have their own sub-specialty exam
planning for, and management of disasters and mass casualty certification: Pediatric EM, Toxicology, Critical Care, Sports
situations, both of which also require close interaction with Medicine, Hyperbaric Medicine, Emergency Medical Services,
prehospital care. and Palliative Care. Additional EM sub-specialty fellowship
programs include International EM (or Global Health), Ultrasound,
EM has well-developed residency training programs for medical
Research, Education, Simulation Training, Aeromedical, Disaster,
school graduates in many countries. The length of these training
Trauma, Administration, and Information Technology. Check the
programs varies from country to country but generally is three to
website www.saem.org for the most up to date listing of EM
five years. The EM residencies each have some clinical rotations
fellowship programs.
on other services or specialties (such as anesthesia, surgery,
23
One of the greatest assets of EM as a career is the wide variety of national healthcare system, and there is extensive medical
post-residency career choices or options. These include literature support for the value and efficacy of EM.
practicing in a variety of hospital types: university, teaching,
Another nice EM career aspect is the opportunity after residency
community, government, military, etc. EM physicians can also
or fellowship to participate in one or more of the EM specialty
practice in “freestanding” ED’s (not directly connected to a
state, national, regional, or international organizations. Most
hospital) or in urgent care centers. If a person does not want to
countries have a national EM organization which carries out some
practice at just one hospital, there is the option to undertake
activities including annual educational conferences. The
“locum tenens” practice in which the person works clinical shifts
International Federation for EM (IFEM) has a large number of
at multiple different facilities. For those in the military or interested
committees, task forces, and special interest groups which are
in a military career, EM has been shown to be one of the most
carrying out a wide variety of projects which need more
needed specialties in the military. EM physicians can undertake
individuals to participate and contribute (check www.ifem.cc for
leadership positions in hospital administration, prehospital care,
more information on IFEM). Becoming involved with one or more
and in the government developing and directing health policy.
of the EM specialty organizations can provide one with career
Unique advantages of EM as a career include the almost satisfaction in helping improve and develop the specialty as well
unlimited opportunities in international EM development, control as obtaining leadership training and experience.
over and predictability of one’s work schedule, usually not having
So in summary, EM is a great career choice with a very wide
to be “on-call” when not directly on duty, and having “geographic
range of post-residency work options, a very safe job market for
flexibility” in the variety of places to practice. There are also a
the future, and the personal satisfaction of knowing one’s work
relatively small number of EM physicians in academic practice, so
directly and quickly helps patients, and that one’s work is a
it is often easy for physicians interested in an academic career to
critical component of the national healthcare system.
rapidly advance up the “academic ladder”.
References and Further Reading, click here.
Another positive aspect for EM is that in most countries it is
projected to be an undersupplied specialty for many years, and
so there will continue to be many open job opportunities in EM.
EM has also been shown to be a critical component of any
24
Section 3
“Emergency Medicine is the most While other doctors dwell on the question, “What does this patient have? (i.e.,
“What’s the diagnosis?”), emergency physicians are constantly thinking “What
interesting 15 minutes of every other
does this patient need? Now? In 5 minutes? In two hours?” Does this involve a
specialty.” different way of thinking?
– Dan Sandberg, BEEM Conference, 2014 The concept of seeing undifferentiated patients with symptoms, not diagnoses, is
alien to many of our medical colleagues. Yet we do it on a daily basis, many times
during a shift. Every time I introduce myself to a patient, I never know which
direction things are going to head. But I feel like I should give the following
disclaimer. Hello stranger, I am Doctor Joe Lex. I will spend as much time as it
takes to determine whether you are trying to die on me and whether I should admit
you to the hospital so you can try to die on one of my colleagues. You and I have
never met before today. You must trust me with your life and secrets, and I must
trust that the answers you give me are honest. After today, we will probably never
see one another again. This may turn out to be one of the worst days of your life;
for me, it is another workday. I may forget you minutes after you leave the
department, but you will probably remember me for many months or years,
Audio is available here
possibly even for the rest of your life. I will ask you many, many questions. I will do
25
the best I can to ask the right questions in the right order so that I For the most part, this has not changed. And Lewis Thomas
come to a correct decision. I want you to tell me the story, and for wrote: “The great secret of doctors, learned by internists and
me to understand that story, I may have to interrupt you to clarify learned early in marriage by internists’ wives, but still hidden from
your answers. Each question I ask you is a conscious decision on the public, is that most things get better by themselves. Most
my part, but in an average 8 hour shift I will make somewhere things, in fact, are better by morning.” Remember, you don’t
near 10,000 conscious and subconscious decisions – who to see come to me with a diagnosis: you come to me with symptoms.
next, what question to ask next, how much physical examination
You may have any one of more than 10,000 diseases or
should I perform, is that really a murmur that I am hearing, what
conditions, and – truth be told – the odds of me getting the
lab study should I order, what imaging study should I look at now,
absolute correct diagnosis are not good. You may have an
which consultant will give me the least pushback about caring for
uncommon presentation of a common disease or a common
you, is your nurse one to whom I can trust the mission of getting
presentation of an uncommon problem. If you are early in your
your pain under control, and will I remember to give you that work
disease process, I may miss such life-threatening conditions as
note when it is time for you to go home? So even if I screw up
heart attack or sepsis. If you neglect to truthfully tell me your
just 0.1% of these decisions, I will make about ten mistakes
sexual history or use of drugs and alcohol, I may not follow
today. I hope for both of our sakes you have a plain, obvious
through with appropriate questions and come to a totally
emergency with a high signal-to-noise ratio: gonorrhea, a
incorrect conclusion about what you need or what you have.
dislocated knee cap, chest pain with an obvious STEMI pattern
on EKG. I can recognize and treat those things without even The path to dying, on the other hand, is rather direct – failure of
thinking. If, on the other hand, your problem has a lot of respirations, failure of the heart, failure of the brain, or failure of
background noise, I am more likely to be led down the wrong metabolism.
path and come to the wrong conclusion. I am glad to report that
the human body is very resilient. We as humans have evolved You may be disappointed that you are not being seen by a
over millennia to survive, so even if I screw up, the odds are very, “specialist.” Many people feel that when they have their heart
very good that you will be fine. attack, they should be cared for by a cardiologist. So they think
that the symptom of “chest pain” is their ticket to the heart
Voltaire told us back in the 18th century that “The art of medicine specialist. But what if their heart attack is not chest pain, but
consists of amusing the patient while nature cures the disease.” nausea and breathlessness; and what if their chest pain is aortic
26
dissection? So you are being treated by a specialist – one who these interruptions derail me from doing what is best for you
can discern the life-threatening from the banal, and the cardiac today.
from the surgical. We are the specialty trained to think like this.
I will use my knowledge and experience to come to the right
If you insist on asking “What do I have, Doctor Lex?” you may be decisions for you. But I am biased, and knowledge of bias is not
disappointed when I tell you “I don’t know, but it’s safe for you to enough to change my bias. For instance, I know the
go home” without giving you a diagnosis – or without doing a pathophysiology of pulmonary embolism in excruciating detail,
single test. I do know that if I give you a made-up diagnosis like but the literature suggests I may still miss this diagnosis at least
“gastritis” or “walking pneumonia,” you will think the problem is half the time it occurs.
solved, and other doctors will anchor on that diagnosis, and you
And here’s the interesting thing: I will probably make these errors
may never get the right answers.
whether I just quickly determine what I think you have by
Here’s some good news: we are probably both thinking of the recognition or use analytical reason. Emergency physicians are
worst case scenario. You get a headache and wonder “Do I have notorious for thinking quickly and making early decisions based
a brain tumor?” You get some stomach pain and worry “Is this on minimal information (Type 1 thinking). Cognitive psychologists
cancer?” The good news is that I am thinking exactly the same tell us that we can cut down on errors by using analytical
thing. And if you do not hear me say the word “stroke” or reasoning (Type 2 thinking). It turns out that both produce about
“cancer,” then you will think I am an idiot for not reading your the same amount of error, and the key is probably to learn both
mind to determine that is what you are worried about. I types of reasoning simultaneously.
understand that, no matter how trivial your complaint, you have a
After I see you, I will go to a computer and probably spend as
fear that something bad is happening.
much time generating your chart as I did while seeing you. This is
While we are talking, I may be interrupted once or twice. See, I essential for me to do so the hospital and I can get paid. The
get interrupted several times every hour – answering calls from more carefully I document what you say and what I did, then the
consultants, responding to the prehospital personnel, trying to more money I can collect from your insurance carrier. The final
clarify an obscure order for a nurse, or I may get called away to chart may be useless in helping other health care providers
care for someone far sicker than you. I will try very hard to not let understand what happened today unless I deviate from the clicks
and actually write what we talked about and explained my
27
thought process. In my eight hour shift today I will click about telling of my wondrous career, I quickly stop short and tell
4000 times. myself “You will just be adding more blather to what is already out
there – what you have learned cannot easily be taught and will
What’s that? You say you don’t have insurance? Well, that’s okay
not be easily learned by others. What you construe as wisdom,
too. The US government and many other governments in the
others will see as platitudes.”
world have mandated that I have to see you anyway without
asking you how you will pay. No, they haven’t guaranteed me any As an author, Norman Douglas once wrote: “What is all wisdom
money for doing this – in fact, I can be fined a hefty amount if I save a collection of platitudes. Take fifty of our current proverbial
don’t. A 2003 article estimated I give away more than $138,000 sayings– they are so trite, so threadbare. None the less they
per year worth of free care related to this law. embody the concentrated experience of the race, and the man
who orders his life according to their teachings cannot be far
But you have come to the right place. If you need a life-saving
wrong. Has any man ever attained to inner harmony by
procedure such as endotracheal intubation or decompression
pondering the experience of others? Not since the world began!
needle thoracotomy, I’ll do it. If you need emergency delivery of
He must pass through fire.”
your baby or rapid control of your hemorrhage, I can do that too.
I can do your spinal tap, I can sew your laceration, I can reduce Have you ever heard of John Coltrane? He was an astonishing
your shoulder dislocation, and I can insert your Foley catheter. I musician who became one of the premiere creators of the 20th
can float your temporary pacemaker, I can get that pesky foreign century. He started as an imitator of older musicians but quickly
body out of your eye or ear or rectum, I can stop your seizure, changed into his own man. He listened to and borrowed from
and I can talk you through your bad trip. Miles Davis and Thelonious Monk, African music and Indian
music, Christianity and Hinduism and Buddhism. And from these
Emergency medicine really annoys a lot of the other specialists.
disparate parts he created something unique, unlike anything ever
We are there 24 hours a day, 7 days a week. And we really expect
heard before. Coltrane not only changed music, but he altered
our consultants to be there when we need them. Yes, we are fully
people’s expectations of what music could be. In the same way,
prepared to annoy a consultant if that is what you need.
emergency medicine has taken from surgery and pediatrics,
I have seen thousands of patients, each unique, in my near-50 critical care and obstetrics, endocrinology and psychiatry, and we
years of experience. But every time I think about writing a book
28
have created something unique. And in doing so, we altered the
world’s expectations of what medicine should be.
29
Chapter 2
Emergency
Medicine
Clerkship: Things
to Know
Section 1
Introduction
by Linda Katirji, Farhad Aziz, Rob Rogers The Emergency Medicine (EM) clerkship typically takes place during the fourth
year of medical school. However, some programs may have an optional elective
during the third year. Whether or not you plan to specialize in Emergency
Medicine, the rotation is an important aspect of your medical education. The
emergency room is a unique learning environment which is different than any other
setting in the hospital. It provides clinical opportunities that are largely unavailable
in other clerkships and rotations. During residency, many specialties will also
spend a significant amount of time in the Emergency Department (ED). This may
be within a structured EM rotation, or while admitting or seeing patients for a
certain medical or surgical service. Therefore, it is important to gain an
understanding of the flow of the ED as well as the particular thought process that
must be employed with emergency department patients. This chapter will discuss
some of the unique aspects of the emergency department, some of the skills to
acquire during the EM clerkship, as well as how to best be successful and take the
most away from your rotation.
31
stream of patients, some of whom may require immediate life- s y n d r o m e s , a o r t i c dissection, pulmonary embolism,
saving measures, means that many times there is little to no time pericardial tamponade, pneumothorax, esophageal rupture.
to review history or any medical records prior to seeing the Additionally, ED doctors have to use a different thought process
patient. A majority of the time you will need to assess a patient in determining the disposition, or outcome, of the patient. The ED
without knowing anything about their background. Therefore, it is doctor essentially wants to avoid sending a patient home that
important to gain an understanding of what the most important should not go home, where as a consultant, or admitting service,
pieces of information to gather are for each patient. This can be does not want to admit a patient who shouldn’t be admitted. This
difficult since most patients will arrive with completely may seem trivial however this difference in thought process can
undifferentiated complaints. Some common examples of these occasionally create tension between the ED and admitting
undifferentiated complaints are “chest pain” and “abdominal services.
pain”, where the etiology can range from completely benign to
Teaching in the ED is different than most other settings in the
immediately life-threatening, or “weakness”, where the differential
hospital as well. There is usually no time set aside for formal
diagnosis includes essentially the entire spectrum of medical
rounds, so most teaching is done at the bedside or at the time the
pathology.
student or resident presents the patient. Many times, attending
This undifferentiated patient is the standard in the ED. However, physicians will pick out “teaching points” for each patient. Each
they can present in any medical setting. It is important to learn physician will have a different teaching style, and your learning
the thought process and develop a strategy for thinking through will, in general, be more active than passive.
these types of patients whether or not you plan on a career in EM.
Lastly, the ED is a great place for medical students and first-year
Emergency Physicians (EPs) must employ and master a
residents to learn to take responsibility for their patients. Students
completely different style of practice than most physicians. EPs
often time have an increased level of autonomy compared to
must always think worst case scenarios for each chief complaint
other rotations. Many times, the student will be the first person to
and must be knowledgeable and comfortable with associated the
assess the patient, which is a very important role. It is important
workup and treatment. A good example of this is chest pain. Even
to learn to distinguish whether a patient is “sick” or “not sick”,
though many times the complaint of “chest pain” is found to be
and whether or not at first glance you think this patient could go
caused by a non-acutely life threatening etiology, EPs must
immediately think of six fatal causes of chest pain: acute coronary
32
home or needs to be admitted not matter what the diagnosis may variety of procedures. Whether you intend to pursue a
be. career in pediatrics, internal medicine, orthopedics, general
surgery or any other specialty, your rotation through the ED will
Unique Skills To Take Away From EM expose you to a wide array of procedural skills ranging from
Clerkships intubating and placing central lines and arterial lines in the
Emergency medicine is a wonderful rotation that exposes you to critically ill to performing lumbar punctures and fracture
different patient populations but also a variety of pathology. This reductions in children. Autonomy is encouraged with procedures,
diverse collection of patients and pathology lends emergency and you will have the opportunity to improve your skills and
medicine residents and students a unique opportunity to gain a techniques under the guidance of residents and attendings. EM is
mastery of different skills. These skills range from a knowledge of a very hands on specialty. You should take advantage of medical
how to approach critically ill patients, gaining procedural skills, student and resident didactics as a which may include procedure
reading radiographs and CT scans and performing ultrasounds labs on mannikins or cadavers and simulation. This will give you
and much more. an opportunity to practice and provide better patient care during
your rotation.
Often you may be busy doing different tasks when you have to
drop everything and manage a critically ill patient. This is one of In addition to becoming familiar with a wide array of procedures,
the exciting aspects of emergency medicine. These patients offer your EM clerkship will also allow you to familiarize yourself with a
students a great opportunity to learn the principles of variety of imaging modalities ordered in the ED. There is a
resuscitation, such as managing airways and circulatory collapse, tremendous amount of pathology found in the ED which lends
identifying causes for the patient’s decompensation, and itself to a range of imaging. Whether it be learning to perform
instituting the appropriate treatment. Whether you pursue a bedside ultrasonography on a crashing patient or simply learning
career in emergency medicine or choose to pursue a different how to approach a chest x-ray or a CT scan of the abdomen,
specialty, critically ill patients will always be a part of your patient your EM rotation will give you plenty of opportunities to become
population. Understanding how to approach and stabilize these proficient in a skill you will need later in your career.
patients is an important part of being a physician.
Though your EM clerkship gives you exposure to a tremendous
Though learning the art of resuscitation is a vital part of the EM amount of skills which will help you become a savvy doctor, no
rotation, this is also an opportunity to gain competence in a
33
skill is more important than compassion and humility. Everyday k n o w a n d t a k e t h e opportunity to learn how to diagnose,
you will meet patients on the worst day of their life. Realizing this treat, and manage your patient.
and comforting them and their families is paramount to your
The best way to build confidence during your EM rotation is to
success as a physician. You will also encounter a variety of
gain experience and knowledge. Try to be proactive in learning
consulting physicians. Some are nice and professional while
new procedures or treatments with attending or resident
others are not. Having a general understanding that they all have
assistance. Additionally, it’s very important to keep up with
knowledge that you can learn from will set you up for a successful
reading and studying. In the Emergency Room, you may see
career in medicine.
medical pathology you’ve only read about and will be expected to
How To Be Successful on Your EM Clerkship know how to diagnose and treat these diseases properly.
Many of the of the same qualities that allow you to be successful
Good communication is essential for a physician in any specialty,
in other rotations will help you to be successful in the ED. It is
and in the ED, it is an imperative skill to have. You will be working
important to be hardworking, proactive, and knowledgeable.
with a large team of nurses, technicians, consulting doctors,
Keep a close eye on your patients, re-evaluate them frequently,
social workers, and paramedics, just to name a few. When you
and make sure to follow up on any results, including labs,
see a patient, it is a good idea to speak with the nurse before you
imaging, and any recommendations by consultants. The unique
enter the room to gain a better understanding of the patient’s
aspects of the ED and EM clerkship discussed previously mean
complaint, as well as gather any information that was relayed by
the first few shifts may be stressful and seem hectic. For every
EMS. By communicating the plan of care to the nurse and
student and resident that rotates through the ED there is a
supporting staff, you will not only improve patient care and
significant learning curve – with each shift you spend in the ED,
reduce mistakes but also forge relationships that will enrich your
things will feel less and less daunting. It’s important during this
experience in the ED. In acute settings such as a patient code or
time that you know your limitations and what you are comfortable
rapidly decompensating patient, good communication with the
and not comfortable with. Many times you will be the first person
entire team is critical. As a medical student or rotating resident,
to assess the patient. You should have a low threshold for alerting
this is a great time to practice and improve your communication
an upper-level resident or attending if the patient appears to be
skills in these acute settings under the direction of residents and
sick, or if they present with a complaint you are uncomfortable
attendings.
with. At the same time, you should be confident in what you do
34
Your EM rotation will be an exciting, unique experience during
medical school and residency. Whether you plan to specialize in
EM or not, you will learn many procedural skills, improve your
own method of diagnosing and treating patients and be able to
practice a different method of medical decision making.
35
Section 2
Medical Professionalism
Introduction
by Amila Punyadasa It is prudent to commence this chapter with some relevant definitions. A
profession is a specific type of occupation, one that performs work with special
characteristics while competing for economic, social, and political rewards. A
“The Dimensions That All Medical professional, it follows, is a person who belongs to a group (profession) which
Students Should Know About” possesses specialized characteristics (specifically, knowledge, skills, and
attitudes) that have been obtained after a long period of study and are used to
benefit other members of society. Thus, professionalism is used to describe those
skills, attitudes and behaviors. We expect from individuals during the practice of
their profession and includes such concepts as maintenance of competence,
ethical behavior, integrity, honesty, altruism, service to others, adherence to
professional codes, justice, respect for others and self-regulation. In fact, it has
been said that professionalism serves as the basis of the medical professions’
relationship to society and that this relationship is a social contract, underpinned
by professionalism. Medical professionalism thus comprises physicians’ behaviors
that demonstrate they are worthy of the trust the public and patients place in
them.
In essence, our profession involves healing. Kirk (2007) eloquently stated that in
any patient encounter, we consider both a right and good healing strategy for our
patients. The right action is informed by evidence-based medicine, while the good
36
action incorporates the patient’s values and preferences aligned Although there are many definitions of professionalism, most
with the physician’s judgment (or, in other words, requires the contain a list of responsibilities that the physician should exercise;
physician to exercise various dimensions of professionalism). they are based on three fundamental principles:
Interestingly, this ‘judgment’ itself has three concrete steps: 1. The principle of primacy of patient welfare – This is based on a
dedication to serving the interest of the patient with altruism; in
1. The diagnostic question – What is wrong with the patient? –
turn, contributing to trust, the core of the doctor-patient
Incorporates both the clinical assessment and investigations
relationship. This principle should be unsullied by economic,
the patient was subjected to.
administrative or sociocultural exigencies.
2. The therapeutic question – What can be done for the patient? –
2. The principle of patient autonomy – The patient’s autonomy
Informed by evidence and may involve a plethora of treatments
must be respected, and doctors should not only be honest
and interventions.
with their patients but also empower them to make informed
3. The prudential question – What should be done for the patient? decisions about their healthcare, as long as these are within
– This involves the patient in the final decision-making process, the ethical practice and do not lead to demands for
preserves patient autonomy, and ensures a patient-centric inappropriate care.
approach to healthcare provision.
3. The principle of social justice – This includes the fair
The advantages of teaching students to practice professionalism distribution and access to health care resources and the
include imparting a greater sense of purpose, building a elimination of discrimination, whether that be racial, gender-
framework for harmonious and efficacious healthcare provision, based, religious, socio-economic or any other social category.
as well as building trust and mutual respect. Additional benefits
The definition proposed by Wilkinson et al. (2009) is both
include improving patient satisfaction, reducing complaints and
thorough and explicit. His list of specific behaviors necessary for
litigation, improving treatment compliance, and improving clinical
medical professionalism is enumerated. Also incorporated in the
outcomes.
appendix is the Emergency Medicine Clerkship’s core curriculum
learning objectives that pertain to professionalism.
• Honesty/Integrity
37
• Confidentiality • Balancing availability to others with care of ones-self
• Politeness/Courtesy/Patience • Self-Reflectiveness
• Teamwork • Leadership
38
2. Abuse of power – with respect to colleagues, patients, and explicitly taught but also explicitly tested (or assessment
position in the hierarchy. driven learning and practice). Other motivators include
bestowing rewards and recognition for demonstrating positive
3. Arrogance – towards patients or colleagues
behaviors, a form of positive reinforcement.
4. Conflict of Interest
2. Observing role models are of the utmost importance. This
5. Misrepresentation – for example, lying or being fraudulent. entails not only the incorporation of good behaviors observed
but also the recognition of negative behaviors exhibited by
6. Apathy – pertaining to lack of commitment, irresponsibility or poor role models and purposefully not engaging in such
doing the bare minimum for patients. behaviors. I shall delve into this concept in more detail in part 4
below.
7. Impairment – secondary to illness, alcohol or drugs.
3. Continued exposure to aspects of professionalism is important
Many of the core criteria of professionalism are related to the
to inculcate its tenets. Vertical integration into a spiral
assimilation of good old-fashioned virtues and the development
curriculum, in my opinion, is required to achieve this goal.
of soft skills that must not only be taught but also reinforced
through modeling and active practice. When devising any 4. Reflection and feedback are keys. Self-reflection on aspects of
professional curriculum, take careful consideration of common professionalism, as well as timely and effective feedback of
themes that positively impact necessary behavioral changes. specific behaviors from peers and seniors, will help mold the
Some of those themes include the following: medical student into doctors that demonstrate professional
behaviors. Good feedback, based on observable behaviors,
1. Motivation (or Getting “Buy-In”)
explains not only what should be done but also why it should
a. Intrinsic – Medical students must be convinced of the be done, and both are essential for effective learning.
importance of the desired change in behaviors for it to be a
The importance of teaching medical professionalism to
driving force.
undergraduates is well documented in the literature and is integral
b. Extrinsic – The principal extrinsic motivator for medical to the medical profession. What is perhaps less clear is exactly
students is the knowledge that professionalism will not only be how this teaching should be conducted. The solution lies in
39
understanding how to utilize all aspects of the curriculum between knowledge-based teaching and in-situ experiential
including the formal, informal, and hidden curriculum. learning.
Strategies for Teaching the Formal In my personal undergraduate and postgraduate training years,
Furthermore, there have been two principle approaches • Problem-based reflective practice
described in the teaching of professionalism.
• Role-modeling
• Explicitly Teaching the Basics of Professionalism
• Portfolio based training
• Experiential Learning
• Clinical contacts with tutor debriefs
One should utilize both of these approaches. In fact, to
• Simulation-based training
paraphrase the situated learning theory, a balance must be struck
• Didactics and tutorials
40
The Informal and Hidden Curricula in Medical curriculum. For example, empathy among medical students
41
an ongoing conflict between the formal curriculum and the Classically, a role model is someone who is admired for the way
informal/hidden curriculum. he acts and for his professionalism and whose behavior is
considered as a standard of excellence to aspire to.
An obvious remedy is to engage the various stakeholders
involved in training medical students in a constructive dialogue on It is important to show students what right practice is, and that
how the hidden and informal curricula can be manipulated to applies to both clinical and professional conduct. This is the
influence student learning positively. This understanding will not essence of role modeling.
only help avoid the visible conflict between formal curriculum and
Paice et al. (2002) described the act of being a role model as
informal/hidden curricula but will also extract the advantages of
serendipitous, a beneficial but chance outcome. I respectfully
the informal/hidden curriculum to produce better physicians.
disagree. Senior tutors and physicians all act as role models and
It is undeniable that medical school faculty, both senior and junior must be cognizant of everything we do in front of our students.
doctors, and other healthcare workers are all role models who Knowing that we will be observed and scrutinized should make us
may influence medical students’ learning. The professionalism ultra self-conscious, and we should try hard to showcase and
demonstrated by all these people is of great importance not only inculcate the virtues of sound clinical practice and
for their patients but also for the next generation of doctors. professionalism at every opportunity.
Hence, we have to keep paramount in our minds that our practice
The vast majority of the literature is in agreement that role
and interpretation of professionalism, and all its dimensions, is
modeling is not only important but also integral to medical
keenly being observed by our students and that we have a huge
education. Role models not only affect the attitudes, behaviors,
role to play in the development and molding of their moral and
and ethics of medical students but also imbibe professionalism in
professional wellbeing.
trainees. I am sure we can all recall a specific role-model that
Role Modelling in Medical Professionalism impressed upon us the virtues of professionalism while
This connects back to the most powerful tool to teach demonstrating punctuality, responsibility, honesty, ethical
professionalism, role modeling. Role modeling involves a reasoning, accountability, collegiality and patient-centric
physician (or role model) who teaches a student by example; its management while embracing diversity with a sense of decorum.
importance is unquestionable and has been documented for Such role models also influence career choices of students and
many years. function in the formal, informal and hidden curricula. However,
42
drawbacks have also been described. Sinclair (1997) wrote that • Collated views of co- workers
he noted medical students being drawn to and indeed emulate
• Simulation
senior doctors who held positions of responsibility and status. He
further noted a warning of their professional ideals and behaviors • Paper tests
as they evolved.
• Patient opinions
Assessment Techniques in Medical
• Ratings by a Superior
Professionalism
Unfortunately, despite the unquestionable importance of • Self-assessment
professionalism to the everyday functioning of every medical
doctor and student, my experiences (spanning two decades and • C r i t i c a l i n c i d e n t re p o r t / R e c o rd s o f i n c i d e n t s o f
three countries) with its assessment has been rather limited. In unprofessionalism
fact, during my postgraduate years of clinical practice, the
assessment of professionalism has been rather rudimentary, with
Social Media and Professionalism
It seems like nearly everyone, certainly from the Generations Y
its evaluation often subordinate to the assessment of clinical
and Z, is using Facebook or Twitter these days for one reason or
competencies.
another. Although not a fan myself, I do concede that when used
If we are to take the assessment of professionalism seriously, with prudence, social media and the Internet is an invaluable
then we must improve our framework for assessment. resource for teaching and learning. It can support physicians’
Specifically, we need to implement a number of different methods personal expression, improve camaraderie and improve the
to effectively measure all levels of Miller’s pyramid, while also dissemination of public health messages. Equally, it risks
covering the multidimensional breadth of professionalism. broadcasting unprofessional content online that reflects poorly on
individuals, their affiliated institutions, and the medical profession
I shall now consider some assessment tools that will enable the alike.
ability to assess the multidimensionality of medical
professionalism. These are; For example, let us consider a hypothetical tweet from a female
doctor to her colleague describing a recent patient: ‘Just saw an
• Assessment of an Observed clinical encounter 18-year-old unmarried G5P0, with Chlamydia, herpes, and
43
gonorrhea. Disgusting!’ This tweet would have contravened a few accurate and appropriate. With regards to interaction with
of Wilkinsons (2009) so-called ‘behaviors inherent to good patients through social media, again, this interaction should fall
medical professionalism.’ This doctor should have had “respect within the boundaries of established professional norms. If a
for her patients’ diversity” and shouldn’t have been so judgmental physician feels that such an interaction transgresses such norms,
(in this case, about the patients alleged sexual promiscuity and he/she should report the matter to the relevant authorities. Finally,
lifestyle). She also should have upheld patient confidentiality (as it is imperative that physicians realize that inappropriate online
although the patient’s name wasn’t tweeted, the descriptors used interactions may have a negative impact on their reputations and
about her obstetric and sexual histories would surely have made that of their institutions, career advancements, and, perhaps most
her easily identifiable amongst her friends and family who might damning, may serve to undermine public trust in the medical
have come across this tweet). The doctor should have, in my profession as a whole.
opinion, had better regard for professional boundaries and
References and Further Reading, click here.
exercised greater judgment and discretion.
44
Section 3
Introduction
by Vijay Nagpal and Bret A. Nicks Emergency Medicine and the situations within the department can present a
stressful, rapidly changing environment where it may feel as though there is too
little time for effective patient communication, patient-centered care or the
opportunity to establish an appropriate provider-patient relationship. It is also an
environment unlike any other in medicine, where a unique team of individuals faces
varying degrees of chaos with limited available information to work together and
address the medical conditions of those presenting to the department. Few would
recommend entering such an environment in the absence of an established care
process and means of clear communication. The tone of the department is set
prior to walking into the ED; from the moment you walk into the department,
preconceived notions and prejudices remain at the door.
45
other health professions bring to the team can help us to look while you may not be able to solve the patient’s condition or
from a different perspective to better understand our patients and chronic illness, using effective communication skills and providing
facilitate the best care that can be offered in the ED (Klauer & a positive patient experience will assuage many patient fears
Engel, 2013). (Mole, 2016). Keep in mind, in general, patients remember less
than 10% of the content (what was actually said), 38% of how
Essentials of Communication you say it (verbal liking), and 55% of how you look saying it (body
The approach to providing quality patient care in the ED starts language) (Helman, 2015).
with recognizing the patient-provider mismatched perspective on
what has happened and what is occurring (Helman, 2015). It is Effective provider communicators routinely
essential to recognize the patient-physician relationship starts employ these 5 Steps
with a significant power imbalance. Attempts should be made to 1. Be Genuine
normalize or reduce this power imbalance, to empower the
patients and their families. This will enable an open discussion We know it. People can sense the disingenuous person – whether
about their medical concerns and assist in making informed it is a gut feeling or through other senses. Try to see the situation
decisions about their care. It is important to acknowledge the wait from the patient’s perspective, and it will ensure that you are
or process they have already endured before seeing you. Thank acting in his best interest and with integrity.
the patient (and family) for coming to the ED and allowing you to
2. Be Present
address their medical concerns. Also, take the time to introduce
yourself to everyone in the room with the patient and find out who As emergency providers, we are interrupted more than perhaps
they are in relation to the patient. This can help establish rapport any other specialty. However, for the few moments that we are
with the patient and those around them (Chan 2012, Cinar 2012, engaged with the patient or his family, be all in. If there is a
Hobgood 2002). planned interruption upcoming, make it known prior to starting a
discussion. Be focused on them and the conversation; value what
While many believe the environment of care is the greatest
they have to share. At the end of your encounter, briefly
limiting factor as opposed to quality communication, literature
summarizing what the patient has told you can help to reassure
would suggest otherwise. Establishing a positive patient-provider
the patient that you were listening and also give them the chance
relationship is essential for patient care. One must recognize that
to clarify discrepancies.
46
3. Ask Questions additional information. Doing this also allows the patient to
be more involved in his care and ask further questions regarding
To effectively communicate, one must listen more than he talks.
his workup and treatment plan. Additionally, helping the patient to
After introducing yourself, inquire about the patient’s medical
understand what to expect while in the department can help to
concern; give them 60 seconds of uninterrupted time. Most
alleviate fear associated with unannounced tests or imaging
patients are amazed and provide unique insights that would
studies, especially when these tests may require him or her to be
otherwise not be obtained. Once the patient has provided you
temporarily taken out of the department (e.g., a trip to the CT
with his concerns, begin asking the specific questions needed to
scanner).
further differentiate the care needed. By asking questions and
allowing for answers, you make it about them and give them an Many of these concepts have been identified in patient
avenue to share with you what they are most concerned about, satisfaction and operational metrics. In one study, wait times were
enabling you to address those concerns. not associated with the perception of quality of care, but empathy
by the provider with the initial interaction was clearly associated
4. Build Trust (Helman, 2015). In addition, patient dissatisfaction with delays to
Given the nature of the patient-provider relationship in emergency care is less linked to the actual time spent in the ED and more
medicine, building trust is essential but often difficult. Building with a to set time expectations about the care process, a
trust is like building a fire; it starts with the initial contact and perceived lack of personal attention, and a perceived lack of staff
builds with each interaction. Trust is also built on engaging in communication and concern for the patient’s comfort.
Ensure that at the end of your initial encounter you have to try and understand the patient’s agenda. One can accomplish
established a clear plan of care, what the patient can expect, how this by asking, “Help me understand what brought you in today.”
long it may take, and when you will return to reassess or provide “Help me understand what I can do for you.” “Tell me more.” This
47
will help to normalize the patient’s situation and gain unique • Take Action – discuss and define the care steps (and what to
insights into his care concerns. expect)
There are four easy steps to improve reflective listening and • Express Appreciation – thank the patient for allowing you to
perceived empathy in the ED: care for them
1. Echo – Repeat what the patient says; this gives the message The Approach
that you heard the patient. As with many life circumstances, effective communication is the
glue that helps establish connections to others and improve
2. Paraphrase – Rephrase what the patient says as this gives the
teamwork, decision-making, and problem-solving. It facilitates the
message that you understand the patient.
ability to communicate even negative or difficult messages
3. Identify the feeling – Say, for example, “you seem frustrated,” without creating conflict or distrust. Recognizing this helps
“worried,” “upset.” This produces trust. provide the best foundation and approach for successful patient
communication, an essential element in the ED. In addition to
4. Validation – Validate the patient’s feelings verbally by saying
understanding the five steps of effective communication, ones
statements such as “I can see why you feel that way.”
approach to effective communication must also be guided by the
There is also a great online module and mnemonic for Empathetic individual patient and adjusted accordingly. So, consider seeing
Listening skills development (SMACC, 2016). The RELATE your approach from the patient’s perspective, and set the tone
mnemonic is: with the following three starting points.
• Listen – not just hearing, encourage the patient to ask questions • Sit down next to the patient
• Answer – summarize what they have said and confirm their • Maintain an open posture (avoid crossing your arms)
understanding
48
• Maintain good eye contact, if culturally appropriate Do
• Let the patient tell his/her story (Roscoe, 2016)
• Smile appropriately, nod affirmingly
• Establish what the patient’s agenda is, what his/her fears are
2. How you speak
• Provide the patient with information regarding what will happen
• Speak slowly and quietly (given the constraints of the ED)
during his/her stay. This puts the patient more at ease and
• Use a low tone in your voice improves satisfaction (Hobgood, 2002).
• Empathy can be heard in your tone • Provide expected wait times. Some experts suggest
overestimating the time for results and consultant services
3. What you say (Disney Technique).
• Introduce yourself in a culturally appropriate manner • Explain the reasons for delays and apologize for it
• Use the patient’s last name (helps to minimize power imbalance) • After your history and physical, map out the next steps in the
process (i.e., establish expectations).
• Acknowledge everyone in the room and ask what their
relationship to the patient is (i.e., shake hands if culturally
Don’t
appropriate) • Fold your arms over your chest as this displays an aggressive
posture
• Adjust medical wording based on patient’s medical literacy
• Ask why the patient did not come in earlier
In addition to understanding the five essentials of communication
and setting the tone for the initial care approach, it is important to • Say, “I guess.”
understand a few of the common reasons communication either
fails or succeeds in the Emergency Department. While a single • Repeatedly ask, “why.”
approach framework doesn’t always fit, there are some essential
• Use the words “never” or “always.”
Do’s and Don’ts that must also be considered.
49
The Difficult Patient Frequent Fliers
When facing difficult patients in the emergency department,
High recidivism may be frustrating, but it is important to
understanding the situation and the motivation for the patient
understand that there may be an underlying reason for frequent
may help to navigate better the communication challenges that
ED visits. Socioeconomics and poor access to care are common
are present. A difficult patient encounter in the emergency
reasons. Knowing the available resources (e.g., social workers,
department can often be frustrating for both the physician and
clinical support nursing) can make a difference.
the patient. These patients often present with chronic medical
issues that are superimposed onto individuals with social Combative/Agitated or Intoxicated Patient
disparities (Hull & Broquet 2007, Dudzinski & Timberlake 2016).
It is most important to keep both the patient and the staff
These are just a few examples of types of patients that one may
(including yourself) safe. Redirecting the patient and emphasizing
encounter in the emergency department:
the importance of caring for them medically may help to calm the
Patient Type and Suggestion situation. Psychopharmacological intervention may be necessary
Angry Patient at times.
Don’t ignore the fact that a patient may be angry or upset – often For a deeper dive into effective patient communication related to
it is related to delays, expectations or care concerns. Try to managing difficult patients, listen to Episode 51: Effective Patient
explore this emotion by asking neutral and non-confrontation Communication – Managing Difficult Patients by Anton Helman.
questions. Acknowledgment and a simple apology for process
issues may prove invaluable. The Handoff
Communication between providers and patient care transitions
Manipulative Patient present one of the well-known challenges in patient care and
errors in care management. This handoff communication, often
While these patients may clearly have a secondary agenda, their
perceived as the “gray zone,” has been characterized by
medical complaints may still be legitimate. Approach these
ambiguity regarding the patient’s medical condition, treatment,
patients with an open mind, but be prepared to say no to
and disposition (Akper, 2007). Communication errors, particularly
requests that are not clinically indicated.
related to patient hand-offs, account for nearly 35% of ED-related
50
care errors. Establishing a standardized process to ensure the saturation at 93%. We are currently attempting to wean O2
quality and clarity of transitions in care are essential. One such requirement as tolerated.
example is the I-CAN format that is specifically focused on the ED
patient population. N – Next Steps and Anticipated Disposition
Describe to the receiving provider what will need to be followed
ED-based Patient Handoff Tool (I-CAN) up and the anticipated disposition of the patient. For example, the
patient will need to be admitted for a COPD exacerbation with a
I – Introduction new O2 requirement. He can go to a floor bed if he remains stable
Briefly describe what brought the patient into the emergency
on nasal cannula.
department today. For example, the patient is a 53 yo male with a
past medical history of COPD who presents today with a While many examples for a unified handoff exist, identifying a
productive cough, wheezing, and shortness of breath. defined approach and establishing the expectation for routine
use, especially when integrated into the electronic health record
C – Critical Content & Interventions Performed at transitions of care, ensure improvement with patient care,
Relate information that helps the receiving provider understand quality, and throughput (Akper 2007, Rouke 2016). If the patient
the ED course taken up to this point. and family are involved with this handoff, not only will they
For example: On initial evaluation, the patient was unable to understand care expectations but the will also better understand
speak in full sentences, and O2 saturation was 88% on room air. issues with delays, next steps, and care updates.
52
Section 4
Data Gathering
Introduction
by Chew Keng Sheng Although a medical student has always been taught to take a comprehensive
history and a complete physical examination from head-to-toe, she may find this
methodical approach a challenge in the emergency department (ED). Many of the
patients who come to the ED are often first-time patients, unfamiliar with
procedures, and have diverse complaints ranging from a manipulative attempt to
obtain a sick leave certificate to a complex, life-threatening situation. This
challenge is further compounded by the fact that many patients in the ED are
suffering from acute illnesses or injuries that compromise their cognitive capacity
to comprehend and respond.
In such a situation, the linear clinical approach – history first, followed by physical
examination and investigation – may not be feasible. Rather, data gathering from
the patient’s history, physical examination, and investigation may need to be
performed concurrently. The most important element in the approach to the
patient in emergency medicine is to establish the composite initial impression of
53
the patient. This is based on data gathering from multi-sources Ask the 5-Ws and 1-H q u e s t i o n s : “ W h a t ? ” “ W h y ? ”
including the history, physical findings, and bedside “Who?” “When?” “Where?” and “How?”
investigations. Of particular importance is answering the vital
question: is there any life or limb threat in this patient? And once Pay particular attention to any symptom developed acutely. Acute
a life or limb threat is identified, immediate measures must be onset of a headache, for example, suggests a vascular origin. If a
initiated to reverse the insult before moving on in the data patient has had a chronic, persistent or recurrent condition, the
gathering process. important question to ask is “Is there any difference between the
symptom before and the symptom now?” A patient with a
Activity 1 migraine headache, for example, can present with a sudden
“worst ever headache” suggestive of subarachnoid hemorrhage
Watch a video podcast on General Approach to the Emergency
rather than a chronic migraine. If we do not ask for the symptom
Department Patient.
pattern changes, the patient may not volunteer this information.
Discuss
What
• What are the strengths and limitations you see in this
What is the message that the patient is trying to convey to me
emergency medicine approach model where all processes of
through the words he does and does NOT use? Observe the non-
data gathering (history-taking, physical examination, and
verbal communication cues that he is trying to convey, e.g., a
investigation) may have to occur simultaneously as compared
sense of nervousness, fidgety movements, etc. Often, patients
to the traditional linear clinical approach?
are prone to conceal sensitive information such as sexual history
As tough as it may seem, a doctor working in the ED must still as well as psychiatric/psychological complaints that may only be
establish a good communication rapport with the patient, as detected through non-verbal cues.
much as possible. To attain this, one must utilize open-ended
Why
questions.
Examples: Why does the patient choose to come in the middle of
the night? Why does the patient choose this form of treatment
54
and not another? Why does the patient think that his or her illness Non-verbal cues
is not serious? Be attentive to the patient’s non-verbal cues as well, not just the
verbal contents of his visit. Albert Mehrabian, a professor of
Who
psychology, developed the classic 7-38-55 rule. This rule consists
Examples: Who is/are taking care of the patient at home? Whom of the following: while 7% of what the patient communicates
does the patient seek advice from when he/she is sick? Who else comes from the actual words used (the content), 38% of the
knows about the patient’s illness? Who is/are the eyewitnesses of message comes from the way it is said (the tone), but 55% of the
the accident or the trauma that the patient was involved in? Who message comes from the non-verbal cues including but not
is the patient’s next of kin? Who can be a legitimate surrogate limited to the facial expression, eye contact, etc.
decision maker for the acutely ill patient?
Does the patient appears fearful and defensive? Aggressive?
When Angry? Disinterested? Click here to watch a video on Mehrabian’s
study.
Examples: When does the pain occur? When does the patient
first notice the swelling, the discoloration, etc.? A sudden onset This is especially so when the patient is trying to communicate
of symptoms is a warning sign and may suggest a vascular event. across sensitive information such as his sexual history or
psychological symptoms. Unfortunately, it was found that only
Where between 20 – 40% of doctors responded positively to the
patient’s verbal and non-verbal cues (Beckman 1984).
Examples: Where did the accident happen? Where does the
patient come from? How far from the hospital? Allow the patient to describe his/her concerns using his own
words without interruptions. It has been found that a doctor
How
interrupts his patients as early as 18 seconds into the
Examples: How did the accident happen? Did the patient lose conversation, even though it takes at least 150 seconds for the
his/her consciousness before or after the event? patients to tell his stories (Beckman 1984).
55
Activity 2 alleviate these emotions of fear and anxiety in their clinical
encounters?
Watch this short video: Presenting your patient to your attending
in Emergency Medicine by Dr. David Pierce 3. The speaker also talked about the long waiting time in the ED.
How does the long waiting time affect your data gathering
Reflect: In the video, Dr. Pierce admonishes his residents not to
process?
miss anything important by thinking of 5 other differential
diagnoses. Why is it especially important to adopt a broad-based References and Further Reading, click here.
approach in diagnoses formulation in the ED?
Activity 3
1. In his talk, the speaker stated that “most patients do not take
going to the ED casually.” How does knowing that most
patients do not take going to the ED casually affect the way
you view your patients, especially in the middle of the night?
2. The second thing that the speaker said is that fear and anxiety
are routine emotions experienced by ED patients. Do you agree
with this statement? If yes, why do you think this is so, and
how would this affect your data gathering process? In your ED
rotation or posting, observe whether it is indeed true that fear
and anxiety are routine emotions experienced by the patients
you see. Do you think the doctors have done enough to
56
Section 5
Case 1
by Yusuf Ali Altunci A fifty-one-year-old male patient is admitted to your
emergency department (ED) with chest pain that started 30
minutes ago. On his ECG, there are 2 mm ST elevations at DII,
DIII, and aVF derivations. Do you need high sensitive troponin
analyzes results for acute management of this patient?
Case 2
A thirty-five year- old female patient presented to your ED with
sudden onset shortness of breath. She has tachycardia. There
is no pathologic finding at auscultation. Her blood pressure is
90/60 mmHg. In history, there is swelling and pain on her left
leg for two days. She is using oral contraceptives. For this
patient can normal D-dimer result rule out pulmonary
embolism?
57
Introduction rules try to answer; therefore, the diagnosis found through the patient’s
The emergency physicians frequently development of these reliable clinical history and physical examination (Wald
make difficult clinical decisions with decision rules is imperative for the 2011). For emergency management, it is
limited information while encountered advancement of modern emergency usually more important to rule out life
with a multitude of demands and medicine (Pines 2012). threating pathologies.
distractions (Kovacs & Croskerry 1999).
“Listen to your patient; he is So why do we need diagnostic tests? For
EDs are crowded places. Usually, you detecting the problem, of course;
telling you the diagnosis.” –
have limited time to diagnose and treat however, the decision to test is impacted
the patients. Today, diagnostic tools are
William Osler (1849-1919) by multiple factors such as clinical
better than they were in the past. This suspicion, persuasion, physician’s
may help provide an easier diagnostic
Diagnostic Testing Approach decision, consultant’s or patient’s request
Polymorbid patients, different diagnostic
approach, but the difficulty is knowing (Wald 2011).
and therapeutic options, more complex
how and when you should use these
hospital structures, financial incentives, Patients often express strong preferences
tools. Even if the technology has become
benchmarking, and perceptional and for medical tests or treatments of their
available more frequently in clinical
societal changes cause pressure on own choosing, even when physicians
practice, clinical expertise and skills are
doctors, especially if medical errors come believe that those interventions are not
still important factors for making correct,
up. This is especially true for the ED beneficial (Brett & McCullough 2012).
timely diagnoses in patients (Wahner-
structure, where patients encounter Patients are also increasingly willing to
Roedler 2007).
delayed or erroneous initial diagnostic or challenge physicians’ intellectual
So this triggers the question: is there one therapeutic actions and expensive authority, often requesting interventions
diagnostic approach for each emergency hospital stays due to sub-optimal triage based on media publicity about new
illness that can render the best result for (Schuetza 2015) research findings, sometimes before
the patient, maximize timeliness and physicians are even made aware of them.
Diagnostic tests should primarily be
accuracy, and limit cost? This is the Internet sources with clinical information
ordered to rule in or out a particular
essential question that clinical decision also empower patients to make medical
condition based on the differential
58
judgments independent of consultations “Medicine is a science of •Sensitivity = True Positive/(True
with physicians (Brett & McCullough Positive + False Negative)
uncertainty and an art of
2012). The Internet continues to create
new, unschooled Internet doctors and, in probability.” – William Osler Specificity refers to the likelihood of the
test being negative or normal in the
turn, new challenges. (1849-1919)
absence of disease
Chosing the test or not test in the ED also
Statistics • Specificity = True Negative/(True
depends on the resources of the hospital.
You decided on one of the diagnostic
Negative + False Positive)
Some hospitals allow easy access to
tests for your patient. Do you think you
radiographic testing and laboratory A test that has high specificity means that
should know some statistics in order to
testing. In other hospitals, obtaining a it has a low rate of reporting false
evaluate the results? Let’s check some
diagnostic test may not be that simple positives. A test that has low specificity
basic statistical terms that we regularly
(Pines 2012). has a high likelihood of false-positive
face as a doctor.
results (Wald 2011).
Questions for diagnostic strategy
Random ordering of laboratory tests and
described by Wald (2011) are Positive predictive value (PPV) refers to
shortcomings in test performance and
interpretation may cause diagnostic the likelihood of the patient truly having
• What am I going to do with the test
results? errors. Test results may be vague with the disease when the test is positive or
false positive or false negative results and abnormal.
• How is this test going to help me generate unnecessary harm and costs.
confirm or exclude the diagnosis? • PPV = True Positive/(True Positive +
Laboratory tests should only be
False Positive)
demanded if results have clinical
• How will the test result affect my
consequences (Schuetza 2015). Negative predictive value (NPV) refers to
diagnostic strategy, management, or
final disposition? the likelihood that the patient does not
Sensitivity refers to the likelihood of a
have the disease when the test is
test being positive or abnormal in the
negative or normal (Wald 2011).
presence of disease.
59
• NPV= True Negative/(True Negative + False Negative) Five causes taxonomy of testing-related diagnostic error
(Epner 2013)
Probability
1. An inappropriate test is ordered.
The other important element in testing is the probability.
Previously, the physicians’ role in emergency medicine was 2. An appropriate test is not ordered.
clinical problem solving by history taking and examination only.
3. An appropriate test result is applied incorrectly.
Now it has changed and incorporates determining the pre- and
post-test probabilities essential for the ordering and interpretation 4. An appropriate test is ordered, but a delay occurs somewhere
of laboratory tests (Schuetza 2015). Probability relates to your in the whole testing process.
concern about a particular patient having an illness or condition
and how that concern may or may not be impacted by the 5. The result of an appropriately ordered test is not accurate.
the results of most diagnostic tests are known within a few hours. greater access to the results of a multitude of diagnostic studies
The importance of diagnostic tests in Emergency Medicine is an in a timely fashion (Wald 2011). It is our responsibility to practice
undeniable fact. For example, there are a lot of diagnostic medicine in a cost-effective manner that benefits our patients and
imaging alternatives available in the ED including USG, CT, and does not overburden them and the health care system with
MRI in the ED. So, the pathologies that were mostly detected at unnecessary and, at times, overused testing (Wald 2011).
autopsies in the past, such as pulmonary embolism or an aortic Blood circulating biomarkers play a crucial role in the present
aneurysm, became a clinical problem for today (Wald 2011). diagnostic workup of ED patients. A biomarker may be
Unfortunately, many “routine” laboratory tests are being ordered considered as any protein or other macromolecules that can be
in “bundles” without any impact on diagnostic or therapeutic objectively measured and evaluated as an indicator of normal
management (Schuetza 2015). biological processes, pathological processes, and course of
diseases or pharmacological responses to a therapeutic
60
intervention. Readily measurable biomarkers give important m a n a g e m e n t t o o u r patients. However, in the same time,
information about etiology of a disease and the necessity for it is our responsibility to use our resources wisely. Therefore,
interventions and prognosis. Diagnostic biomarkers justify the ordering the appropriate tests is very important. The tests which
presence or absence of a disease (Schuetza 2015). you think it will change your management and you know what are
you going to do with the results are the best tests for your
In Emergency Medicine practice, we use algorithms or clinical
patients. In addition, this approach will help to use our resources
decision rules (Ottawa Ankle Rules, PECARN minor head trauma
efficiently and decrease the cost of of unnecessary tests.
algorithm, etc.) to make standard management. These are useful
and practical tools to make an acceptable decision. Clinical References and Further Reading, click here.
decision rules try to make objective criteria that may help you to
distinguish who requires a test or not (Pines 2012). Some people
call it “cookbook” medicine, and, of course, “one size cannot fit
all.” Today, however, they are the most evidence-based
approaches to pathologies. So staying within the rules is one of
the best methods that will assist you when contemplating when
to utilize diagnostic tests.
61
Section 6
Introduction
by Chew Keng Sheng As the patient’s physiologic condition is dynamic and changes from time to time,
we need to remember that the action plan is not static and can change in a
moment. As such, we must not be too fixated with our earlier impression and fail
or refuse to change it in light of discriminating evidence. This is further
compounded by the challenge that the emergency department (ED) can be a high-
acuity clinical environment that does not afford us the luxury of providing care in a
structured manner as a low-acuity outpatient setting does.
62
A doctor working in the ED needs to have adequate knowledge of Temperature
emergency conditions commonly presented to the ED. An
Patients in the extreme age group may not mount a sufficient
emergency condition is any medical condition of sufficient
febrile response to an infection to cause an elevation in body
severity (including intense pain) and when the absence of
temperature. Always remember to ask whether the patient has
immediate medical attention could reasonably be expected to
taken any anti-inflammatory or antipyretic medications (e.g.,
result in mortality and morbidity. Hence, unlike in conventional
paracetamol, aspirin, non-steroidal anti-inflammatory drugs)
patient approaches, working in the ED requires a doctor first to
before coming to the ED. The thermoregulatory center is located
ask this important question, “Is there a life or limb threatening
in the anterior hypothalamus; thus, any central nervous system
condition that I must rule out in this patient”? A life-threatening
infection or injury that affects the hypothalamus such as
condition is a threat to the airway, breathing, and circulation.
cerebrovascular accident and subarachnoid hemorrhage may
Once a life or limb threatening condition is identified,
affect thermoregulation. Certain drugs (e.g., anxiolytics,
interventions must be instituted immediately to address it before
antidepressants, oral antihyperglycemics, beta-blockers), adrenal
moving on to another form of examination and investigation.
insufficiency, end-stage renal disease and thyroid disorders can
Importance of Vital Signs also affect basal body temperature or temperature regulation.
In addition to knowing emergency conditions, it is essential not to
Pulse
forget to look at the vital signs chart when formulating your action
plan. Bear in mind that “normal” vital signs can be abnormal When taking the pulse, the rate, regularity, and volume should be
(Markovchick 2011). For example, an elderly patient with BP that noted. The pulse rate should also be interpreted taking into
usually ranges from 140 – 160/90 – 100 mmHg can mean that he consideration the patient’s age. For adolescents and adults, the
is unstable with a BP of 110/70 mmHg and persistent vomiting maximum sustained HR estimation can be calculated with the this
and diarrhea. A patient with severe asthmatic exacerbations who formula: maximum sustained HR = (220 – age in years) × 0.85.
was tachypneic and restless initially does not mean that he is now
stable if he is “calmer” with a respiratory rate reduced to 10 Bradycardia is defined as a heart rate lower than 60 beats/min in
breaths per minute. In other words, noting the trend of the vital adults. However, a well-conditioned athlete may have a normal
signs is much more important than reading an isolated vital sign resting heart rate as low as 30 to 40 beats/min. Ask also if the
measurement. patient is taking any medication that could affect the pulse rate.
63
For example, digitalis compounds, β-blockers, and depth of breathing and the pulse oximetry for the oxygen
antidysrhythmics may alter the normal heart rate and the ability of saturation.
this vital sign to respond to a new physiologic stress.
Respiratory rate of >60 breaths per min in an acutely ill child
Physiologically, for every one-degree increase in Fahrenheit, the under the age of 2 months is a predictor of hypoxia. Respiratory
heart rate increases by ten beats/min. As 1 Celsius equals to 9/5 rate generally increases in the presence of fever; therefore, it can
or 1.8 Fahrenheit, the increase of every one-degree Celsius be difficult to determine whether the tachypnea is a primary
results in an increase of pulse rate by 18 beats/min. This is known finding of respiratory problems or is simply associated with the
as the Leibermeister’s rule. However, there are conditions fever itself. Observe the breathing patterns of the patient as well.
whereby the increase in temperature is not followed by an Look for any abnormal breathing patterns such as Cheyne-Stokes
increased pulse rate. This is known as relative bradycardia (or the breathing (episodes of progressive shallow-deep-shallow cycles
Faget sign). Causes of relative bradycardia can be divided into suggestive of stroke, trauma, carbon monoxide poisoning, and
infective and non-infective causes. Infective causes include the metabolic encephalopathy, etc.) and Kussmaul breathing
following: Legionella, Psittacosis, Typhoid Fever, Typhus, (increased rate and depth of breathing). Click here for a video of
Babesiosis, Malaria, Leptospirosis, Yellow fever, Dengue fever, Cheyne-Stokes breathing and a video of Kussmaul breathing.
Viral hemorrhagic fevers, Rocky Mountain spotted fever, etc. The
Pulse oximetry
non-infective causes beta-blockers (but not an angiotensin-
converting-enzyme inhibitor, ACE inhibitor; calcium-channel Pulse oximetry is a non-invasive measurement of the oxygen
blocker nor digoxin), central nervous system lesions (tumors and saturation. The relationship between SaO2 and the partial
bleeds), lymphomas and drug fever (Cunha 2000). pressure of arterial oxygen (PaO2) is described by the
oxyhemoglobin dissociation curve (ODC). Because of the sigmoid
Respiratory Rate
shape of the ODC, a unit reduction of PaO2 change in this
The respiratory rate only informs us how fast or slow the relatively flat portion of the ODC produces only a small change in
breathing rate is; it does not inform us about the depth of the SaO2 as compared to a unit of reduction of PaO2 in the relatively
breathing or the oxygenation status of the patient. Therefore, steep part of the curve that produces a much greater degree of
besides looking at the rate, we should also pay attention to the reduction of PaO2. The point of intersection between the
relatively flat portion of the curve and the relatively steep portion
64
of the curve is known as the ICU point, and it corresponds to a cool, clammy skin, and delayed capillary refill. However, the
SaO2 of around 92% and the PaO2 of 60 mmHg. Therefore, systolic blood pressure (BP) is still within the normal range even
always attempt to maintain the SaO2 above 92%. PaO2 below 60 though the pulse pressure is decreased. The decrease in pulse
mmHg means that the patient can markedly desaturate. pressure is due to the increased levels of circulating
Conversely, at a PaO2 above 60 mmHg, increasing the PaO2 will catecholamines, causing an increase in peripheral vascular
not result in a marked increase in the SaO2. In fact, giving too resistance, and raising the diastolic BP.
much supplemental oxygen may result in an ever increasing PaO2
For children, the blood pressure measurement varies according to
with a SaO2 maintained at 100%. Hyperoxia (too high PaO2) can
age. A formula for estimating the 95th percentile BP (normal) in
be harmful as it can lead to adverse effects such as generation of
young children is as follows: BP = 80 + (2 x age in years).
reactive oxygen species and release of angiotensin II resulting in
Hypotension is defined as less than the 5th percentile BP that can
vasoconstriction. (Click here to access two articles for more
explanation and diagrams: Hooley J. Decoding the be estimated by the following formula: hypotension = less than
Blood pressure, defined as the force exerted by blood on the References and Further Reading, click here.
vessel wall, only indirectly measures perfusion, as blood flow
equals to the change in pressure divided by resistance. But
because peripheral vascular resistance varies, normal blood
pressure does not necessarily mean good tissue perfusion. The
normal blood pressure may be “maintained” by an increase in
peripheral vascular resistance. Furthermore, hypotension is a late
sign of shock; this is especially true in children. For example, in
class II hemorrhagic shock (with a loss of 15%–30% blood
volume), the findings usually include tachycardia, tachypnea,
65
Diagram 2.1 Data gathering and creation of action plan
66
Section 7
Documentation
67
snapshot of the patient’s general condition at any given sensitive interventions were done or when medications were
encounter. There is always room to learn about and improve administered (Carrol, 2016a and 2016b).
medical documentation. Therefore, this section will review the key
elements used when documenting in the ED (Murphy, 2001; Components of the history include
CDEM, 2010)
1. Chief Complaint
Emergency Medicine Note
Before writing your note, the nursing triage notes and vital signs, This usually includes the presenting complaint, ideally in the
if available, need to be reviewed. If obvious discrepancies are patient’s words, with the duration (Example: Abdominal Pain – for
seen, these need to be verified with the nurse and patient, as two days).
there may be errors. In addition, any abnormal vitals in triage
must be acknowledged and written in the note. 2. History of Present Illness
Like any other medical record, the ED document will comprise of In general, there are two formats when writing a history of present
the patient’s history, physical exam findings, differential illness (HPI), the narrative format and bullet points format. Both
diagnoses, investigations ordered, lab and imaging findings, are acceptable as long as the history is written in a
assessment and plan. Each component will be discussed comprehensive, concise and coherent manner. It is of added
separately, and suitable examples will be provided accordingly value if pertinent negatives and positives are added when writing
(CDEM, 2010; Carrol, 2016a and 2016b). the HPI, to show the physician’s thought process. This will lead
the person reading the chart towards what differential diagnoses
History to consider and what to rule out, depending on what the patient is
When writing the patient’s history, one needs to be clear, presenting with. Certain mnemonics may be used to aid in writing
thorough, and concise avoiding any long and complex phrases. a systematic HPI (Example: OLDCARS or OPQRST).
Ideally, it needs to flow in a logical and chronological sequence.
Unnecessary details are better avoided as they serve as Example 1: A 45-year-old man, with a history of Coronary Artery
distractors and may confuse other readers. Recording the date Disease and Hypertension, presenting to the ED with chest pain
and time when the patient was seen is crucial, especially in that started 3 hours ago. The pain was of gradual onset while
critical patients, as it helps create a timeline for when time- sitting on his chair, localized in the center of the chest and lasted
68
for 20 minutes. It was described as “a heavy boulder on my 4. Past Medical/Surgical History, Medications, and Allergies
chest.” The pain started when he had a quarrel with his daughter
List any known active illnesses the patient might have or had in
and was relieved with sublingual nitroglycerin. It was associated
the past. Include any surgical procedures he had. State what
with nausea and sweating, but no vomiting. Was localized and
medications he is actively on and whether he has any drug or
not radiating to the shoulders or arms. He claims it was
food allergies.
moderately intense at 4/10 on the pain scale. He denies any
shortness of breath, palpitations, dizziness, or abdominal pain. 5. Family and Social History
Example 2: A 26-year-old male, previously healthy, presents with Document a brief family history that may be relevant to the chief
a sore throat for one week. It is associated with subjective fever complaint (Example: Family history of Diabetes and Cardiac
and fatigue. It is aggravated whenever he drinks or eats but Disease in a patient presenting with chest pain). Social history
denies any difficulty swallowing or drooling. The patient also mainly includes asking about smoking habits, alcohol
denies any chills, runny nose, cough, night sweats, or shortness consumption, sexual history and illicit drug use. It also might be
of breath. No recent travel history reported. Has several sick important and relevant to ask about the patient’s financial and
contacts at home with similar symptoms. health insurance status, particularly in certain healthcare settings,
to avoid ordering unnecessary tests and paying extra costs.
3. Review of Systems
Other organ systems and symptoms that were not mentioned in Physical Examination
the HPI are to be reviewed to make sure the patient does not When recording physical examination (PE) findings start with the
have other complaints or organ system involvement. If the review patient’s general appearance and vital signs, highlighting
or system (ROS) cannot be obtained because of the patient’s abnormal ones. It is important not to document or fabricate any
underlying condition (i.e., unconscious, critically ill, or having findings that were not examined; committing to such findings may
dementia), this should be noted in the chart. Generally, ask have medical and medico-legal implications that are best
patients questions from head to toe (Example: “Do you have a avoided. Document all findings from examined systems including
fever, chills, headache, sore throat, chest pain, abdominal pain, findings from inspection, palpation, auscultation, etc. There is no
urinary symptoms, etc.”). Document all positive ROS symptoms need to document findings that are not pertinent to the chief
and state the remaining ones as otherwise normal. complaint (Example: Neurological examination findings in a
69
patient with a sore throat). Include important positive and instructions should be documented clearly (CDEM, 2010;
negative findings for any given case (Carrol, 2016a). Carrol, 2016a and 2016b).
• Important negative findings: No rebound tenderness, guarding, 3. The brief review of systems
rigidity, or peritoneal signs
4. Focused past medical and surgical history
Assessment 5. Focused pertinent medications and allergies
Should capture the essence of the case and defend the rationale
for potential further investigations. It usually includes an objective 6. Very focused family and social history if required
summary of the case with differential diagnoses based on history
7. Vital signs, highlighting any abnormal readings
and physical examination findings.
70
• If you make a mistake, draw one line through it and sign your • If a patient leaves against medical advice (AMA), document that
initials you have explained the specific risks of leaving AMA to the
patient and relatives
• Document a focused but thorough History and Physical
Examination • Document plan for outpatient care and follow-up
• Avoid using unclear abbreviations that are not used commonly • If using an electronic medical record (EMR) instead of a
handwritten one, all of the above sections, components and
• Document vital signs and address abnormalities
hints apply (Murphy, 2001; Dunbar, 2014; Virtual Mentor, 2011)
• Document the results of all diagnostic tests that were ordered
Sample ED Note, please click here.
when appropriate
References and Further Reading, click here.
• When speaking to a consulting service, document the name of
the physician and the time the call was made
71
Section 8
Discharge Communications
Introduction
by Justin Brooten and Bret Nicks The process of patient discharge from the emergency department (ED) provides
critical information for patients to manage the next steps of their care. Hospital
accreditation and governmental organizations often require these instructions for
quality or monitoring metrics. However, studies show that many patients do not
fully understand or recall the instructions they receive (Clarke, 2005; Clark, 2005).
Add to this the myriad challenges inherent in every emergency department that
only perhaps compound this lack of comprehension and subsequently impact care
compliance, outcomes, and patient experience.
72
first step of a patient’s care transition and greatly impacts quality quite poor (Clarke, 2005; Clark, 2005; Crane, 1997; Engel,
outcomes, litigation, experience and team morale (Henry, 2013; 2012; Sameuls-Kalow, 2015; Taylor, 2000; Zeng-Treitler & Hunder,
Siff, 2011). 2008). This raises significant concerns for care plan adherence
and medical outcomes. Given current trends toward value-based
Understanding the Challenges care and the fact that nearly half of the lawsuits in emergency
Emergency physicians face unique challenges while ensuring medicine revolve around discharge instructions and the discharge
high-quality care due to distractions and time limitations that are program given to patients, ongoing improvements in the
common throughout ED settings. In most cases, emergency discharge communication process is essential (Henry, 2013; Siff,
physicians have little or no previous knowledge of their patients, 2011). While some of this relates heavily to the ability of the
making effective communication paramount when patients are provider to establish a trusting and positive patient-provider
discharged from the ED (Jon, 2013). Recognizing the value of relationship within the ED constraints, several strategies can be
early quality communication continued throughout the patient used to enhance the recall of instructions, improve compliance,
care encounter may carry over to the discharge care processes and minimize litigation.
and, in turn, improve an important aspect of quality and patient-
centered emergency medical care. Discharge Essentials
Effective discharge communication provides an opportunity for
It has been demonstrated that many patients are discharged from
the ED team to summarize a patient’s visit, teach them how to
the ED with an incomplete understanding of the information
care safely for themselves at home and provide specifics
needed to care safely for themselves at home (Clarke, 2005;
regarding the next steps in their care process. It also gives ED
Crane, 1997; Engel, 2012; Sameuls-Kalow, 2015; Taylor &
physicians a chance to address any remaining questions or
Cameron, 2000). Patients have demonstrated particular difficulty
concerns (Jon, 2013), often augmenting patient and family
in comprehending post-ED care instructions regarding
understanding while improving care plan retention. Although
medications, home care, and follow-up expectations. And while
patient education at discharge typically begins with initial
all patients discharged from the ED should be provided
assessments and conversations with the patient and his family,
instructions for ongoing management of their medical condition,
other factors can also influence the success or failure of how
studies have demonstrated that the patient recall and
information is transmitted at discharge (Jon, 2013).
understanding of diagnosis, treatment, and follow-up plan are
73
Common interventions included in an effective ED discharge is needed and why, as well as how to care for oneself until that
process consist of a standardized approach (content), information time, improves outcomes and compliance. Some have phrased
delivery, confirmation of comprehension, post-discharge care these basic tenants of discharge as the ‘rules of the road’;
follow-up planning, review of vital signs and a patient-centered however, this may serve as the basis from which to develop your
closure (Table 2.1) (Taylor, 2000; Zeng-Treitler & Hunder, 2008). process.
Table 2.1 Table 1. Interventions in the ED Discharge Process Rules for the Road
1. Have the right diagnosis
DOMAIN INTERVENTION
Content Standardize approach 2. Time & Action Specific Instructions
completion of their medical evaluation and treatment. In this can assist in determining capacity, especially in the case of
situation, it is essential for the last health care professional caring patients with mental health conditions.
77
Elopement is a similar process where patients disappear during verbal instructions remain m o r e e ffe c t i v e t h a n w r i t t e n
the care process. While it is difficult to provide discharge instructions, but both are needed. Be explicit, keep it simple and
paperwork for these patients, documenting the actions taken to have the patients repeat back instructions to ensure
find the patient is essential (e.g., searching the ED, having understanding. These simple steps will improve patient
security check the surrounding areas). In addition, attempt to outcomes, compliance and avoid legal pitfalls.
reach the patient by phone to discuss his elopement and any
References and Further Reading, click here.
additional care issues or concerns. Documentation of these
attempts or any additional conversation is very important (Henry,
2013; Siff, 2011).
Conclusion
Discharge instructions are a very important part of the ED care
process and record. It is essential to ensure each patient has a
complete understanding of her instructions and to recognize that
78
Chapter 3
General Approach
to Emergency
Patients
Section 1
80
As a standard structure, currently, all • acute torso discomfort (may be than minutes, can result in death or
modern emergency departments have a associated with radiation to jaw, brain damage.
triage unit to prioritize the patients. It anterior neck or shoulder/medial upper
• The order is performed sequentially to
aims to select more critical patients as arms) suggestive of an MI/
avoid skipping crucial steps and
e a r l y a s p o s s i b l e a n d c re a t e a n cardiovascular problem.
generally to manage the most serious
appropriate patient flow in the emergency
• severe acute headache first, however, the sequence can and
department. However, triage can be done
should be performed simultaneously
in the field by EMS staff, and patients • intractable seizure (may not show
(horizontal approach) in those with
may directly bring to the resuscitation muscular signs after a period of time)
multiple life-threatening conditions if
room.
• history of significant trauma, drug there are enough team members.
Potential critically ill patients ingestion, exposure, suicidal/homicidal Modify as appropriate to the individual.
may present with: ideation
• Because management may need to be
• altered mental status (unresponsive or
• significant vital signs abnormalities simultaneous, the team approach is
confused/agitated)
(age-dependent) crucial in successfully resuscitating any
• noisy respiration (gurgling, stidor, critically ill patient.
wheezing) Point of Care Testing
• adjunct tests/equipment that help guide • It is also important to emphasize that
• inability to speak normally (acute early decision-making the availability of various treatment
hoarseness or inability to articulate modalities at each medical facility.
words) • results should be back within seconds
to minutes, not hours! Meaning of the letters in the ABCDEF
• respiratory distress (rapid/deep or slow/ sequence:
shallow/agonal respirations) The ABCDEF Sequence
A = Airway Disorders with C-spine control
• Each letter represents a crucial body
• acute weakness or inability to ambulate
system that, if significantly disrupted B = Breathing Disorders
(diffuse/focal muscle weakness or light-
and left untreated over hours rather
headedness/syncope)
81
C = Circulation/Cardiovascular Disorders A – Airway with C-spine Point of Care Testing
83
bottom of the stairs, or on the side of the sequence may improve the mental edema, laryngeal cartilage fractures
the road, unconscious, then assume status, making intubation unnecessary secondary to trauma
an injury and protect the c-spine by such as low blood sugar. Be prepared
• laryngeal cartilage fractures secondary
simply immobilizing as best possible. to log roll quickly if the patient vomits.
to trauma
Typically a C-collar is slid under the
Conditions causing airway
back of the neck while someone • expanding paratracheal hematoma
immobilizes the head. If airway compromise
84
• unilateral decreased breath sounds with very poor ejection fraction, etc. to •fix all upper airway critical issues
(either dull or hyper-resonant) help make a decision about treatment. first
• wheezing or poor air movement If still not clear as to a management • slow, agonal respirations or significant
strategy, add point-of-care testing, i.e., respiratory acidosis on ABG – provide
• rales (fine crepitation) or rhonchi
lung sonography or upright portable CXR. BVM ventilation and administer Narcan.
4. Chest wall abnormalities affecting
Point-of-Care testing • rapid breathing with hypoxia – provide
breathing dynamics – flail chest/open
supplemental O2 by the non-rebreather
punctures • pulse Oximeter mask to keep O2 saturation greater
Obtain as much focused history/exam as • C02 waveform monitor than 94%.
able to help define the need for a
• arterial (ABG) or venous (VBG) blood • sucking chest wound – seal with an
particular emergent treatment strategy for
gas occlusive dressing (3 sides only)
the common causes of critical respiratory
conditions. For example, two common • portable CXR (upright, if possible) • tension pneumothorax – place a 14
causes of severe respiratory distress are gauge needle, immediately followed by
pulmonary edema and COPD. Both may • pulmonary ultrasonography: a chest tube
present with wheezing (“cardiac asthma”
evaluate lung sliding for • massive hemothorax/pleural effusion –
in CHF), pedal edema and/or JVD,
pneumothorax drain fluid, contact trauma surgeon
making the decision for which type of
since may need transfusion/transfer to
emergent management strategy difficult. assess costophrenic angles for
OR for massive hemothorax
Obtain as much focused history/exam in effusion/hemothorax
a brief period of time, i.e. family states • no improvement in oxygenation despite
assess lung field segments for A/B
heavy smoker with similar episodes in the placement of non-rebreather mask or
lines, signs of consolidation
past, all resolved with inhaler therapy or above procedures, either –
the patient has a history of recent ECHO Management Algorithm for Acute
Respiratory Disorders
85
a l l o w t h e p a t i e n t t o b re a t h e Emergency Equipment for Managing b.C o n s i d e r s p e c i fic p o i s o n i n g
spontaneously under tightly held BVM Breathing Emergencies antidotes, i.e., cyanide antidote or
mask with PEEP valve on exhalation hyperbaric/100% O2 for CO
port and 15 L/min nasal cannula O2 1. Noninvasive ventilator NIV poisonings. See the toxicology section.
placed under the mask or 2. BVM (bag-valve-mask) with O2 supply c. Sepsis, Pulmonary embolus, and
provide NIV (non-invasive and added PEEP valve pericardial tamponade management
ventilation) with CPAP/BiPAP 3. additional wall or tank for an additional are discussed in more depth in the
86
acute ventilatory failure. (Only 250 cc • pulmonary embolus, air/amniotic fluid/ Skin – i.e., cool, diaphoresis, pale,
of oxygen is used by the resting adult fat embolus poor capillary refill, hives, erythema
per minute. However, 6-10 L of air
• massive hemothorax or massive pleural Mental status changes – i.e.,
must be moved per minute to
effusion confusion, slow responses, agitation
adequately ventilate a normal adult
and prevent the rise in pCO2.) • exhaustion from prolonged Rhythm/quality of pulses in all four
hyperventilation extremities
Conditions Associated with
Respiratory Failure • chronic lung conditions: cancer, Assessment for hidden blood loss,
sarcoidosis, fibrosis, etc. i.e., rectal for melena, pelvic instability,
• Pulmonary edema
pulsatile abdominal mass
• COPD/asthma
C – Circulation Disorders
Poor perfusion, Hypertensive crisis, Acute history: internal/external bleeding/
• severe pneumonia MI trauma, vomiting/diarrhea, oral intake/
urine output, fever, diabetes/renal
• ALI/ARDS from any cause (drugs, Clinically assess for poor perfusion i n s u ffic i e n c y / c a r d i a c f a i l u r e ,
aspiration, etc.) associated with medications, drug abuse/OD, last
menses
• tension pneumothorax • tachycardia: > 100 abnormal in adults,
> 150 frequently clinically symptomatic. Clinically assess for hypertension
• chest wall dysfunction, (flail chest,
muscular weakness, open sucking associated with
• bradycardia: < 60 abnormal, < 30
wound) frequently clinically symptomatic.
• signs of end-organ damage/
• respiratory depressants (narcotic OD, involvement, i.e., encephalopathy and/
• hypotension: systolic < 90
sedative OD) or papilledema, pulmonary edema,
• Perfusion and cardiovascular cardiac ischemia, renal impairment,
• bronchiolitis assessment may include and/or neurological abnormalities
87
• pregnancy (generally 3rd trimester/first Point-of-care testing •Hemocult paper (only needed if any
weeks postpartum); any new elevation question of blood/melena in stools)
of BP >140/90, particularly associated • EKG (perform within 10 minutes of ED
presentation; may include right-sided • Urine beta-HCG for critical childbearing
with a headache, abdominal pain,
leads RV3,4 and posterior leads V8, V9) age females
jaundice, shortness of breath and/or
visual disturbances • Cardiovascular ultrasound to include Emergency Equipment for Managing
assessment of: Cardiovascular Emergencies
Clinically assess torso discomfort for
likely MI LV cardiac contractility – normal, 1. pelvic binders/gauze for compression/
hyperactive, weak tourniquets
• description varies; besides chest
discomfort, symptoms may include the ratio of right to left ventricle size 2. defibrillator/external pacemaker
either/or epigastric discomfort, mid-
back discomfort, radiation to shoulders, p e r i c a r d i a l flu i d / t a m p o n a d e 3. large bore IV’s and 0.9% saline or
anterior neck, jaw or upper, inner arms. physiology Ringer lactate fluids
place two large bore IV’s and attach administration determined by clinical/ place external pacemaker per ACLS
unstable pelvis – apply pressure/ appropriate specialty, i.e., surgery, OB, magnesemia therapy
89
evidence of obstructive shock by 2. drug OD (i.e., b-blocker or calcium Hydralazine, Labetalol, or Nifedipine),
clinical/sono – treat appropriately as channel blocker – treat with high dose immediate OB consult.
guided by diagnosis, i.e., Insulin/glucose)
Management Algorithm for Torso
thrombolytics/interventional radiology
Management Algorithm for Severe Discomfort
for pulmonary embolus,
pericardiocentesis for tamponade, Hypertension associated with
• acute torso discomfort with MI
chest tube for tension pneumothorax,
• e v i d e n c e o f e n d - o rg a n d a m a g e documented by EKG – contact
etc. (ischemia, heart failure, encephalopathy, cardiology for immediate PCI/transfer
and/or no response to fluids or (Labetalol, Nitroprusside, etc.) Avoid depending on location and timing of
previous therapies – start pressors, pure beta blockers if suspect cocaine event per ACLS
• drug toxicity/OD
Psychological Disorders) • fingerstick glucose measurement
Clinically assess for
• cardiogenic shock • non-contrast head CT to be performed
• depressed consciousness (lethargic,
in less than 30 minutes
• anaphylaxis confused, comatose) (may use GCS to
assess the degree of unresponsiveness) • acute malaria screen in appropriate
• neurogenic shock
environments
• pupil size, symmetry, and reactivity
• adrenal crisis
• rapid HIV test
• agitation, delirium (waxing and waning
• thyroid storm
level of consciousness associated with • electrolytes (Na+, and Ca++, in
• obstructive shock confusion/disorientation and/or particular), if available, on ABG/VBG
hallucinations – typically, visual/tactile) assessment, sono for evaluation of
pulmonary embolus papilledema
• acute focal weakness/paralysis, or
pericardial tamponade inability to speak • sono for evaluation of papilledema
tension pneumothorax
• severe, acute headache, nuchal rigidity Emergency Equipment Needed for
gravid uterus compressing IVC Neurological Management
• signs of status epilepticus, including
subtle seizure-like activity (i.e., twitching 1. CT scanner
• tachydysrhytmias/bradydysrhythmias
with or without electrolye disorders e y e l i d s , s t i ffn e s s , p e r s i s t e n t
u n re s p o n s i v e n e s s a f t e r o b v i o u s 2. access or ability to transfer to
• symptomatic hypertensive with or seizure-like activity) neurosurgical equipped OR
without pregnancy
3. LP tray
• acute psychiatric disorder with either
• acute MI suicidal or homicidal ideation 4. leather restraints
• acute aortic dissection/rupture
91
5. stretchers that allow for head elevation • agitation, unable to calm with above •History acute fever, headache,
and/or patient an imminent danger to without focal neurological signs, recent
Management Algorithm for Critical
self/others – call for ‘man-power’ seizure history or impaired immunity
Neurological Disorders support and apply four-point restraints. and exam/sono shows no papilledema
Acute Agitation/Delirium Algorithm (Provide close monitoring of the patient – check malaria smear, rapid HIV test,
and remove restraints as soon as perform LP, initiate empiric antibiotic
• in all patients attempt to talk first to deemed safe) treatment (possible steroids first), based
calm and remove anything that might on age/likely etiology. Before any meds
cause injury Acute Mental Status Depression
given attempt to quickly determine if
Algorithm
allergic, from family, old records, etc.
• agitation, particularly in young patients
or possible drug toxicity/withdrawal – • fix the airway, breathing and circulation
• History acute fever, headache, with
administer Benzodiazepines. Avoid in conditions first
focal neurological signs or seizures,
elderly with dementia; likely to increase impaired immunity and/or exam/sono
• Check fingerstick glucose – if low
confusion. Monitor respirations in all. administer bolus or drip of D50/D25 or shows papilledema – do not perform
D10 depending on patient age. May immediate LP – check malaria smear,
• agitation, with signs of hypoxia,
give IM Glucagon if unable to start IV rapid HIV test, initiate empiric antibiotic
hypoperfusion – consider Ketamine
and patient cannot swallow. Administer treatment (possible steroids first), based
starting dose 1mg/kg with continued
Thiamine with the glucose. (Narcan on age/likely etiology. Before any meds
ABC resuscitation
should have already been given under given, attempt to determine if allergic,
• agitation, with a known history of section B). from family, old records, etc. Follow
psychiatric disorder or likely new-onset with CT and possible LP, ASAP.
psychiatric disease – administer • if GCS < 9 after ABC resuscitation – the
patient likely requires intubation to • consider status epilepticus in all non-
psychotropic agent, i.e., Haldol IV, IM.
protect from aspiration – prepare responsive patients, (motor signs may
with or without Benzodiazepine.
equipment be minimal) or if not awakening
between seizures:
92
check electrolytes – if blood/ xanthochromia, immediate Causes of critical neurological
hyponatremic administer 2cc/kg neurosurgery consultation, control BP < disorders
over 10 min of 3% NaCl (max 160/90. See SAH guidelines.
100cc) • conditions affecting airway, breathing
• Normal CT, likely thrombotic stroke – and/or circulation
Third trimester/post delivery – initiate TPA/endovascular therapy per
administer MgSO4/consult OB protocols, control BP to <185/110. If • metabolic disorders:
unable to use TPA, do not drop BP Hypoglycemia/hyperosmolar
likely INH OD or neonatal
unless >220/120. See thrombotic stroke coma/DKA
dependency – administer
guidelines.
Pyridoxine. thyroid disorders
• New intra-cerebral bleed on CT –
all others – start with electrolyte disorders (primarily Na+
control BP to <140/90; reverse
Benzodiazepines, consult and Ca++)
anticoagulants. See hemorrhagic stroke
neurology
guidelines.
liver/kidney failure, etc.
• if no improvement with above – obtain
• epidural/subdural/nontraumatic SAH on
head CT; follow management in the • drug toxicity/OD or drug withdrawal
CT – immediate neurosurgery
section below. syndromes
consultation for possible OR/IR
Focal Neurological Signs/AMS (with or intervention. • acute psychiatric disorders
without head trauma) and/or a Sudden,
• Evidence of acute herniation – raise the • mass lesions (hemorrhage, tumors,
Severe Headache Algorithm
head of bed 30-45 degrees (assuming abscesses)
• obtain a head CT in all patients, if no spine trauma), consider Mannitol,
3% NS, and/or mild, brief • infections – meningitis/encephalitis
available
(bacterial, fungal, viral, parasitic
hyperventilation. Consider IV
• normal CT, likely SAH by history (onset infections including cerebral malaria)
dexamethasone for a tumor with
> 6 hours), perform LP – nontraumatic herniation. • status epilepticus and post-ictal states
93
• stroke syndromes – thrombotic, • evidence of hidden bleeding – manage F – Fever (Extreme
intracerebral hemorrhagic, SAH as per Section C Temperature Disorders)
Clinically Assess
E – Exposure • evidence of clothes/skin contamination
Clinically evaluate – decontaminate, according to toxicity • skin warmth/coolness
and protect self and others in the
• areas hidden by clothing/body position process (self-protection should be • skin color (pale/red), dryness,
for missed lesions (rashes/stab/gunshot implemented at the onset of patient diaphoresis
wounds) by undressing and log rolling. evaluation)
• muscle rigidity, shivering
• the body for evidence of self/child/ • re-dress patient in a gown to prevent
• thyroid for nodules/enlargement
elder/domestic abuse and evidence of cooling and provide privacy
IV drug abuse. • obtain the history of medications
Equipment Needed for Exposure/
(recent psychotropic/succinylcholine,
• for possible contaminated clothing/skin: Decontamination
anesthetics, etc.), drug abuse,
substances absorbed through the skin
1. shower with containment for water endocrine disease, outdoor exposure,
(i.e., hydrocarbon pesticides), caustics,
runoff excessive exercise
radiation or objects causing continued
burns, etc. • Note: normal temperature is 98.6 F or
2. protective gowns, masks, gloves for
staff 37 C. Any temperature above 100.4 F or
Point-of-care testing
38 C rectally is considered a fever.
• none 3. i s o l a t i o n r o o m w i t h a i r v e n t H o w e v e r, i t i s t h e e x t re m e s o f
containment temperature that require emergent
Management Algorithm for Exposure
management, usually > 105 F (40.5 C)
Disorders 4. shears/metal cutter
or < 95 F (35 C)
• rectal – most accurately reflects core possible, but not able to easily monitor.)
• severe, <30 degrees – consider
temperature.
• cool IV fluids a d d i t i o n a l c o re re w a r m i n g , i . e . ,
• initiate heat loss for all by • evidence for thyroid storm – initiate b- • t o x i n s / O D ’s ( a n t i c h o l i n e r g i c s ,
blockade, cortisone, PTU, then iodine sympathomimetic, MAOI drugs, ASA,
last etc.)
95
• sepsis (for both extremes)
96
Section 2
Abdominal Pain
Case Presentation
by Shaza Karrar A 39-year-old female presented to the emergency department
(ED) complaining of right-lower-quadrant (RLQ) pain; pain
duration was for 1-day, associated with nausea, vomiting, and
loose motions. Abdominal pain started centrally and was
described as diffuse and colic, 3 hours later it gradually shifted
to the RL and became continuous in nature. Her Last-
menstrual- period (LMP) finished a week ago. She denied any
regular medications, known allergies or using any
contraceptive pills. Also, she denied any past surgical history,
travel history, or eating outside. Upon examination, she was
found to be afebrile and vitally stable. The abdomen was soft,
non-distended, with RLQ Tenderness, positive rebound
tenderness, and positive bowel sounds.
97
Table 3.1 Types of abdominal pain
General Approach and Critical Bedside
Actions
98
unstable patient, is part of your oath and a cornerstone of your Figure 3.2 Bedside actions
practice during training years.
Differential Diagnoses
Abdominal pain can originate from intra-abdominal and extra-
abdominal or non-GI conditions; hence, it’s advisable to be
systematic in your approach to narrow down your differential
Bedside actions are taken in patients presenting with diagnoses. (i.e., Cardiac, GI, infectious, hematologic, urologic,
abdominal pain and are tailored to each patient’s clinical gynecologic, etc.) When diagnosing abdominal pain, the
picture; those include (Figure 3.2), detailed further in the differential diagnoses can be based on anatomic localization of
chapter. pain (Figure 3.3).
99
This, in turn, helps direct your approach. An EP should prioritize
Figure 3.3 Differential diagnoses according to location
possible life-threatening conditions in his differential diagnoses,
and be mindful of other possible extra-abdominal causes
attributable to abdominal pain (Table 3.2).
100
History Taking and Physical Examination Associated symptoms: Be systematic – Fever, nausea,
Patient Demographics: Gender, age. Others: Clues of an atypical presentation – considering Extra-
Abdominal and non-GI pathologies including weight loss,
Onset and progression of pain: Sudden, gradual, episodic/ unspecific systemic symptoms, etc.
intermittent, continuous.
Always try to screen for high-risk patients; certain history findings
Localization of pain and radiations (Figure 3.3). can help narrow your differential diagnoses. Table 3 demonstrates
history findings, coinciding with their potential differentials.
The character of pain: Dull, sharp, colicky, stabbing, burning
Severity: Pain Scale – mild, moderate, severe, or a scale from Physical Examination Hints
A focused and systematic Physical Examination (P.E.) aims at
1 to 10
verifying your clinical impression constructed from your history
Alleviating and aggravating factors: Relieved by eating, sitting findings; it also aids in exposing unforeseen findings that may
up, or worsens after eating, lying supine, movement, and make you reassess your differential diagnoses and approach.
coughing, etc. Hence, an EP must have in mind specific working differentials
obtained from the history before examining the patient (Figure 3.3
101
and Table 3.3). Make sure that your patient is comfortable with • Note any instability in vitals, consciousness level, the
adequate pain relief as necessary, suitably positioned and posture of the patient, hydration status and signs of pallor,
appropriately exposed from nipples to lower abdomen/pubic- jaundice.
symphysis in a properly private environment. In the case of
Examination of extra-abdominal systems:
children, the presence of family members can aid your
examination. Assessment of vital signs, hemodynamic stability, • Entails an assessment of the cardiorespiratory functions.
and signs of shock should be noted, keeping in mind that normal
vital signs would not rule out a life-threatening condition. • Other extra abdominal systems of suspicion attributing to the
patient history and clinical picture.
• Palpation:
• The light then deep palpation begins with the opposite non-
tender quadrant, progressing through all quadrants.
• Specific signs and maneuvers: (Table 3.4) • Genital and pelvic examination:
• For an overview of the focused Abdominal Examination, • Pelvic exam in all females with lower abdominal pain and
please watch the following video. query pelvic pathologies.
• Serial abdominal examinations are important to reassess • Genital exam in males with possible testicular pathologies
your patient’s progress and response to treatment. and hernias.
• Rectal examination: In suspected GI bleeds, perianal and Emergency Diagnostic Tests and
prostatic disease, foreign bodies, and impacted stools. Interpretation
Table 3.4 Abdominal signs Bedside tests
• 12-lead ECG
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Image 3.1 ECG • B l o o d - U r e a - N i t r o g e n (BUN): Assess dehydration.
• Urine Pregnancy test: All females of childbearing age, • Amylase: Increased in most intra-abdominal pathologies.
regardless of history findings
• Lipase: Levels twice the normal is highly indicative of
• Urine analysis: Signs of hematuria or Urinary Tract Infections pancreatitis, joined with elevated LFT, could raise the suspicion
(UTI). of Gallstones pancreatitis.
• Capillary Glucose test: Hyper/Hypoglycaemia and DKA • Inflammatory markers: CRP or Procalcitonin
Laboratory tests • TestType and screen: For all patients possibly proceeding for
• Complete-Blood-Count: Leukocytosis, Hemoglobin level, surgical interventions
Platelets count
• Rh Status: All female patients with possible ectopic pregnancy
• Electrolytes: Correct any derangements caused by fluid losses.
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Imaging modalities Ultrasound (US)
X-rays
• Extended sonographic studies can further your assessment;
• An initial imaging modality, quick yet not very sensitive considered the study of choice in pregnant women.
• Chest X-rays: Delineate Air under the diaphragm in perforated • Abdominal US: Evaluation of biliary tract pathologies,
viscus or pneumonia. intraabdominal organs, and free intraperitoneal fluid,
Intussusception, appendicitis, etc.
• Abdominal X-rays: Usually in erect and decubitus positioning;
looking for Bowel distention, air-fluid levels, obstruction, foreign What is your opinion about below ultrasound samples in a patient
bodies. with abdominal pain?
What is your opinion about below abdominal x-ray in a patient Image 3.3 Abdominal US, RLQ
with abdominal pain?
• K i d n e y - U r e t e r- B l a d d e r K U B U S : N e p h r o l i t h i a s i s ,
hydronephrosis, urine retention, etc.
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• Vascular US Studies: assessment of the abdominal aorta
Figure 3.4 Resuscitation of unstable patient
Computed tomography (CT) scan: (With/Without Contrast,
Angiography)
Secondary survey: Identify life-threatening conditions (Table A hemodynamically stable patient should be properly
3.2), and screen for the high-risk patients, and special age worked up and reassessed frequently, as he/she may
groups (Table 3.3). deteriorate and become unstable.
Hemodynamically unstable patients should be resuscitated Patients with possible peptic ulcer disease (PUD) and
without any delay, entailing the following keystones (Figure gastritis can benefit from a “GI cocktail,” typically
3.4).
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constituted of a combination of antacid, viscous lidocaine, A b d o m i n a l p a i n should be addressed with liberal
and antispasmodics. analgesia, including the use of opioids, as it has been
recently proven that they do not alter physical exam findings
Otherwise, stable patients who are responsive to treatment,
or increase the number of incorrect management decisions.
with conditions of low acuity, can be fit for discharge from
the ED with an appropriate disposition and follow-up plan. Opiate-dependent patients and chronic users may need
higher doses for an adequate response.
Medications
Analgesics should be tailored to each patient’s clinical Always monitor patients for respiratory depression with
picture, pain score, and response, with an aim to relieve his opioids and always consider dose adjustments in geriatrics
distress and pain to a manageable level, making him more and patients with renal and hepatic impairments.
comfortable and cooperative for the abdominal exam and
NSAIDs like Ketorolac are suitable for biliary and renal colic
reassessment (Table 3.5).
but not in PUD.
Procedures: None
Table 3.5 Table 5. Medications in abdominal pain
Pediatric, Geriatric, Pregnant Patient and
Other Considerations
Pediatric Patient
• The list of differential diagnoses tends to rearrange in acuity
according to the age at presentation in pediatric patients. For
example:
108
Disposition Decisions • Patients with an unclear etiology of pain who are stable
enough for discharge should be reassessed again within 12 to
Admission criteria 24 hours; hence, a follow-up plan should be instituted and
• Hemodynamically unstable patients require admission to the emphasized to the patient.
Intensive Care Unit (ICU), especially post possible surgical
interventions. Referral
• Follow up plans in patients that are discharged decrease high
• Elderly patients with multiple comorbidities or anticipated
morbidity and mortality, a chance of a missed diagnosis, and
clinical course deterioration require an ICU admission as well or
decrease unnecessary ED presentations of benign and low
a High Dependency Unit (HDU) if available.
acuity abdominal pain.
109
• Yet pregnant women are strongly instructed to return to the
ED in case of recurred, progressing or persistent symptoms,
especially in cases of uncorrected volume loss due to
vomiting and loose motions, vaginal bleeding/discharge, and
abdominal pain.
110
Section 3
Case Presentation
by Murat Cetin, Begum Oktem, Mustafa Emin An 80-year-old female presents to the emergency department
Canakci
with a tendency to sleep (altered mental status), failure in
recognizing people and answering questions. She is a
nursing-home inhabitant. The caregivers express she was
feverish and fatigued for several days now, but her mental
problems have recently begun. The patient has a history of
hypertension and diabetes mellitus. Her only routine
medications are angiotensin-converting enzyme inhibitors
(ACE inhibitors) and insulins. Vital Signs: Blood Pressure:
110/70 mmHg, Heart rate: 110 bpm, respiratory rate: 20 rpm,
temperature: 38.8 degrees Celsius, peripheral capillary oxygen
saturation: 98%, finger-stick blood sugar: 95 mg/dL. Physical
Exam: She is in mild distress, lethargic and confusional with
no lateralizing signs. The pupils are reactive to light and equal
Audio is available here in size. On a Glasgow Coma Scale, she is registered at 12 (E3,
111
M5, V4) and she had neck stiffness. The heart is • A combination of these two functions.
irregularly tachycardic with no abnormal cardiac The altered mental state may mean coma, confusion, aggression,
sounds. The breath sounds are clear and equal personality alteration, or difficulty in awakening. Approximately
3% of patients in the emergency department have impaired
bilaterally. The abdomen is soft, non-tender, non-
mental status. In the elderly patients, this rate is between 10%
distended. Skin: warm, dry, no rash. A lumbar and 25%. 85% of patients have metabolic and systemic
puncture is performed to diagnose or exclude diseases.
E (Exposure): The findings should be evaluated in terms of • Ask a family member, caregiver, or medical personnel
trauma, transdermal drug tapes, dialysis intervention area,
• Check for medical alert identification
sources of infection and petechiae.
• Ask for medical information sheet (i.e., on the refrigerator)
Glucose level, ECG should be performed. Bedside ultrasound
(eFAST or RUSH protocols) should be added to the • Ask surrounding environment (i.e., living quarters, alcohol
investigation of patients with shock or trauma. bottles or drug paraphernalia).
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Altered mental status is a result, not a diagnosis. The diagnosis
Table 3.6 Mnemonic AEIOU-TIPS for Altered Mental Status
is based on clinical suspicion. The cause may be transient
MNEMONIC THINGS TO CONSIDER
(seizure) or permanent (stroke), benign or life-threatening. If not
Alcohol Alcohol levels, serum osmoles treated timely and accurately, most causes may be mortal or
Epilepsy/ Endocrine/ EEG, referral to neurology, TFTs, cause neurologic sequelae. The systematic and structured
Electrolytes/ cortisol, chemistry panel, LFTs/NH3
approach makes diagnosing and management easier.
Encephalopathy
Insulin Glucose
Physical Examination Hints
Oxygen/ Opiates SatO2%, ABG, hypoxia makes A focused and systematic physical examination aims at
agitation, hypercarbia makes
somnolence confirming the clinical impression formed by the history. It also
Look for needle marks aids exposing unexpected findings that may make the clinician
Uremia BUN/Cr reassess the differential diagnoses and approach. Repetitive
Things changing serum osmolarity
examinations should be performed to track changes.
affect mental status. Uremia, Sugar,
Alcohol are common ones
• Vital signs should be evaluated very carefully in terms of
Trauma/ Temperature CT Head, C-Collar, CT C-Spine
hypotension, hidden shock, hypoxia, respiratory rate and
Infection CBC, BCx, UA, UCx, CXR, LP/CSF
pattern, and temperature.
Sepsis and CNS infections are more
important. But, even simple fever may
cause AMS in elderly and kids • Head: Signs of trauma, pupils’ size and reaction to light, cterus,
Poisoning/ Psychosis Drug Levels (e.g. lithium, digoxin) pale conjunctiva
Shock/ Stroke/ SAH/ Space ECG, Troponin, CT Head, LP • The fundoscopic exam may show hemorrhage, papilledema
occupying lesion
• Neck: Rigidity, bruits, thyroid enlargement
If the normal state of the patient is unclear, all changes must be
evaluated as if they are acute. Strokes, seizures, cardiac events, • Heart and Lungs may show heart failure, pneumonia findings
intoxication, psychiatric disorders cause sudden changes,
• Abdomen: Organomegaly, ascites
whereas; infections, metabolic disturbances, or an expanding
intracranial mass may cause gradual changes. • Extremities: peripheral cyanosis
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• Skin: Diaphoretic/dry, rash, petechiae, ecchymoses, splinter Table 3.8 Full Outline of Un-Responsiveness (FOUR) Score
hemorrhages, needle tracks EYE MOTOR BRAINSTEM
RESPIRATION
RESPONSE RESPONSE REFLEXES
• Neurologic exam should be done in order of GCS (Table 3.7),
4: Eyelids open 4: Thumbs-up, 4: Pupil and 4: Not
FOUR score (Table 3.8), pupil dimensions, neck stiffness, or opened, fist, or peace corneal reflexes intubated,
lateralizations . In the secondary evaluation, the full tracking, or sign present regular
neurological exam should be applied. The mental status exam blinking to breathing
command pattern
should be the main part of neurological exam and repeated as
3: Eyelids open 3: Localizing to 3: One pupil 3: Not
needed. but not tracking pain wide and fixed intubated,
Cheyne-Stokes
breathing
Table 3.7 Glasgow Coma Scale pattern
BEST VERBAL BEST MOTOR 2: Eyelids 2: Flexion 2: Pupil or 2: Not
EYE OPENING
RESPONSE RESPONSE closed but open response to corneal reflexes intubated,
to the loud pain absent irregular
4: Spontaneously 5: Oriented and 6: Obeys command
voice breathing
converses
1: Eyelids 1: Extension 1: Pupil and 1: Breaths
3: To verbal 4: Disoriented and 5: Localizes pain
closed but open response to corneal reflexes above ventilator
command converses
to pain pain absent rate
2: To pain 3: Inappropriate 4: Flexion withdrawal
0: Eyelids 0: No response 0: Absent pupil, 0: Breaths at
words; cries
remain closed to pain or corneal, and ventilator rate
1: No response 2: Incomprehensible 3: Flexion abnormal with pain generalized cough reflex or apnea
sounds (decorticate) myoclonus
status
1: No response 2: Extension
(decerebrate) Gujjar AR, Jacob PC, Nandhagopal R, Ganguly SS, Obaidy A, Al-Asmi AR.
Full Outline of UnResponsiveness score and Glasgow Coma Scale in
1: No response medical patients with altered sensorium: interrater reliability and relation to
outcome. J Crit Care. 2013 Jun;28(3):316.e1-8. doi: 10.1016/j.jcrc.
2012.06.009. Epub 2012 Aug 9. PubMed PMID: 22884530. - Please read
Glasgow Coma Score (GCS) (Modified from Teasdale, G., & Jennett, B. this article to get more insight about this score.
(1974). Assessment of coma and impaired consciousness: a practical scale.
The Lancet, 304(7872), 81-84.) - Please read this article to get more insight
regarding GCS.
115
Emergency Diagnostic Tests and Arterial/venous blood gas investigation is necessary for many
• ECG may help to understand arrhythmias and some toxic Liver function tests are useful in the suspicion of hepatic failure,
effects of drugs such as TCA overdose.
hepatic encephalopathy or biliary tract problems.
• Bedside US such as eFAST for trauma patients and RUSH Electrolytes are essential to evaluate altered mental status. There
protocol for nontraumatic hypotensive patients can be valuable are many electrolyte abnormalities can change the level of
to understand the underlying causes. Some other US consciousness such as hypo/hypernatremia, hypo/hyperkalemia,
applications can be used for altered mental status cases such hypo/hypercalcemia.
as optic nerve sheet diameter measurement to understand
increased intracranial pressure. Urinalysis shows ketone bodies of diabetic ketoacidosis and
provides information about urinary tract infection.
Laboratory tests
Many laboratory tests can help the management of altered mental Thyrotoxicosis and myxoedema coma are important endocrine-
status cases. These tests and their possible findings were given related causes of altered mental status. Therefore thyroid function
below. tests can be valuable in some circumstances.
116
Cardiac enzymes can be necessary because myocardial Image 3.4 CT head
infarction may cause a low ejection fraction or trigger arrhythmias
and patients may show altered mental status.
Imaging modalities
• Head CT: Non-contrast CT for ruling out hemorrhage, mass
effect, edema.
117
Image 3.5 MRI • E E G : I f t h e r e i s a suspicion for seizure, non-convulsive
status epilepticus, etc.
glucose mainly depends on the bedside glucose results. appropriate empiric antibiotics for the suspected source of
Similarly, we are using portable saturation devices, depending infection and possible microorganisms. Broad-spectrum
on the SatO2 level measured on the bedside, oxygen antibiotics are an option.
application decisions may change. Therefore, these drugs may Intravenous insulin infusion for diabetic ketoacidosis or
not be routine blindly anymore. In addition, it is better to hyperosmolar hyperglycemic syndrome. Electrolyte imbalances
emphasize that flumazenil (a benzodiazepine antidote) is not in must be corrected using appropriate fluid replacements.
the coma cocktail, and should not be used routinely also.
Procedures
• Empiric antibiotics must be initiated as soon as possible if
• LP: Indicated if central nervous system infection or or
sepsis or central nervous system infection is suspected.
subarachnoid bleeding (with negative CT scan) is suspected.
119
Pediatric, Geriatric, Pregnant Patient, and A-Accident/abuse (e.g., trauma with a suspicious history)
Mnemonic VITAMINS situation of the patient. The majority of the patients require
admission, either to the ward or intensive care unit.
V-Vascular (e.g., AV malformations, vasculitis)
If the underlying cause is completely reversed and unlikely to re-
I-Infection (e.g., sepsis, meningitis, encephalitis) occur, the patient reached his/her baseline mental status, vital
signs are normal and stable, preparing a discharge plan may be
T-Toxins (e.g., drugs, environmental toxins)
considered.
120
References and Further Reading, click here.
121
Section 4
Cardiac Arrest
122
Introduction C a r d i a c A r r e s t Rhythms
Cardiac arrest is a condition that every emergency physician must The pulseless cardiac arrest is caused by 4 different types of
be an expert in managing. The EM doctor will face it and have a primary arrhythmias that consist of 2 shockable rhythms
love/hate relationship with it. You love it when the patient is (ventricular tachycardia and ventricular fibrillation), and 2 non-
resuscitated and breathing on his own; you can then tell the shockable rhythms (pulseless electrical activity and asystole).
family their loved one is alive. You feel great because, after all,
we are here to save lives, and it’s the reason we joined this Shockable rhythm
specialty. You hate it when your eyes are tearing up as you
Ventricular Tachycardia
inform the parents of the newborn that he or she did not make it. Ventricular tachycardia (VT) has 2 different types. The most
This illness is due to the lack of effective perfusion of the organs common is the monomorphic (VT) and is defined as 3 or more
of the body 2nd to the abrupt failure of the heart to pump consecutive ectopic ventricular beats (QRS complexes) of the
blood. Every year, over a quarter of a million lives are lost same type.
123
Image 3.8 Torsade De Pointes N o n - s h o c k a b l e rhythms
Pulseless Electrical Activity
Pulseless electrical activity (PEA) shows organized electrical
rhythm on the electrocardiogram with no mechanical contractions
of the heart muscle (no pulse). It is also called electromechanical
dissociation.
Ventricular Fibrillation
Ventricular fibrillation is rapid and unorganized electrical impulses
which makes the ventricles of the heart quiver while no pumping
of the blood occurs.
Asystole
Asystole is defined as no electrical activity in the heart and no
mechanical contraction of the heart muscle (no pulse). It is also
called flat line or cardiac standstill.
124
Pediatric dosage 5 mg/Kg (can be repeated up to 300 mg)
Image 3.11 Asystole
Adult dosage 300 mg (can be repeated at 150 mg)
Frequency 1st dose after the 3rd shock and repeat dose after the
fourth defibrillation
Amiodarone: 5mg/kg for pediatric and 300 mg for adult • Hydrogen Ion (acidosis)
126
• Hypo-hyperkalemia Diagram 3.1 Cardiac Arrest
Management Made Easy
• Hypothermia If the patient developed a pulse at any
time during resuscitation
• Tension pneumothorax
• Stop CPR
• Tamponade
• Intubate the patient and secure the
• Toxins
airway
• Thrombosis (coronary and
• Start post resuscitation care
pulmonary)
• Induced hypothermia
• Trauma
• Admit to ICU
127
Section 5
Chest Pain
Introduction
by Asaad S Shujaa Chest pain is one of the most common symptoms presented in the emergency
department (ED), and it is worrisome because the differential diagnosis widely
range between non-emergent conditions and life-threatening conditions such as
acute coronary syndromes (ACS), pulmonary embolism (PE), aortic dissection,
pericarditis with tamponade, pneumothorax, and esophageal rupture. Chest pain
caused by non–emergent conditions include esophageal reflux, peptic ulcer, biliary
colic, muscle strain, costochondritis, pleurisy, pneumonia and non-specific chest
wall pain.
Currently, we do not have data regarding how many patients visit the ED with
chest pain in the Middle East; however, in the USA, approximately 6 million
patients visit ED with chest pain, which accounts for almost 9% of all ED cases.
This makes it the second most common complaint in ED visits.
128
General Approach to Patient with Chest Pain shock. Also, unequal BP in both arm or pulse deficient indicates
“As a general rule, any chest pain is ischemic in • Looks sick or not sick or
• Assessment of circulation by listening to heart sounds. Are • Are you having discomfort, chest pain?
there any S3,4 gallop rhythm (CHF) or new murmurs such as
mitral regurgitation (papillary muscle dysfunction). • How would you describe it?
• Checking the pulses, capillary refill to understand the shock • Where is it?
situation.
• Does it radiate anywhere?
Vital signs should be assessed and repeated at regular intervals.
• Frequency?
For example, respiratory distress with low O2 saturation may
indicate pulmonary edema, plus low BP indicates cardiogenic • Time of onset or acute worsening?
Physical Examination
• Repeat assessment of the airway, breathing, and circulation
with full examination steps.
130
Bedside test • 1 2 l e a d E C G f o r myocardial infarction and 15 lead
ECG for posterior myocardial infarction
ECG
ECG is the main bedside test for any chest pain patient. • Any ST elevation in 2 contiguous leads should be evaluated
as S.T. Elevation M.I. However, please do remember, there
What is your opinion about below ECGs in patients with different are many other problems can elevate S.T. segment.
type of chest pain?
• Any other changes such as ST depression, T inversion and Q
Image 3.12 Case – 54 yo female presented with 3 days wave should be evaluated
history of right side chest pain (pleuritic).
• ECG is more useful as ‘rule in’ than ‘rule out.’
131
of the ECG in a patient with suspected PE is ruling out other Others
life-threatening diagnoses such as acute myocardial infarction. Complete blood count, ESR, C reactive protein, blood
culture, and lactate may help to rule out some infections such as
• Some aortic dissection cases may also show ST-segment
pericarditis or mediastinitis because of esophageal rupture. But,
elevation as in acute myocardial infarction.
their value in the acute setting is questionable.
• ECG may also help to diagnose pericarditis, especially chest
pain patients with fever. Imaging modalities
Chest X-Ray
Laboratory tests • To look for heart failure and evaluate for other cause of chest
Cardiac markers pain such as Aortic Dissection, pneumothorax, pneumonia etc.
• Troponin I or T rise within 3-6 hours and then remain elevated
• Widened mediastinum, abnormal aortic knob, pleural effusions
for about one week
for aortic dissection. These findings are not sensitive for the
• Serial testing improves sensitivity aortic dissection. Only 25% of the patients have wide
mediastinum.
• In acute coronary syndrome suspicion, an increased Troponin is
a marker for increased risk of AMI and death • Esophageal rupture signs in chest X-ray; Hydropneumothorax,
Pneumothorax, Pneumomediastinum, Subcutaneous
• However, cardiac enzymes do not diagnose cardiac ischemia Emphysema, Mediastinal widening without emphysema,
Subdiaphragmatic air and Pleural Effusion.
D-dimer
• Only use is in a low-risk patient What is your opinion about below chest x-ray in a patient with
chest pain?
• A negative test makes PE very unlikely
132
Image 3.14 Case – 58 yo male presented with 1 day history CT scan
of sudden onset lef side chest pain radiating to left shoulder. • CT with contrast shows large, central emboli, it is also very
sensitive for aortic dissection.
V/Q scan
It is very sensitive but not specific for patients with suspected PE.
Bedside ultrasound
• RUSH protocol evaluates aorta and pericardial space to rule out Depending on your history, physical exam and bedside
tamponade (video) investigations as well as laboratory and imaging results, the focus
should be given to rule out myocardial ischemia or infarction,
• Consider Doppler ultrasound to see deep vein thrombosis in
pulmonary embolus, pneumothorax, pericarditis with tamponade,
legs (video)
aortic dissection, and esophageal rupture. Each of this specific
133
disease entities has various risk stratification methods, treatment
options, and dispositions. Now, it is time to look to some cases
and discuss more specific management in the ED. Case 1 – Critical Bedside Actions and General
Approach
Case 1 Place the patient in a monitored bed, make sure security
A 46-year-old male with a history of diabetes mellitus, chamber established (monitor, IVs, oxygen, etc.)
hypertension, and coronary artery disease presents to the ED. He
ABC intact
is a smoker. He complains of chest tightness and heaviness. The
symptom started gradually 3 hours ago and lasts 20 minutes Vitally stable except he has tachycardia (HR: 110)
when he was watching TV. The pain scale was 5/10, radiated to
Quick History and Physical Examination as described in the
his jaw. The pain is associated with nausea and sweating. He
text. Chest exam: Equal air entry, no wheeze or crackles
took Nitroglycerin spray, and the pain was relieved. The pain
started again before he reached the ED. The pain scale is 10/10. CVS exam: S1+S2 no additional sound, no murmur, JVP was
The initial assessment at triage: ABC intact, BP: 140/80, HR: 110 normal
RR: 24, O2Sat: 98% on room air, Temperature: 37.3, Random
Blood Sugar: normal. No lower limb edema, pulses for four limb present and equal
134
Case 1 – Differential Diagnoses • The history does not suggest any past Case 1 – Emergency
There are six life-threatening differential esophageal rupture Treatment
diagnoses for any chest pain patients. • Aspirin should be given immediately
• Physical exam not lead to cardiogenic
These consist of:
shock or pulmonary edema • Great benefit, little risk
1. Myocardial ischemia or infarction (MI)
• No sign of pneumothorax in the exam • Give the minimum of 182 mg
2. Pulmonary embolus (PE)
• Pulses all equal for four limbs and no • Rapid decisions on reperfusion
3. Pneumothorax inequality in BP in both arms, which
• Based on ECG only (PCI vs.
does not go with aortic dissection
4. Pericarditis with tamponade Fibrinolysis)
• ECG suggested Inferior MI, no sign of
5. Aortic dissection • Antiplatelet options:
pericarditis in ECG
6. Esophageal rupture • Heparin (LMWH versus
Case 1 – Emergency Diagnostic
unfractionated)
Case 1 – History and Physical Tests and Interpretation
Examination Hints • ECG suggested Inferior MI, no sign of • Clopidogrel
• The chest pain is typical angina pain pericarditis in ECG
• Symptomatic / pain control
(heaviness radiating to jaw associated
• Portable CXR: normal which rules out
with nausea and sweating), the pain is • GTN Vasodilator also reduces
pneumothorax and aortic dissection (no
not sharp such as in PE or tearing like preload
wide mediastinum)
in aortic dissection
• Troponin I is high, which suggests • Can give SL or IV
• The patient has cardiac risk factors
Myocardia Ischemia
(DM, HTN, CAD, Smoker, and MI 1 year • Morphine for pain control and reduce
ago) • In bedside echocardiography, there is anxiety and stress
hypokinetic in the inferior wall and no
• No PE risk factors • Secondary prevention
sign of cardiac tamponade
135
• B-Blocker, statins and ACE inhibitor Case 2 Case 2 – Critical Bedside
A 30-year-old male had an open Actions and General Approach
Case 1 – Disposition Decision reduction and internal fixation (ORIF) of • O2 Supply and monitor bed
Assess the risk stratification by using
right ankle fracture 2 weeks ago. C/O
TIMI score • ABC intact
sudden onset of chest pain today. He has
Case 1 – Admission criteria pleuritic sharp chest pain associated with • Vitally stable except he is tachycardia
• Establish risk level using the TIMI short breath, increased during inspiration. (HR 120)
scoring system
Initial assessment at triage • The quick history that suggested the
• Moderate risk: Admit for further • ABC intact patient had a major surgery 2 weeks
evaluation; add beta blockers, ACE ago and was immobilized 2 weeks.
• Vital signs
inhibitors. Follow cardiac enzyme
• Physical examination shows
levels. If MI ruled out, exercise stress • BP 120/80
test before discharge • Chest exam: Equal air entry, no
• Pulse 120
wheeze or crackles
• High Risk: Admit for cardiac
catheterization • RR 40
• CVS exam: S1+S2 no additional
• O2 sat 88% on room air sound, no murmur, JVP was normal
Case 1 – Discharge criteria
• Low-risk TIMI score: May be • T 36.5 • There is calf swelling in right site of
discharged after symptom control and surgery, pulses for 4 limbs present
follow up with cardiologist outpatient • 12 ECG shows sinus tachycardia, T and equal
for the stress test and lipid profile test inversion V2,3 and 4, deep S lead I and
Q and T inversion in the lead III, St • To do 12 lead ECG shows sinus
Case 1 – Referral elevation V1 and V4R suggested tachycardia, T inversion V2,3 and 4,
• Cardiology pulmonary embolism deep S lead I and Q and T inversion in
the lead III, St elevation V1 and V4R
suggested pulmonary embolism
136
• Patient in pain need analgesia • Physical exam not lead to pneumonia Case 2 – Emergency
no crackles in chest exam Treatment
Case 2 – Differential Diagnoses • Heparin (Will limit propagation but does
1. Pulmonary embolus (PE) • No sign of pneumothorax in the exam
not dissolve clot)
2. Myocardial ischemia or infarction (MI) • Pulses all equal for four limbs and no
• Unfractionated: 80 u/kg bolus, 18 h/
inequality in BP in both arms, which
3. Pneumothorax kg/hr.
does not go with aortic dissection
4. Pericarditis with Tamponade • Fractionated (Lovenox): 1 mg/kg SC
• ECG suggested PE, no sign of
BID
5. Aortic dissection pericarditis in ECG
• Fibrinolysis
6. Esophageal rupture Case 2 – Emergency Diagnostic
Tests and Interpretation • Consider with large if the patient is
Case 2 – History and Physical • ECG suggested Pulmonary embolism, unstable
Examination Hints no sign of pericarditis in ECG
• The chest Pain is atypical angina pain • No study has shown a survival
(sharp, pleuritic chest pain increased by • Portable CXR: normal which rules out benefit, but it is very difficult to study.
inspiration and associated with pneumothorax and aortic dissection (no
• Alteplase 50–100 mg infused over 2–
shortness of breath, no radiation), the wide mediastinum)
6 hrs (bolus in severe shock)
pain is not angina pain OR no tearing
• D- Dimer is high
pain as in aortic dissection Case 2 – Disposition
• Cardiac enzymes are negative If there is suspicious of PE, we need to
• There are PE risk factors (major surgery,
do pre-test probability; there are multiple
immobilization 2 weeks) • Bedside echocardiography there is
systems for doing this. Most widespread
signs of right ventricle enlargement and
• The history does not suggest any and validated is Well’s score
strain and no sign of cardiac
previous Esophageal rupture
tamponade There is a difference in Well’s score for PE
& DVT
137
PE – Well’s criteria Case 2 – Referral 200/100 on the left arm, tachycardia
• ICU (HR 110)
• 3 points for:
• Unstable Patient, massive PE, • Quick history which suggested sudden
• PE ‘most likely diagnosis onset central chest pain, described as
Bilateral PE
• Signs and symptoms suggesting ripping his chest and radiating to the
• Medical Ward
DVT back, no associated symptoms.
• PR>100,
Case 3 • Chest exam: Equal air entry, no
A 60-year-old male patient presented to wheeze or crackles
• history (PE/DVT), the ED with sudden onset central chest
pain, described as ripping his chest and • CVS exam: S1+S2, a grade 2/6
• immobilization in 2 weeks s y s t o l i c m u r m u r, a n d a s o f t
radiating to the back, no associated
symptoms and patient, previous history decrescendo diastolic murmur are
• 1 point for:
with HTN, CAD, and smoker. Initial heard at the second right intercostal
• Hemoptysis or malignancy assessment by EMS was ABC intact. space. JVP was normal
Vitals were BP 190/95 Right arm, Pulse
Risk Stratification • There is radial to radial pulsation
110, RR 20 , T 37 , O2sat 98%.
delay
• <2 low risk (10%), D-Dimer is good to
rule out PE Case 3 – Critical Bedside • There are abdominal and bilateral
Actions and General Approach femoral bruits, with absent distal
• 2-6 medium risk (25%), Spiral CT chest • O2 Supply and monitor bed
pulses.
with contrast to rule out PE
• ABC intact
• 12 lead ECG shows no ST, T wave
• >6 high (50%), start changes, no sign of MI
• Vitally stable except he is high BP
anticoagulation(LWMH) and Spiral CT
185/85 mmHg on the right arm and
chest with contrast
138
• Portable CXR shows wide mediastinum, • Physical exam not lead to pneumonia, •Bedside Echo has no sign of
no sign of CHF, pneumothorax or no crackles in chest exam tamponade
pneumonia
• No sign of pneumothorax in the exam • CT scan is the most accurate and
• Patient in pain need analgesia fastest option
• Pulses delay in radio –radio pulsation
Case 3 – Differential Diagnoses and different BP in both arm and Case 3 – Emergency Treatment
1. Aortic dissection abdominal and bilateral femoral bruits, • Involve Cardio-Thoracic surgery as
with absent distal pulses with going soon as possible.
2. Myocardial ischemia or infarction (MI)
with aortic dissection
• Control the blood pressure
3. Pulmonary embolus (PE)
• ECG no sign of ischemic changes, no
• SBP goal is 120-130 mmHg
4. Pneumothorax sign of pericarditis in ECG
• Broad-spectrum antibiotics – No
randomized clinical trials exist for
antibiotics and esophageal perforation;
h o w e v e r, e m p i r i c c o v e r a g e f o r
anaerobic and both gram-negative and
gram-positive aerobes should be
141
Section 6
Case Presentation
by Jabeen Fayyaz A 2-month-old female child was brought in with a history of
cough and fever for 2 days. As per mother, the fever was high
grade, documented as 38.5ºC with an inability to drink for the
last 4 hours. There was history of an episode of cyanosis at
home with coughing an hour ago. On examination, the child
was looking dull and lethargic. Her vital signs were: Temp
39ºC, HR 170/ min, RR 65/ min, SPO2 89% in room air, BP
75/50mm of Hg, and Capillary refill time 4 sec. Chest on
auscultation has bilateral crepitation. The child was taken
immediately in the resuscitation area and was put on high flow
oxygen. The blood work up and CX-ray ordered showed right
middle zone consolidation. IV antibiotic, Cefotaxime was
administered. The child was kept on IV fluids and cardiac
monitoring. The child was admitted to the high dependency
unit.
142
Overview c h i l d r e n r e s u l t s i n s i g n i fic a n t p a r e n t a l a n x i e t y.
Fever is one of the most common reasons for the Pediatric Management decisions about febrile children are further
Emergency Department (PED) visits. It accounts for almost 10% complicated by the fact that parents and physicians weigh the
to 25% of PED visits annually. Febrile illness in children is caused risks and costs differently.
mostly by viral infections, but a significant proportion, especially
In a study (Byington 2004), common sources of bacterial infection
in children who are less than 3 months old, are caused by serious
in children less than 90 days were found UTI, bacteremia, soft
bacterial infection (SBI). As an ED physician, the goal is to identify
tissue infection, meningitis, and pneumonia.
this population at risk and to promptly manage them.
Fever is defined as temperature ≥38°C measured rectally or
SBI has been reported to affect 6-10 % of infants who are
tympanic/axillary temperature of approximately 37.5°C. If parents
younger than 3 months and 5-7% of children who are between
state that fever is documented at home by a thermometer, it
3-36 months of age. Therefore, you should always be very careful
should be considered as fever recorded in the ED and should be
when evaluating a child with fever under 3 years old. The infant’s
evaluated in the same manner. Another important consideration
immune system is relatively immature during the first 2 to 3
mainly in neonates is hypothermia. Neonates may respond to SBI
months of life. This puts them in a very high risk group.
with hypothermia rather than hyperthermia, so they need to be
SBI can even be found in the presence of viral infection evaluated carefully for any other sign of toxicity.
concomitantly, 5% of patients with confirmed viral sources having
Temperature in children can be measured at the axilla, rectally,
urinary tract infections or other SBIs. Infants and children
orally or via the ear (tympanic). Younger children (<5 years old)
presenting with a fever and signs of a viral illness should have
cannot manage the glass thermometers because it can break
investigations to confirm the viral etiology, but should also be
easily. Therefore, this method is not recommended for this age
assessed for other sources of bacterial infections. Details of this
group. To check the temperature in newborns and young children,
approach can be found in Policy Clinical Guideline.Children with
axillary measurement is an acceptable method. However, children
an apparent focus or are sick looking are easy to manage.
under 2 years of age may need confirmation with a rectal
However, it is very challenging and many gray zones in managing
temperature. Rectal temperature is considered the gold
the well-appearing infants and children with febrile illness without
standard. Bundling a young child may increase the skin
any source in the chaotic ED environment. Febrile illness in
temperature but not the core temperature. It should also be
143
considered in neonates and children less than 2 years of age Table 3.11 Recommended methods to measure temperature
where other methods are not reliable. by age
provided by author.
144
History and Physical Examination Hints Examination of skin is very important. So, skin color, cyanosis or
The detailed history and physical examination are the most vital in jaundice, rashes should be evaluated. Although the skin may give
the assessment of the febrile child. It is critical to pay attention to a clue about the degree of hydration, tears during crying,
the history provided by parents for documented fever at home as moisture on the oral mucosa/lips and tongue should be checked.
studies have shown it is moderately accurate; further evaluation For the neonate, “gentle” palpation of the anterior fontanelle
should always be carried out because a subjective fever at home indicates current the fluid status. If the fontanelle is sunken, this
may be the only indicator of a possibly serious bacterial infection shows hypovolemia/dehydration.
in a child who is afebrile in the ED.
An assessment of the child’s overall appearance is critical.
Focused history on fever characteristics should be asked, as it Although there is an imperfect correlation between physical
may provide useful clues. There is an increase in the rate of examination findings and serious bacterial illness, ill-appearing
pneumococcal bacteremia with a rise in temperature, especially children are more likely than well-appearing children to have
in young children. Studies suggest that the incidence of SBI is serious bacterial infection, and most well-appearing children do
higher in patients who have higher temperatures. The duration of not have serious bacterial infection.
the fever at the time of ED presentation does not help to predict
Toxic appearence includes lethargy with poor perfusion (delayed
occult bacteremia. The response to antipyretic medications does
capillary refill, cold hands and feet, pale or mottled skin) or
not predict bacterial or viral infection. Other important data to be
cyanosis or respiratory distress findings. Grunting is considered
considered include associated signs and symptoms, underlying
one of the most important signs to identify a sick child and may
medical conditions, exposure to ill contacts, and immunization
indicate an impending respiratory failure.
status.
145
The physical examination may reveal focal infection, and if so
Table 3.12 Assessment of Clinical Condition in Children on
Physical Examination the need for additional testing decreases. For example, the
children who have clinically obvious viral illness such as croup,
WELL UNWELL TOXIC chicken pox have lower rates of bacteremia than the children who
have no obvious infection source. Except for neonates and
Wakes only with
Strong cry or Drowsy / prolonged young infants, if a child has a nontoxic appearance, a more
not crying / decreased stimulation/ unable selective approach can be undertaken. When a child has an
Alertness/ smiles / stay activity / poor to arouse/ weak cry
Activity awake/ normal smile/response / high pitched cry/ identifiable cause, the treatment and disposition should generally
response to to social cues/ continuous cry/ be tailored to this specific infection.
social cues irritable bulging fontanelle /
grunting
NICE green light system.
Chest indrawing /
Normal work of RR more than age
Breathing
breathing
Nasal flaring
specific rates/ Emergency Treatment Options
grunting Airway, breathing, circulation (ABC) is the priority for all patients.
Normal lips, Supplemental oxygen or advance airway measure can be
Color / Pale per Pale / mottled /
skin, tongue necessary. Open intravenous access to draw blood samples, fluid
Circulation caregiver blue / ashen
color
infusion, and medications. Monitor the patients’ vitals. Early
Poor feeding in
Normal skin infants / dry treatment of fever is important. This gives the patient comfort as
Reduced skin
Fluid/ Urine and eyes/ mucus well as optimal physical examination condition for the physician.
turgor / bilious
output moist mucus membranes /
vomiting
membranes reduced urine
Acetaminophen and ibuprofen both can be used. They can
output
overlap during the treatment period to control fever. Some studies
Appears very
New lump >2 favor acetaminophen because of its fast effect. Other studies
Others unwell to health
cm
care professional found that combination of acetaminophen and ibuprofen is very
provided by author effective regime. Recommended doses are acetaminophen 15
mg/kg and ibuprofen 10 mg/kg.
146
Empiric antibiotic regimes day with the primary physician are factors •No underlying or chronic illness
should also be considered affecting admission decisions. However,
• No previous admissions
Age 0-28 days: ampicillin + admission is warranted for febrile infants
gentamicin or a third-generation 28-56 days old regardless of the above • CSF – WBC < 8/hpf
cephalosporin factors.
• WBC – 500-15000/mm3, PMNL < 0.2
Age 29-56 days: Ill appearing children If the patient meets all of the following
can receive same regimen above. The low-risk criteria, they may be discharged • Urine WBC <10/hpf
children who can discharge home do home.
• No infiltration on chest x-ray
not need empiric antibiotics.
• Full-term birth
• Fecal leukocytes < 5/hpf
Ceftriaxone is a preferred agent by
• Not hospitalized longer than the mother Red Flags to be explained to parents at
some clinicians before ED discharge.
• No toxic appearing the time of discharge. The parents should
Age 2-24 months: Empiric antibiotic
be instructed to follow-up after 24-48
therapy is not indicated for well- • Not received antibiotic within 48 h hours as per clinical condition in the
appearing children if there is no
primary health care system. A detailed
defined bacterial source and will be • No dehydration
account of danger signs should be
managed as outpatients.
• No lethargy explained to parents and if possible given
Finding venous access, waiting the lab a handout. It should be emphasized to
• No irritability
results and availability of the antibiotics them that if they notice or observe any of
are couple obstacles to apply timely • No wheezing the following, they should come back to
antibiotics to children with fever. the ED immediately as it indicates
• No infections in the ear, skin, soft worsening of the child’s condition:
tissue, skeletal
Disposition Decisions
• Have breathing difficulty
Toxic appearance, need for monitoring,
• No focal infection source
need for fluid treatment, poor social • The lips, tongue or nails appear blue
condition, follow up chance for the next • No hyperbilirubinemia
147
• Crying continuously and inconsolable
• Has headache
• Has stiffness
148
Section 7
Gastrointestinal Bleeding
Case Presentation
by Moira Carrol, Gurpreet Mudan, and Suzanne A 61-year-old man with a history of liver cirrhosis secondary to
Bentley
chronic EtOH abuse presents to the Emergency Department
(ED) with a complaint of vomiting bright red blood that began
prior to arrival. He arrives actively vomiting; a significant
amount of blood is noted in his emesis basin. He is now
complaining of dizziness and appears pale.
149
Overview result of diverticulitis, the most common cause of LGIB, or
Gastrointestinal bleeding (GIB) can be generalized into two from hemorrhoids, colitis, anal fissures, inflammatory bowel
categories based on the site of bleeding. Upper GIB (UGIB) is disease including Crohn’s disease and ulcerative colitis, colon
defined as any bleeding that occurs proximal to the ligament of cancer or angiodysplasia.
Trietz near the terminal duodenum. Lower GIB (LGIB) is any
bleeding that occurs distal to the ligament extending to the Table 3.13 List of upper and lower G.I. bleeding causes
rectum. Most GIB seen in the ED is attributed to UGIB with an
incidence of 90 per 100,000 population. LGIB, on the other hand,
presents with a rate of 20 per 100,000 population. LGIB is more
commonly seen in the elderly but has a wide range of
presentations and causes. As a result, the approach to LGIB has
been less standardized.
identified in 11% of cases, whereas a lower GI source is found Please check for the general approach in Figure 3.5 (F1).
150
Figure 3.5 Approach to GIB Indications for transfusion include hemodynamic instability
despite crystalloid resuscitation, Hemoglobin (Hb) Hb < 9 g/dL in
high-risk patients, Hb < 7 in low-risk patients. High-risk patients
are considered those who are likely to rebleed or have severe
hemorrhage, whereas low-risk patients are less likely. Various
decision tools exist to help risk stratify patients based on multiple
clinical criteria and lab values. Consider FFP to correct
coagulopathy if present in a patient on anticoagulation or with
severe liver dysfunction. Placing the patient on a cardiac monitor
continually to assess changes in heart rate, blood pressure, and
oxygen saturation is imperative.
151
sign of UGIB. In patients with UGIB, Similarly, a patient who complains of expected blood transfusion. Initially,
between 90-98% presented with either blood in the stool with a history of Hb and Hct may be within normal limits.
melena or hematemesis. Alternatively, constipation suggests bleeding caused The values might not immediately reflect
hematochezia is defined as blood within by the diverticular disease. Recent blood loss after an acute hemorrhage
o r a r o u n d t h e s t o o l . H o w e v e r, diarrheal illness can be found in infectious and, therefore, should be repeated.
hematochezia can sometimes be the colitis. An elderly patient presenting with Higher mortality and incidences of
result of a brisk UGIB. Diagnosis can also weight loss or anorexia is concerning for rebleeding were found in patients with Hb
be confounded if there is slow peristalsis malignancy. The duration and timing of < 10 g/dL. Additionally, many recommend
in the setting of an LGIB. the bleeding are important to determine. using the Hb and Hct to inform the
Brisk or continued bleeding can alert to decision to type and crossmatch blood
Therefore, start by assessing the context
the need for resuscitation or emergency versus only drawing a type and screen.
of the bleed as it can give you clues to its
intervention. Finally, the provider must
origin. For example, patients who have a In a patient without kidney disease, a
characterize and quantify the bleeding. In
bleed secondary to PUD might have a BUN to Creatinine ratio that is elevated to
a complaint with multiple pathologic
history of an ulcer, might complain of acid greater than or equal to 36 is strongly
causes, a good history and physical
reflux or have a recent history of frequent associated with UGIB. As blood is
exam are paramount.
NSAID use. Patients with gastric or digested, the BUN is reabsorbed into the
esophageal varices might describe a Emergency Diagnostic Tests circulation leading to elevated serum
history of or risk factors for liver disease, and Interpretation levels. Below 36, however, the ratio has
such as daily alcohol abuse, or have no positive or negative predictive value.
other pathognomonic signs of portal Laboratory Studies BUN/Cr >36 can be helpful in the
hypertension. A history of intractable The most important lab tests for risk diagnosis of an occult UGIB in those
vomiting in the setting of hematemesis stratification for patients with acute GIB patients who present without classic
may suggest Mallory Weiss tears as the are the hemoglobin (Hb) and hematocrit signs of GI bleeding.
cause. (Hct), coagulation studies, and BUN to
Creatinine ratio. A type&screen is The role of nasogastric (NG) lavage and
recommended as well in case of aspiration in the diagnosis of GI bleeding
152
has been controversial. NG aspiration suspected UGIB can undergo endoscopy Tagged Red Blood Cell Scan
positive for blood is highly predictive of a as an inpatient. Early endoscopy, within Tagged Red Blood Cell Scan is a second
UGIB. However, it has not proven to be the first 24 hours of presentation, is line study that can assist in the diagnosis
sensitive. Placement of an NG is not a associated with shorter hospital stays of more indolent and continued bleeding.
benign procedure as there are risks and early instigation of appropriate Scanning within the recommended two-
including perforation and discomfort. treatment. However, most UGIB resolves hour window after the injection has high
without this intervention. Figure shows a rates of positive diagnosis in 95-100% of
Fecal occult blood test duodenal ulcer (Deep demarcated cases but after the recommended time
Performing a fecal occult blood test via a
ulceration with a visible vessel on base period the test is significantly less
rectal exam is important in the setting of
(Forrest Iia) Source: Lai, WEO Endoscopy effective.
a GIB. This bedside test can confirm
Atlas, Date: 2012-12-25.
whether or not blood is present in the Medications
stool, confirming the presence of a GIB. Colonoscopy Only a few medications have been shown
Unfortunately, it is not specific to UGIB or Colonoscopy can be helpful in the to be influential in the acute management
LGIB; however, often the presence of diagnosis of LGIB and is an effective first- of GIB. Pantoprazole is indicated for a
melena or bright red blood can help guide line test, but it is not a gold standard in UGIB in the setting of PUD. It is given as
diagnosis. the diagnosis of LGIB. A diagnosis is an 80 mg bolus followed by an infusion at
made by colonoscopy in 75% of cases. a rate of 8 mg/hour. If variceal bleeding is
Upper Endoscopy Typically, lower GI scopes are not known or suspected, consider starting
Upper endoscopy is overwhelmingly
performed emergently but can be Octreotide or other somatostatin analog.
diagnostic and usually therapeutic for
performed later during hospitalization or Octreotide is given as a 25-50 mcg bolus,
UGIB. Consultation with gastroenterology
a s a n o u t p a t i e n t . F i g u r e s h o w s then 25-30 mcg/hr infusion. In patients
is necessary for the emergent scope of
colonoscopy, bleeding from multiple with cirrhosis, antibiotics such as
patients with continued bleeding and
diverticular outpouchings. Source: Ceftriaxone, Amoxicillin-clavulanate or
suspected UGIB. These specialists can
American Family Physicians, Wilkins et al. Quinolone should be given.
immediately diagnose and treat the
Diverticular bleeding (please see Figure in
source of bleeding. Stable patients with
their manuscript).
153
Procedures behaviors that may increase the risk of
Sengstaken-Blakemore Tube is a device bleeding again, such as NSAIDs and
that is inflated in the esophagus to alcohol.
tamponade uncontrolled bleeding caused
References and Further Reading, click
by varices. It is used as a measure of last
here
resort because of the high complication
rate. EM CRIT – VIDEO – Blakemore Tube
Placement for Massive Upper GI
Hemorrhage.
Headache
Case Presentation
by Matevz Privsek and Gregor Prosen A 52-year old male comes to the ED with a severe headache.
A triage nurse gives you his chart and says that his vital signs
are normal, but he does not look well. You start to question
the patient, and the following history is obtained: his
headache started approximately six hours ago. He was
working in his office when he started to feel squeezing-like
sensation in his head. The pain has gotten worse since then,
but it is still tolerable. It is independent of any physical activity
or position. He already had a few similar episodes of this kind
of headache in the past two years, but now the pain does not
go away after aspirin as it did previously. He denies trauma as
well as any associated symptoms, e.g. no visual disturbances,
hearing loss, weakness, dizziness, stiff neck, loss of
consciousness. He is otherwise a healthy, non-smoker, with
Audio is available here no regular therapy or known allergies. His clinical exam is
155
unremarkable. Conscious, GCS back in 2 hours and are Introduction
Headache is a subjective feeling of pain,
15, alert and oriented, normal completely normal. The patient
crushing, squeezing or stabbing
skin color. Blood pressure now feels much better, with anywhere in the head. They are typically
135/82 mm Hg, pulse 78/min, almost no headache at all. divided to primary and secondary
14 breaths/min, SpO2 99%, Repeated vital signs and headaches. The most important task
emergency physicians have is to exclude
body temperature 36,4 °C. clinical exam are again
any potentially lethal causes of headache.
Neurologic exam shows no unremarkable. You explain to
According to some data, around 85% of
declines from normal, as well the patient that most likely he
the adult population experience
as the rest of the physical had a tension headache, warn headaches at least occasionally, and
exam. him about red flags regarding 15% does so regularly. A headache is the
chief complaint in around 3-5 % of all
headaches, and discharge him
You set up an intravenous emergency departments (ED) visits.
home with a prescription for
cannula, draw blood for
peroral analgesics with a Pathophysiology
testing, and gave the patient The pain in the head originates either
follow-up at his general from the meninges, blood vessels or
some parenteral analgesics
physician. surrounding tissues; the brain
(metamizole 2.5 g, ketoprofen
parenchyma itself is insensitive to pain.
100 mg) along with 500 ml of Because most of the pain is mediated
normal saline. You put him into through the fifth cranial nerve, the
patient’s ability to localize the pain is
the observation room. Lab
often poor. More specific localization of
results (complete blood count, the pain is associated with specific
basic biochemistry panel) came
156
inflammation in a specific structure (e.g. sinusitis). unknown. It is estimated that less than 1% of patients with
headache have a serious, life-threatening underlying disease.
Etiology
A vast number of diseases can cause a headache. We divide Management
them into primary headaches, in which the headache is the
disorder in itself, and secondary headaches, in which headaches
Critical Bedside Actions And General Approach
Regardless of the patients’ chief complaint, an emergency
are caused by various exogenous disorders (Table 3.14).
physician’s first task is assessing a patient’s condition and vital
Table 3.14 Etiology of headaches signs, and stabilize him/her, if necessary. After the patient is
stabilized, we continue with establishing the chief complaint,
precise history, and physical exam, setting the working diagnosis
and list of differential diagnoses, and diagnostic and treatment
plan.
Differential Diagnosis
An emergency physician has to exclude life-threatening causes of
headache, based on history, physical exam, and diagnostic tests.
Subarachnoid hemorrhage (SAH), meningitis, encephalitis, carbon
monoxide poisoning, and temporal arteritis considered as critical
diagnoses. Other emergency causes of headache are shunt
failure, dub or epidural hemorrhage, tumor/mass lesions,
mountain sickness, glaucoma, sinusitis, brain abscess, anoxic
hedache, anemia, and hypertensive crisis.
157
History And Physical Examination Hints • patient’s activity at the onset of the pain (headaches
The leading symptom has to be thoroughly “dissected” and a associated with exertion are suggestive of vascular bleeding),
focused medical history must be obtained. Useful mnemonics for
• history or possibility of head trauma suggests possible epidural
this are “SOCRATES” and “SAMPLE” (Table 3.15).
or subdural hematoma, traumatic SAH, skull fracture, and
closed-head injury (e.g. diffuse axonal injury),
Table 3.15 Getting fast and effective history about chief
complaint
• in immunocompromised or HIV-infected patients one must
consider for brain abscess, toxoplasmosis, or cryptococcal
meningitis,
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physical activity. Pain is blunt, squeezing-like. It is most common
Table 3.16 Emergency diagnostic tests for headache
in the afternoon or evening.
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On the other hand, head CT scan within 6 hours of onset of the Table 3.18 Initial treatment options for primary headaches
pain has almost 100% sensitivity for SAH; therefore, lumbar
puncture is reasonable only when head CT does not confirm the
diagnosis, yet the clinical picture is highly suspicious for SAH.
Disposition Decisions
The vast majority of patients with headache can be discharged
home with a prescription for analgesics and a close follow-up.
These patients are those in whom ED therapy was successful in
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pain relief, have normal clinical exam and vital signs, and no
serious illness has been identified or suspected. All other patients
require additional work-up or admission.
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Section 9
Multiple Trauma
Case Presentation
by Pia Jerot and Gregor Prosen A 28-year old male was a restrained driver in a head-on motor
vehicle collision. He was entrapped and extricated from the
vehicle. Transient loss of consciousness was reported. He
complains of severe chest pain, abdominal pain, and right
upper leg pain.
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Critical Bedside Actions and General D: disability
Approach E: exposure
Multiple trauma patients are primarily stabilized by the ambulance
crew on the field according to Prehospital Trauma Life Support In case of massive external hemorrhage, “C” takes advantage
(PHTLS) or International Trauma Life Support (ITLS) algorithm. over A and B. When the bleeding is controlled, we can continue
This chapter is about the approach to multiple trauma patients in with A and B.
the resuscitation room and mainly focuses primary survey.
A – Airway and cervical spine control
Preparing For Patient Arrival When the patient arrives at the trauma center, talk to the patient
The ambulance service has to provide information to the trauma and quickly asses his consciousness and airway. If the patient is
center for the arrival of the seriously injured patient. The trauma conscious and talking with a normal voice, his airway is adequate
team puts on protective clothing (rubber latex gloves, plastic for a period. If it is obstructed, the airway has to be secured.
aprons, eye protection, etc.). A team leader should brief the team While securing the airway, C-spine has to be protected, especially
and make sure that every member knows his role and all when we are dealing with a patient with neck pain, focal
necessary equipment is ready. neurological signs, coma, suspected head injury or a history of
high-speed impact.
Primary Survey
In the first few minutes, a primary survey has to be done. The Do not delay C-spine and vertebra stabilization in a trauma
primary survey is a structured assessment in which we identify patient with proper size of c-collar, side pads, and trauma board..
and immediately treat conditions that are life-threatening. The
The airway can be temporarily opened with a jaw thrust or basic
primary survey should always be the same, following the ABCDE
adjuncts such as nasopharyngeal or oropharyngeal airway. If the
algorithm listed below.
patient’s airway is still compromised, it should be secured by
A: airway and cervical spine control endotracheal intubation or surgical airway. Indications for
endotracheal intubation are listed in Table 3.19. Intubated
B: breathing patients should be monitored by continuous capnography.
C: circulation
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Table 3.19 Indications for ET intubation C – Circulation and hemorrhage control
The main objective of this step is to identifying shock situation in
the patients. If there is massive external hemorrhage, it should be
controlled before we proceed with A and B assessment. Radial
pulses, heart rate and blood pressure (BP) should be assessed at
that stage. The patient should be attached to the monitor. If we
are dealing with a major trauma patient, at least two large bore
(14G or 16 G) IVs have to be established. As an alternative,
intraosseous line can be used.
B – Breathing
“Permissive hypotension” with systolic BP 80-90 mmHg should
All trauma patients should be given 15 L O2 via non-rebreather
be maintained when bleeding is not controlled (internal bleeding).
mask. The respiratory rate has to be evaluated. Expose the chest,
If the patient is hemodynamically unstable, fluid resuscitation
and inspect for any deformities, wounds, bruising, asymmetrical
should begin with 1 L of warm isotonic fluid, either normal saline
movement or flail chest. The chest has to be palpated for any
or lactated Ringer’s. At this moment, it is better to keep in your
crepitus or subcutaneous emphysema. The lungs should be
mind that normal vitals are considered stage I shock which
auscultated to assess the presence of breathing sounds
patients could lose up to 750 cc blood. So, starting fluid support
bilaterally.
to patients suspected multiple trauma is a standard approach
Chest injuries that can impair breathing have to be identified and regardless of their vital signs. If the patient is still unstable after 1
treated. Life-threatening thoracic conditions are tension Liter of fluid or is having ongoing blood loss, we should
pneumothorax, massive haemathorax, cardiac tamponade, open administer a transfusion of O-negative blood and order type-
chest wound, flail chest (video). If any of those conditions are specific blood. The patients who have an identified bleeding
found, immediate action is needed. source will usually require surgical intervention. Do not delay
surgery departments’ involvement. Internal bleeding in the thorax,
We can also use ultrasound at this moment to identify
abdomen, pelvis or around fractures of long bones (particularly
pneumothorax, haemathorax, and cardiac tamponade.
femur) should also be evaluated. For identifying bleeding into
abdominal, pleural, or pericardial cavities, we can use the bedside
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ultrasound (e-FAST exam). In the hemodynamically unstable If there is time, Glasgow Coma Scale (GCS) can be used to
patient with normal e-FAST, one should think pelvic injuries. assess the level of consciousness. Otherwise, GCS is assessed in
the secondary survey. GCS is listed in Table 3.20.
Image 3.17 Positive eFAST exam (peri-splenic free fluid)
Table 3.20 Glasgow Coma Scale
E – Exposure
D – Disability All clothes have to be removed from the patient so that hidden
In the primary survey pupil size, symmetry and reactivity should
injuries and bleeding can be identified. The patient has to be log-
be assessed. To detect the level of consciousness, the patient
rolled. In a log-roll, back of the head, neck, posterior chest, lower
has to be assessed by AVPU scale. It stands for A: Awake, V:
back should be inspected, palpated and auscultated as
responds to voice or verbal commands, P: responds to painful
appropriate. If necessary, the rectal examination can be applied at
stimuli, U: unresponsive.
this moment. We have to avoid hypothermia during this stage.
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Secondary Survey • C: Shock because of cardiac tamponade, intra-abdominal,
The secondary survey can be done after the primary survey and intrathoracic, intrapelvic hemorrhage, external hemorrhage
when the patient is responding to resuscitation. It consists of
• D: Head injury
taking history (see “SAMPLE” mnemonic below), head to toe
assessment (including log-roll), interpreting results of • E: Fractures, dislocations and small wounds
investigations, formulating a management plan for the patient and
documenting all findings. History and Physical Examination Hints
History and physical examination hints to help “rule in or rule out”
S: symptoms – social differential diagnoses are listed in Tables 3.21.
A: allergies
Table 3.21 Lorem Ipsum dolor amet, consectetur
M: medications
L: last meal
Differential Diagnoses
There are critical conditions which should have been diagnosed
during the primary survey. These are;
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obstructed airway. Any patients with severe shortness of breath, A trauma patient should be radiographically evaluated with chest
decreased or absent breath sounds on the lung, and hypotension and pelvic radiographs. C-spine X-ray was traditionally used.
is a tension pneumothorax until proven otherwise. Nowadays, any low-risk criteria violation is considered for
computerised tomographic evaluation for the cervical spine.
E m e r g e n c y D i a g n o s t i c Te s t s a n d Cervical spine imaging can be delayed if there are no neurologic
Interpretation findings or persistent moderate hypotension. For assessing C-
spine and other injuries, CT scan is the best choice in the acute
Laboratory tests
setting, when the patient is stable.
Laboratory evaluation of the trauma patient is used for assessing
the adequacy of resuscitation, for determining the proper Imaging studies of the thoracolumbar spine and extremities can
transfusion products and the onset of coagulopathy and for be delayed until higher priority assessments and interventions are
baseline values for follow-up studies. complete.
Imaging
The e-FAST (Extended Focused Assessment with Sonography for
Trauma) should ideally be a part of the primary survey, especially
for unstable patients. It can be used for evaluating pneumothorax,
free fluid in thorax and abdomen and to identify cardiac
tamponade.
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Diagram 3.2 Initial stabilization Medications
Drugs needed for RSI
For RSI, you will need a pretreatment agent (mainly fentanyl),
induction agent (mainly ketamine or etomidate) and paralytic
agent (mainly rocuronium). Dosages and characteristics of drugs
are listed in Table 3.22. Doses must be adjusted in the
hypotensive or shocked patient.
Analgesia
For analgesia, opioids or ketamine can be used. Dosages and
characteristics of drugs are listed in Table 3.22.
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Procedures the neck and the floppy upper airway which can result in
All procedures for initial stabilization should be done in the occlusion of the airway. To prevent this, place a pad under the
primary survey. torso of children younger than eight years.
Airway: If the patient’s airway is compromised after a jaw thrust, Breathing: Normal respiratory rates vary in different ages.
nasopharyngeal or oropharyngeal tube placement, then Newborn respirates 25-50 breath per minute while 6 months to 12
orotracheal intubation is indicated. Rapid sequence intubation year kids respirate 15-30 breath per minute.
should be done. If it is unsuccessful, the surgical airway should
Circulation: Brachial and femoral pulses are usually easy to feel. A
be established.
weak, rapid pulse with a rate over 130 is a sign of shock in
Breathing: If tension pneumothorax is found in the primary survey, children all ages except neonates. Children have a strong
it should be decompressed immediately. Tube thoracostomy compensatory mechanism in early shock and later deteriorate
should be followed this procedure. If massive haemathorax is very quickly. When giving fluid resuscitation, give 20 mL/kg in
found, thoracostomy should be performed. However, in this each bolus.
situation, please make sure that the patient was supplied with
Disability: When evaluating an injured child, the care provider
enough volume and blood. Informing trauma surgery or thoracic
should remember that children of various ages have different
surgery for potential thoracotomy risk is a wise approach.
cognitive skills and interact differently. For assessing child`s
Circulation: If massive bleeding is found, it should be controlled neurological status, special GCS is used.
immediately. If cardiac tamponade is found, it should be treated
with pericardiocentesis.
Geriatric Patient Considerations
The geriatric patient should be assessed and treated by ATLS
protocol for adults. Because of multiple comorbidities in this age
Pediatric, Geriatric, and Pregnant Patient
group, the patients may need special considerations such as
Considerations
medications which affect vital signs and basal laboratory results
Pediatric Patient Considerations which affect the decision on imaging modalities (high kidney
Airway: Airway should be checked the same as in an adult functions). However, life-threatening situations have priority, and
patient. When positioned flat on a stretcher, the occiput can flex immediate actions should be taken as with normal adults.
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Pregnant Patient Considerations • Negative e-FAST and CT scans for free fluid in body cavities.
Primary survey is the same for the pregnant patient as for other
• Minimal head injury with GCS 15 and normal CT scans without
patients.
other body injuries and with normal neurologic status (with
The normal heart rate of a pregnant patient is 10-15 beats faster instructions to return for any changes in mental status,
than usual, and the blood pressure is 10-15 mmHg lower; so, vomiting, or worsening headaches).
normal vital signs can be mistaken for a shock. A blood loss of
• Uncomplicated rib or sternal fractures.
30-35% can occur before there is a significant fall in blood
pressure. Referral
Multiple trauma patients who do not need admission for opetaion
Disposition Decisions or observation are usually referred to a surgeon for the follow-up
Admission criteria or management of their injuries.
The majority of patients will be admitted to the hospital following
References and Further Reading, click here
major trauma for the management of their injuries. Some of them
need operation while other just need observation.
Discharge criteria
The discharge decisions of trauma patients differ between
institutions and systems. However, below list are cover the
general agreement about the patients who can discharge after
trauma.
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Section 10
Poisonings
Case
by Harajeshwar Kohli and Ziad Kazzi An 18-year-old, previously healthy female, presents to the
Emergency Department with nausea, vomiting, and tremors.
She states 45 minutes ago she ingested an unknown number
of diphenhydramine tablets (25 mg) in a suicidal gesture. Past
Medical History: Depression, Medications: none. Social
History: As per family member, she does not smoke or use
illicit drugs. She is single and unemployed. Vital Signs: HR 110
bpm, BP 151/92 mmHg, RR 20 / min, Temp 38.5 degrees
Celsius. Physical Exam: General Appearance: Mild distress,
awake, appears to be hallucinating. Eyes: Dilated pupils
bilaterally but reactive. Cardiovascular: Tachycardic, normal
sounds, and no murmurs. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, non-tender, non-distended,
decreased bowel sounds. Neurologic: Normal motor power,
Audio is available here normal cranial nerves, normal cerebellar exam, alert and
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oriented to self. Not oriented to Initial Approach a defective space heater or electrical
The initial approach to any patient generator can cause altered mental
location or date. Attention level
presenting to the emergency department status. Remember to always check a
waxes and wanes. Skin: warm, begins with airway, breathing, and glucose level in an altered patient!
dry, no rash. Musculoskeletal: circulation (the ABC’s). The physician can
proceed to a more thorough history and Common Toxidromes
No deformities, no clonus, A toxidrome is a constellation of signs,
physical examination after the ABC’s are
normal deep tendon reflexes. symptoms and vital signs findings that
secured. Oftentimes, patients who
clinically correlate with exposure to a
present after an overdose have altered
toxin or class of toxins. The following list
mental status or try to conceal their
includes common toxidromes:
ingestion. This highlights the need for the
physician to gather collateral history from
Sympathomimetic (cocaine,
Emergency Medical Services (EMS)
amphetamines, phencyclidine)
providers, bystanders, family, and friends. Hypertension
The physician should try to find out if the
patient has any psychiatric history or Tachycardia
access to medications. The physician
Diaphoresis
should check the patient’s clothing for
empty bottles or paraphernalia of drugs Mydriasis
of abuse. The physician should also
Agitation
inquire about the physical environment
where the patient was initially found. Anticholinergic (tricyclic
Various environmental toxins can lead to antidepressants,
altered mental status and should be diphenhydramine,
considered in the initial assessment. For antihistamines, jimson weed,
example, carbon monoxide released from atropine)
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Tachycardia A- Abdominal cramps Sedative (benzodiazepines,
gamma-hydroxybutyric acid)
Hyperthermia M- Miosis
Typically normal vital signs
Dry skin Cholinergic (organophosphates, Depressed mental status
carbamates, nerve agents) –
Mydriasis
MTWThF (mnemonic for Bradypnea
Diminished bowel sounds nicotinic effects – days of the
week) Vital Signs
Urinary retention M- Mydriasis Vital signs can help guide the physician’s
differential diagnosis. The following table
Delirium, agitation T- Tachycardia lists some toxins and their effect on vital
signs:
Cholinergic (organophosphates, W- Weakness
carbamates, nerve agents) –
TH- Hyperthermia
SLUDGEBAM (mnemonic for
muscarinic effects) F- Fasciculations
S- Salivation, seizure
Opioid (opiates, opioids,
L- Lacrimation
clonidine)
U- Urination Miosis
D- Diarrhea Hypotension
E- Emesis Bradycardia
B- Bronchorrhea Hypothermia
Diagnostic Evaluation
The initial diagnostic workup for an overdose patient should be
guided by clinical presentation and can be broad. Please note
that this is an introductory chapter and the following is a basic
initial approach and not meant to be exhaustive by any measure.
As an initial suggestion, the following should be ordered initially:
Physical Exam Findings • Complete Blood Count (to assess for hematologic disturbances)
Physical exam findings can guide a physician’s initial assessment
of a possible overdose patient. Track marks could be a clue to • Serum acetaminophen (paracetamol) levels (which is a common
intravenous drug abuse. The following table lists some key cause of overdose, does not cause any clinical manifestations
physical exam findings associated with certain toxins: initially and can be lethal)
174
they are not able to detect a large number of drugs and can Table 3.25 Causes of high anion-gap metabolic acidosis
have false positives.
176
• Enhanced Elimination References and Further Reading, click here
• Urinary alkalinization
• Hemodialysis
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Section 11
Respiratory Distress
Case Presentation
by Ebru Unal Akoglu A 40-year-old female with a history of diabetes mellitus
presents with a complaint of 6 days cough and muscle aches.
Patient has right-sided chest pain with deep breathing. Her
vitals are the following: temperature 37.1 degrees Celcius;
blood pressure 150/97 mmHg; heart rate 120 bpm; respiratory
rate 19/min; and pulse oximetry 89%. On physical
examination, she has diminished breath sounds and ronchi at
the right bases. Her chest X-ray is shown in Image 3.18.
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What are the diagnostic considerations? What is your next move? I n t h e e m e r g e n c y department, respiratory distress is a
What is the most appropriate management strategy? challenging chief complaint and diagnosis, and you should
evaluate, examine and ease (treat) the patient simultaneously. You
have to act quickly with limited information, or your patient can
Image 3.18 Chest x-ray.
decompensate in front of you.
Introduction
Respiratory emergencies are common presentations to
emergency departments. Appropriate assessment and timely
interventions may be crucial in dyspneic patients. Respiratory
distress is responsible for nearly 4 million ED visits each year and
is one of the most common presenting complaints in the
elderly. Management of acute respiratory distress is a challenging
task. Good patient outcomes rely on your ability to assess
ventilation, oxygenation, work of breathing, lung function, airway
resistance and air flow.
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Rapid assessment may necessitate intubation, BiPAP (Bilevel Healthy lungs are the cornerstone of fluid regulation among
Positive Airway Pressure), nebulizations, decompression or other the interstitium and alveoli, which can be destroyed by lung injury.
therapies in the immediate period following the patient’s
Lung injury can cause abnormal gas exchange, impaired
arrival. Sometimes, it may be hard to decide whether your patient
compliance, and pulmonary pressure. Normal lung function
needs medication, suctioning, airway management, intubation,
requires dry, patent alveoli assisted by proper capillary perfusion
mechanical ventilation support (invasive, non-invasive) or just
and patent endothelium.
close observation.
Respiratory distress is a consequence of an alveolar injury
Respiratory distress is a term utilized to summarize a complex of
producing diffuse alveolar damage. Tumor necrosis factor,
clinical features. These are tachypnea, hypoxemia (peripheral
interleukin (IL)-1, IL-6, and IL-8, are the pro-inflammatory
arterial oxygen saturation [SpO2] <90% on room air), increased
cytokines released after injury and recruit neutrophils to the lungs.
work of breathing (intercostal, subcostal, or suprasternal
Activation of neutrophils causes endothelium damage that ends
retractions; nasal flaring; grunting; use of accessory muscles)
with impairment of hydrostatic and oncotic forces of membranes.
apnea, altered mental status, and cyanosis which is characterized
by >5gr/dL of deoxygenated hemoglobin. At this moment, it is Damage to the capillary endothelium causes the escape of
better to share some terms and definitions. Please check Table proteins from intravascular space. The membranous hydrostatic
3.27. and oncotic forces are lost, and the interstitial space fills with
fluid. Also, the clearance ability of the membranes may be lost.
Table 3.27 Terms and definitions in respiratory distress
Increase in interstitial fluid, combined with damage to the alveolar
epithelium, causes the air spaces to fill with bloody,
proteinaceous edema fluid and debris from degenerating cells.
Besides, the functional surfactant is lost, resulting in alveolar
collapse.
Initial Stabilization
The following three assessment questions guide management:
Breathing
Coarse lung sounds, formerly called rhonchi, generally result from
secretions in the airway. Nasotracheal suctioning of accumulated
Table 3.28 Predisposing factors
secretions using a soft, flexible catheter clears coarse-sounding
lungs. Wheezing suggests flow restriction below the level of the
trachea, whereas crackles (or rales) indicate the presence of fluid
or atelectasis at the alveolar level. Administration of an inhaled
bronchodilator significantly reduces wheezing.
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and exacerbation of chronic obstructive common symptoms. Not only family Pulse oximetry is a valuable
p u l m o n a r y d i s o rd e r m a y l e a d t o members, but also a brief conversation monitoring tool for the management of
respiratory distress and arrest. These with the paramedics, who transferred the respiratory distress patients. It is useful
critical problems should be treated during patient, can give you useful information for either making a decision when to
the assessment. about the patient and the surrounding administer oxygen or titration of oxygen
area they took the patient from. to avoid patient harm from too much
While you are examining the patient,
oxygen.
other staff members (such as intern, Physical Examination Hints
nurse, paramedic) may measure vital Although we do a focused and goal- For respiratory distress patients without
parameters and monitor the patient, directed physical exam in critical patients, immediate life threats, your next
obtain intravenous access and do ECG. a detailed physical examination also assessment focus should be to determine
Te a m w o r k w i l l a c c e l e r a t e y o u r provides important guidance. the patient’s work of breathing and
assessment process and allow you to respiratory pattern (video), looking for any
The general appearance of patient –
formulate a treatment plan while others tripoding or retractions. Retractions can
c o n f u s i o n , c y a n o s i s , d ro w s i n e s s ,
obtain a history from family or friends. be visualized during the assessment of
tachypnea, and pallor – can guide your
chest movements, and they are more
History Taking and Physical management. Also, respiratory rate and
valuable than lung sounds in the decision
Examination Hints oxygen saturation are two vital sign
of the respiratory distress severity.
measurements that are helpful in
History Taking Hints assessing and monitoring the degree of Lung sounds (video) such as wheezing,
Acute respiratory distress is one of the respiratory distress. The higher the rales, ronchi, and stridor further guide the
most common chief complaints in the ED. respiratory rate, the greater the work of differential diagnosis. Decreased sounds
The differential diagnosis includes many breathing and the more likely the patient or hyperresonance may also provide
disorders, so a careful history can be will eventually get tired. Oxygen additional clues. Lung sounds should be
helpful to narrow this wide differential. In saturation is important not only in examined from both sides of the chest
addition, past medical and family history, assessing but also following the progress wall even in supine positioned patients
trauma, travel, medications, allergies and of the patient. (video). Orthopnea, or the inability to lie
exposures should be considered with
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flat, is not a test, but rather, a question to 5) restlessness, agitation, decreased level distress. Generally, laboratory and
ask the patient. Sweating and diaphoresis of consciousness. radiological tests take a long time; you
in an environment where others are not should start the treatment before getting
sweating, suggests significant distress. Differential diagnosis results.
Having a wide differential diagnosis list
Jugular venous distension (picture), S3 for respiratory distress will allow you to Bedside tests
gallop, and peripheral edema indicate sort through the possible causes more • ECG, especially in elderly patients who
that the patient has fluid overload. Heart rapidly. In the ED, you must think the usually present atypically with dyspnea
sounds such as murmur, or decreased worst case scenarios first, and you in acute coronary syndrome, is easy
sounds, guide the differential and also should try to rule out them. Respiratory and practical.
management. Pulses must be assessed distress differential diagnoses list has
What are your diagnosis and next action
bilaterally. various critical diseases. These are
about the ECG in a patient with shortness
anaphylaxis, asthma/COPD, acute
It is important to remember that anxiety is of breath and palpitation (Image 3.19)? -
coronary syndrome, pulmonary edema,
common in patients with significant Case – 68 yo female presented with
pulmonary embolism, pneumonia,
medical problems, just as in trauma. palpitation, dyspnea, unable to lay down.
pericardial tamponade, tension
COPD patients have it more often than Vitals are BP: 80/43 mmHg, HR: 160
pneumothorax, and upper airway
the general population. Secondly, even bpm, RR: 32 pm, Temp: 37 Celsius,
obstruction.
healthy, young patients may have a SatO2: 87%. Patient diaphoretic, cool,
medical cause for hyperventilation. A The above diagnoses are crucial and anxious. Chest auscultation revealed
thorough assessment is important not to should be treated immediately. Other basal to mid zone crackles on both sides.
miss clues of a medical or traumatic causes of respiratory distress should also Heart sound irregular. Bilateral 1+ pitting
condition. be assessed and managed properly. edema.
What are your diagnoses about the chest x-rays (Images 3.20 and
3.21) in patients with shortness of breath?
Image 3.20
Laboratory tests
• Arterial blood gas analysis is useful, quick and important to
determine metabolic and/or respiratory cause of respiratory
distress.
185
Image 3.21
Disposition
• Currently, ultrasonography is another option in the evaluation of
if the patient’s condition or blood gas analyze does not improve
respiratory distress (watch this video). Ultrasonography
despite therapy admission should be considered to appropriate
provides valuable information about the origin of symptoms and
clinics.
often diagnosis in the initial assessment of the patient. Also,
ultrasonography is faster than laboratory tests and other References and Further Reading, click here
imaging modalities, repeatable, and portable so that it can be
used for unstable patients. It is also cost-effective.
186
Section 12
Shock
Case presentation
by Maryam AlBadwawi A 61-year-old male with fever, shortness of breath and
vomiting was brought to the ED by ambulance. He also
complained of dizziness, malaise, and reduced urination. His
symptoms started one week earlier and got progressively
worse in time. However, he did not seek any medical
assistance before. His medical history includes diabetes
mellitus and hypertension.
187
Abdominal examination was unremarkable, and His MAP improved to 65 and remained stable.
there was no focal neurological deficit. He was transferred to the ICU.
Adopted from following references. Please read (Marx, J. A., Hockberger, R. S., & Rosen, P. (2014).
Rosen's emergency medicine: Concepts and clinical practice (8th ed., Vol. 1). Philadelphia, PA:
Mosby Elsevier and Avegno, J. CDEM Self-Study Modules. The approach to shock. Retrieved May
11, 2016) references to get more information.
189
Critical Bedside Actions and General • C a r d i o g e n i c s h o c k occurs when more than 40% of the
Approach myocardium undergoes necrosis from ischemia, inflammation,
Early and accurate management is essential as it reduces toxins or immune destruction. It induces the same impairment
mortality significantly in certain types of shock. Heart rate, blood as hemorrhagic shock. Patients have evidence of ventricular
pressure, and partial oxygen saturation must be continuously dysfunction earlier in the disease.
monitored. Optimizing airway, breathing, and circulation (ABC) is
• Obstructive shock should be considered in patients with chest
the priority. Check the airway of the patient, and consider
pain, shortness of breath, and altered mental status. The
intubation in case of inadequate oxygenation and ventilation.
physical examination may reveal jugular venous distention,
Maximizing arterial oxygen saturation through proper oxygenation
muffled heart sounds, pulsus paradoxus, tachypnea,
is crucial. Central venous oxygenation should be monitored with a
tachycardia, cold extremities, friction rub, new murmur, and
target of minimum 70%. Reducing the work of breathing lessens
signs of deep vein thrombosis.
the metabolic load.
• Distributive shock findings depend on the cause. Sepsis and
History and Physical Examination Hints septic shock cause signs of infection. Other symptoms and
Common features of the shock include hypotension, altered signs include hypo/hyperthermia, tachycardia, tachypnea, wide
mental status, and oliguria, regardless of the etiology. The patient pulse pressure, warm extremities, altered mental status,
history is significant to diagnose the type of shock and accurately oliguria, and skin rash. Anaphylactic shock is characterized by
treat the patient. skin and mucosa manifestation such as urticaria, flushing,
pruritis, and angioedema. Respiratory symptoms may include
• Hypovolemic shock might have a history of trauma, pregnancy,
rhinitis, bronchospasm, dyspnea, and stridor (pharyngeal/
gastrointestinal losses or burn. Initially, heart rate and force of
laryngeal edema). The patient may experience dysrhythmias,
contraction increase. Vasoconstriction causes elevated diastolic
hypotension, presyncope, and syncope. Additionally, GI
BP, and pulse pressure (the difference between systolic and
symptoms such as nausea, vomiting, and diarrhea may be
diastolic BP) narrows. The blood flow to the noncritical organs
present.
decreases so that cells produce lactic acid. As bleeding
continues, ventricular filling and cardiac output (CO) decrease, • Blood pressure may be normal or even high in the early course
resulting in decreased BP. Hypotension is a late sign of shock. of shock; however, if left untreated, it may proceed to
190
tachycardia and hypotension. Shock Index (heart rate divided information about prerenal causes showing a volume or
by systolic blood pressure), may reveal obscure shock. The blood loss.
normal shock index ranges from 0.5 to 0.7. A value of >0.9 is
• Urinalysis
considered abnormal and associated with higher mortality.
• Urosepsis is one of the common sepsis causes.
Emergency Diagnostic Tests and
Interpretation • Hepatic function tests
The suspected cause of shock, attributed from the history and
• Hepatic functions impair because of low perfusion.
physical examination, should guide diagnostic testing. The goal is
to determine the involvement of organ hypoperfusion and • Lactate
damage. The following are helpful investigations in shock:
• Lactate gives an opinion about the hypoperfusion status. Its
• Complete blood count and coagulation profile levels considered normal between 0.5-1 mmol/L. Lactate
levels more than 2 considered as abnormal in the critically ill
• Anemia, infection, hypo-coagulopathy related abnormalities
patients. Levels more than 4 shows increased the risk of
can be seen
mortality and morbidity. Therefore, those levels are used for
• Electrolytes some institutions to decide ICU admission.
• Some of the cases may show electrolyte disturbance • Urine pregnancy test
because of their comorbidities or continuous medical
• Considering every female patient in childbearing age as a
problems affecting their nutrition or metabolism.
pregnant patient is essential thinking in the ED.
• Renal function tests
• Chest x-ray
• Blood urea nitrogen/creatinine
• For pneumonia, pleural effusion, and other possible shock
• Renal functions impair because of low perfusion. High causes such as cardiac tamponade, aortic dissection,
blood urea nitrogen compared to creatinine may provide pneumothorax (tension).
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What are your diagnoses in hypotensive patients with below • ECG
chest x-rays?
• For arrhythmias, MI, cardiomyopathy and other findings
Image 3.22 Image 3.24 • US (RUSH protocol to find the cause of the shock (video)
Image 3.23 • SIRS and sepsis: Cultures (blood, sputum, urine, or wound),
head CT and lumbar puncture
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Table 3.30 Important Physiological Changes in Shock
CENTRAL SYSTEMIC TISSUE
SHOCK TYPE HEART RATE VENOUS CONTRACTILITY EXTREMITIES VASCULAR PERFUSION/
PRESSURE RESISTANCE SCVO2
Increased in
Tamponade and
Decreased or
Obstructive Increased +/- Increased +/- Cool PE, but decreased
Increased
in tension
pneumothorax
In any ill-appearing patient with tachycardia and hypotension or high shock index, the shock must be considered. The mentioned signs,
symptoms and relevant diagnostic tests often help to arrive at a diagnosis and initiate appropriate treatment. However, certain disease
processes can complicate the picture and lead to an alternate diagnosis. Therefore, understanding the shock physiology is important
(Table 3.30). The labs should be completed, but it is important not to wait for the results before initiating treatment.
Using certain criteria to help make the diagnosis and point to specific types of shock is more beneficial.
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Septic shock Tachypnoea: respiratory rate greater 2. Heart rate >100 beats/min
• SIRS (Systemic Immun Response than or equal to 22 breath per
3. Respiratory rate >20 breaths/min
Syndrome) – Two or more of the minute. 2 or more criteria violation in
or PaCO2 <32 mmHg
following: Q sofa score is considered the poor
outcome predictor. 4. Arterial base deficit <-4 mEq/L or
1. Temperature >38°C or <36°C
lactate >4 mmol/L
• Septic shock
2. Heart rate >90 beats/min
5. Urine output <0.5 mL/kg/hr
• Sepsis and hypotension despite
3. Respiratory rate >20 breaths/min
adequate fluid resuscitation. 6. A r t e r i a l h y p o t e n s i o n > 3 0
or PaCO2 <32 mmHg
continuous minutes
Hemorrhagic shock
4. WBC >12,000/mm3, <4,000/
• Simple hemorrhage Cardiogenic shock
mm3, or >10% band neutrophilia
• Cardiac failure
• Suspected bleeding with normal
• Sepsis
vitals and normal base deficit • Clinical evidence of impaired forward
• SIRS with finding the source of flow of heart, including presence of
• Hemorrhage with hypoperfusion
infection and associated with organ dyspnea, tachycardia, pulmonary
damage or hypoperfusion. • Suspected bleeding with base deficit edema, peripheral edema, or
<-4 mEq/L or persistent pulse >100 cyanosis.
• Sequential Organ Failure Assessment
beats/min
(S.O.F.A. or sofa) was recently • Cardiogenic shock
described and created multiple • Hemorrhagic shock
• Cardiac failure and at least four
discussions in emergency and critical
• Suspected bleeding with at least four criteria of that similar to hemorrhagic
care journals. q (Quick) sofa score
of the following criteria: shock.
includes Hypotension: systolic blood
pressure less than or equal to 100 1. Ill appearance or altered mental
mmHg, Altered mental status, and status
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Emergency Treatment acceptable. Additionally, controlling the through beta-1 adrenergic agonist
Options source of bleeding is critical. In special effect, and it may cause mild peripheral
cases like hereditary or acquired bleeding vasodilation through beta-2 adrenergic
Fluid Resuscitation diathesis, platelet transfusion is indicated agonist effect. Dopamine at moderate
Two large bore IV access should be if platelet count <50,000/μL. FFP doses (5-10 μg/kg/min) has alpha and
obtained to support the circulatory transfusion is indicated for patients on beta-1 adrenergic effects.
system. A central line is also very warfarin with an elevated INR and
b e n e fic i a l i n d e l i v e r i n g flu i d a n d significant bleeding, liver failure, or Treatment Success
m e d i c a t i o n , e s p e c i a l l y i n o t ro p e s . Monitoring fluid status is encouraged by
massive transfusion (>10 units PRBC in
Crystalloid fluids (normal saline or using a urinary catheter, intra-arterial
24 hours). PCC is used for warfarin
Ringer’s lactate) should be used in blood pressure measurements, and
reversal (FFP, if not available). In a
boluses (2-3 L bolus in 5-20 min – 20ml/ central venous pressure monitoring.
massive transfusion, plasma, platelets,
kg in neonates and pediatrics). Pay close and red blood cells should be given in When patients’ hemodynamic status
attention to patients in cardiogenic shock. 1:1:1 ratio. become normal (blood pressure, heart
Do not administer I.V. fluids rapidly to
rate and urine out put) and necessary
patients with signs of pulmonary Inotropes
volume restored. These help to maximize
congestion. Small fluid boluses such as If volume resuscitation does not improve
tissue oxygenation, resolution of acidosis
250 mL should be preferred in those the patient’s hemodynamic status and
and decrease lactate levels. These are
cases. MAP remains below 65, inotropes may be
the findings of successful resuscitation.
used. Inotropes are also used in
Blood Products Resuscitation cardiogenic shock for depressed LV
Medications
Blood transfusion is considered if there is function. Norepinephrine (2-10 mcg/min) • Distributive shock
no response to two liters of fluid boluses, stimulates alpha and beta-adrenergic
ongoing hemorrhage, or impending receptors, increasing peripheral vascular • The treatment depends on the
cardiovascular collapse. O-negative tone. Dobutamine (2.5-15 mcg/kg/min) specific cause of shock.
blood is standard for child-bearing may improve myocardial contractility and
women and O-positive in men is augment diastolic coronary blood flow
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• In septic shock, it is important to • Pediatrics: 0.01 mg/kg, max 0.3 Image 3.25 Chest X-ray shows
start early broad-spectrum mg of 1:1000 solution IM q5-10 position of the chest tube in a patient
with pneumothorax.
antibiotics: minutes
massive P.E., and afterload reduction until rates from severe shock can exceed 50
• Adults: 0.3-0.5 mg of 1:1000 percent. Even after aggressive treatment
definitive treatment in aortic dissection.
solution IM q5-10 minutes in the ED, ICU admission is required.
196
References and Further Reading, click here
197
Chapter 4
Selected
Cardiovascular
Emergencies
Section 1
Case Presentation
by Lit Sin Quek A 75-year-old obese man comes to the emergency
department. He has history C.O.P.D., hypertension. He is a
smoker and on regular follow-up with primary care. He
describes sudden onset severe flank and back pain for past 2
hours. He denies any chest pain or dyspnea. He informs the
physician about his chronic abdominal pain. His initial vital
signs are HR 98 bpm, RR 24/min, BP 190/105 mmHg, T
36.9C. His examination revealed mild abdominal pain without
rigidity or rebound tenderness. Bedside ultrasonography
performed and the result is shown below.
Image 4.1
199
Introduction The leading causes of AAA are; •Cardiovascular risk factors and
Abdominal Aortic Aneurism (AAA) rupture vascular bed affection: People with
• Atherosclerosis coronary artery disease and peripheral
is one of the serious problems which
should be suspected in every • Genetic predisposition (weakening vs. artery disease are more prone to have
hypotensive elderly with abdominal pain. occlusion) AAA.
This chapter’s learning objectives are;
• Connective tissue diseases • Family history: A family history of AAA
• Understand the epidemiology and increases the risk of developing AAA.
pathogenesis of AAA • Marfan’s, Ehlers-Danlos The risk of developing an AAA may
reach 20% among brothers of a patient
• Appropriate diagnostic measures • Infection (Syphilis, salmonella, others)
with a known AAA.
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• Emphysema: It is the strongest Presentation •Myocardial infarction
independent risk factor for rupture. Abdominal/back pain, a pulsatile mass,
• Musculoskeletal back pain
Prevalence is 5% to 7% of people over and hypotension are known as the classic
the age of 65 in the United States. triad, but only seen 1/3 of the patients. The patients may have a variety of
There is a 3:1 ratio of men to women. So, you have to lower your threshold to differential depending on their symptoms.
After age 65, the prevalence of 3 cm be suspicious for cases showing The important clue to keep in mind is
aneurysms in men increases by epidemiologic warnings described above. each of these specific diseases shows
approximately 6% per decade. their specific symptoms, and as a rule of
Critical Bedside Actions and thumb, these symptoms may be indirectly
Types of AAA General Approach mimicking AAA, especially elderly
• Saccular aneurysm – is an outpouching As described in many other chapters
patients and patient who have risk
arising from one part of the aorta, has a (e.g., Shock), the primary goal is the
factors.
neck, and does not involve the entire re s u s c i t a t e a n y u n s t a b l e p a t i e n t .
circumference of the aorta. Therefore, airway, breathing, circulation History and Physical
should be evaluated immediately and Examination Hints
• Fusiform aneurysm – is tubular in
resuscitative measures implemented. If Many of the patients are elderly. Because
shape, involves the entire
the rupture is suspected, immediate of their pain sensation affected by
circumference of the localized aorta,
s u rg i c a l c o n s u l t a t i o n a n d b l o o d multiple comorbidities, AAA patients may
and has no neck.
transfusion to the patient is a must. Do not give clear history hints to physicians.
• Pseudoaneurysm – dilatation is only at not delay the definitive treatment which is Most of the times, symptoms are very
the outside layer of the aorta (tunica surgery. subtle unless hypotension and shock
adventitia) situation in rupture. The patients showing
Differential Diagnoses epidemiologic risk factors should be
• Mycotic aneurysm – a rare aneurysm • Renal colic
questioned very carefully.
caused by a fungal infection which may
be associated with immunodeficiency, • Diverticulitis
Physical examination of the patients
IV drug abuse, heart valve surgery. should include relevant organ systems
• GI bleeds
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that patient having risk factors or symptoms. Specific attention Laboratory tests
should be given to understand instability. The most important issue for these patients is bleeding.
Therefore, type and cross-match blood is the most critical test.
Specific exam for AAA includes deep gentle palpation, above the
CBC, Urea/Creatinine, coagulation studies and urinalysis are
umbilicus, left of midline, continuous over several heartbeats.
other tests.
Bleeding into retroperitoneum may create doughy abdomen.
Hypotension also minimizes pulsations. Imaging modalities
• Ultrasound provides low cost, reliable, fast and safe approach.
Some facts;
However, it is operator dependent modality. Poor imaging
• 38% patients AAA initially detected by physical examination above renal vessels, obesity, intestinal gas, or very painful
abdomen may affect the proper investigation. Please see RUSH
• 62% found incidentally on imaging studies done for other protocol chapter to learn more about aortic ultrasonographic
indications
evaluation.
E m e r g e n c y D i a g n o s t i c Te s t s a n d
Interpretation
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Abdominal aorta investigation with ultrasound. Tutorial in 3 • Abdominal X-Ray/KUB may incidentally show findings of
minutes take a look this video. AAA. AAA can be seen in 60-75% of cases in the x-ray with the
calcification of aortic wall or paravertebral mass.
• CT Scan with contrast is a gold standard (Image 4.3). It shows
better demonstration extent and complications of an aneurysm, • Cross-table lateral most helpful view and a negative study is not
retroperitoneal blood because of rupture, and dissection. helpful.
However, the patient instability affects the usage of this imaging
modality. Emergency Treatment Options
Medications
Image 4.3 CT scan - AAA There are no specific medications for AAA patients. However,
some patients may require blood pressure and arrhythmia
management. In the unstable patients, intubation with rapid
sequence intubation (RSI) protocol, fluid and blood replacement
should be considered. Analgesics also an important part of the
treatment.
Procedures
Any critically ill patient who diagnosed AAA (potentially rupture)
should immediately be intubated and airway secured. This also
prepares the patient for the operation theatre. Some patients may
have no peripheral IV access because of their shock situation.
These patients require an intraosseous line or central I.V
placement. Although these resuscitative measures keep the
• MRI has no advantage over CT scan.
patient alive and any ruptured patient should directly go to the
• The angiogram is not preferred for diagnosis but good for pre- operation theatre, you should also know some other red flags for
op “mapping.” the indications for repair of AAA.
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• Size more than 5.5 cm. However, 5.0 Additional Information: see the video on are associated with similar mortality
cm still used in common practice by repairs – link up to 10 years.
many surgeons.
Clinical Key Points – putting Patients treated with endovascular
• Symptoms such as abdominal or back it all together repair require long-term surveillance
pain, to groin in some cases or Abdominal aortic aneurysms are owing to a small risk of aneurysm sac
tenderness of AAA. asymptomatic until they rupture, reperfusion and late rupture.
resulting in a mortality of 85 to 90%.
• Risk of Rupture: Emphysema, smoking, Decisions regarding prophylactic
hypertension increase likelihood of Urgent repair is the only definitive repair — whether to pursue and what
rupture. Regarding Powell et al.’s study option for symptomatic patients. type of repair to perform must take
aneurisms less than 5.5 cm in diameter into account anatomy (not all
has less than 1% of rupture in one year. Although the optimal group to be situations can undergo endovascular
Above 5.5 cm risk is between 9.4% to screened remains controversial, repair), operative risk, and patient
32.4 (more than 7 cm). preference.
Smoking men or women 65 to 75
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Discharge criteria
• Asymptomatic patients only patient group can be discharged if
they do not have any risk factor for rupture. Patient with risk
factors should be evaluated carefully. If they are decided to
discharge, close follow-up in the clinic should be arranged. The
outpatientclinic folow-up for other patients must also be
arranged before their discharge from the emergency
department. Instruction specific to AAA should be given to
patients.
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Section 2
Case Presentation
by Khalid Mohammed Ali, Shirley Ooi A 46 years old man with a past medical history of
hypertension and hyperlipidemia developed central crushing
chest pain associated with sweating and shortness of breath
while driving. He presented to the emergency department 1
hour after the onset of chest pain. On physical examination,
his vital signs were as follows; pulse rate: 60 beats/min, blood
pressure: 100/50 mm Hg, respiratory rate: 20/min, SpO2 98%
on room air. Patient has no leg edema, new murmur or
features of heart failure.
206
• Chest pain described as pressure, squeezing or a burning
Image 4.4
sensation across the precordium and may radiate to the neck,
shoulder, jaw, back, upper abdomen, or either or both arms.
• Palpitation
Definition Do not forget to ask about the risk factors. You can use the TIMI
Acute coronary syndromes (ACS) include conditions that share score.
the same pathophysiology of myocardial ischaemic states, i.e.,
TIMI (Thrombolysis in Myocardial Infarction) investigators have
unstable angina (UA), non-ST elevation myocardial infarction
developed a 7-variable risk stratification tool that predicts the risk
(NSTEMI) and ST-segment elevation myocardial infarction
of death, re-infarction, or urgent revascularization at 14 days after
(STEMI).
the presentation:
207
• Prior coronary artery stenosis of ≥ 50% the base of the lung may indicate either existing heart failure or
an acute one secondary to acute myocardial ischemia
• >= two angina events in the preceding 24 hours
• A new cardiac murmur may indicate acute valvular insufficiency
• Aspirin use in the previous seven days
or rupture interventricular septum
• ST-segment deviations of ≥ 0.5 mm on ECG at presentation
• Distant heart sound on auscultation of precordium may indicate
• Positive cardiac biomarkers acute pericardial effusion secondary to rupture of a free
ventricular wall or acute aortic dissection with extension to
Patients are considered to be high risk if their TIMI risk score is ≥ precordium.
5 and low risk if the score is ≤ 2. High-risk patients have a more
significant benefit from early percutaneous coronary intervention In addition to the above, it is essential to check the vital signs
and use of adenosine phosphate inhibitor and low molecular carefully. If the patient has hypotension with acute myocardial
weight heparin than lower risk patients. ischemia, this may indicate cardiogenic shock. Tachycardia may
range from sinus tachycardia to ventricular tachycardia;
Most of the cases with ACS have a normal cardiovascular bradycardia, on the other hand, may range from sinus
examination. In a busy emergency department where time is of an bradycardia to third-degree heart block.
essence, targeted physical examination in the patient with ACS is
important to rule out complications and possible differential Differential Diagnosis
diagnosis. There are many critical differential diagnoses when we consider
A.C.S. Please look for all in the given table. However, Unstable
The following are essential components:
angina, Acute myocardial infarction, Acute pulmonary embolism,
• Differential pulse and BP between both arms, which if present Acute aortic dissection, Tension pneumothorax, Oesophageal
may indicate the possibility of aortic dissection rupture (Boerhaave’s syndrome) are the life-threatening ones. We
advise you to read these chapters form multiple resources to feel
• Tachypnoea, pitting leg edema and raised jugular venous confident.
pressure with crackles in the base of the lung or only crackles in
See the following table:
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• Arrhythmias include tachyarrhythmias and
Table 4.1 ACS/Chest Pain Differential Diagnosis bradyarrhythmias
LIFE REFERRED
CVS RESPIRATORY GI
THREATENING PAIN
• Cardiogenic shock
Unstable Stable angina Pneumonia Gastro- Sub phrenic
angina oesophageal abscess /
Acute Simple reflux inflammation
• Cardiac arrest in the form of ventricular fibrillation
Acute pericarditis pneumothora
myocardial x Oesophageal Hepatobiliary
infarction Myocarditis spasm disease Decision Making Process and Reaching The
Acute
Diagnosis
pulmonary There are three pillars of diagnosis: history, ECG, and cardiac
embolism
enzymes.
Acute aortic
dissection Clinical features of unstable angina include the following:
Tension
pneumothora • Unstable angina differs from stable angina in that the chest pain
x
is usually more intense, easily provoked, more prolonged, more
Oesophageal
rupture
frequent and more severe. All first presentation of angina should
(Boerhaave’s be regarded as unstable. In unstable angina typically there is
syndrome)
either no ECG changes or non-specific ECG changes, the
patient is usually chest pain-free on presentation to the
Acute Complications emergency department, and the cardiac enzymes will be
The acute complication which we may see in the emergency
normal.
department includes the following:
• NSTEMI should be diagnosed in any patient whose cardiac
• Acute pulmonary edema due to acute myocardial ischemia
enzymes are raised without evidence of ST elevation MI. An
which leads to decrease effective ejection fraction and heart
NSTEMI does not need to have ECG changes at the time of
failure
presentation. The ECG may show the following:
• Mechanical complications include rupture of papillary muscles,
1. ST-segment depression
free left ventricular wall, and interventricular septum
209
2. The transient ST-segment elevation that resolves
Table 4.2 ST Segment Changes And Its Anatomical Relation
spontaneously or after glyceryl trinitrate treatment In Acute Myocardial Infarction
3. T-wave inversion ST SEGMENT
LOCATION LEADS
CHANGES
4. Evidence of previous myocardial infarction
The ECG can also be normal. It should not show persistent acute Inferior wall II, III, aVF Elevation
ST-segment elevation.
V8 and V9 Elevation
• STEMI (ST-segment elevation MI) is a true cardiac emergency. Posterior wall
V1-V3 Depression
The criteria of diagnosing ST-segment elevation MI on ECG
are: New ST elevation at the J point in at least two contiguous
Right Ventricular wall
V4R, V5R, V6R Elevation
leads of ≥ 2 mm in leads V2–V3 and/or of ≥ 1 mm in other MI
contiguous chest leads or the limb leads.
210
There are other causes of ST elevation should be known to acute pulmonary congestion or indicate the diagnosis
differentiate it from the ST elevation of myocardial infarction. of other conditions like pneumothorax or acute aortic dissection.
These are;
Emergency Treatment Options
• Acute pericarditis
Initial Stabilization
• Benign early repolarization In typical emergency medicine room, once a patient presents with
chest pain suspecting of acute myocardial ischemia should be
• Brugada’s Syndrome
seen in the monitored area, the patient should remain under
• Hyperkalemia continuous cardiac monitoring, HR, BP, and SpO2.
• Left Bundle Branch Block The proper approach will consist of all following:
• Left ventricular aneurysm ECG should be done immediately or within the first 10
minutes by the emergency room staff nurse, which should
• Left ventricular hypertrophy be interpreted by a senior doctor.
Cardiac enzymes (CKMB, Troponin T or I) are highly sensitive to Radiological examination of the chest will be required only
cardiac muscle injury. Another lab investigation is full blood to diagnosis acute pulmonary edema, rule out possible
count, urea, and electrolyte. A chest x-ray may give clues to differentials like pneumothorax or aortic dissection.
211
Antiplatelet typically aspirin 300 mg and either Ticagrelor
Table 4.3 Advantages And Disadvantages Of Thrombolysis
180 mg or Prasugrel 60 mg. Versus PCI
GTN sublingually or spray to relieve chest pain, if chest pain
THROMBOLYSIS PCI
persists after two sublingual GTN tablet, proceed with GTN
infusion especially if the patient has concomitant Advantages Rapid administration Better clinical efficacy i.e.
Widely available superior vessel patency,
hypertension or heart failure. Convenient TIMI grade 3 flow rates
and reduced occlusion
IV morphine with anti-emetic if chest pain persisted and rates
Less haemorrhage
titrated according to the response of the patient. Early definition of
coronary anatomy allows
tailored therapy and
Oral beta blocker if no contraindication within 24 hours. more efficient risk
stratification
Definitive treatment depends on which condition within the
acute coronary syndrome is diagnosed. Disadvantages Patency ceiling, i.e. Delay limits efficacy
infarct-related artery is Less widely available
restored in only 60-85% Requires expertise
STEMI should undergo reperfusion therapy preferably of patients, with a normal
TIMI grade 3 epicardial
percutaneous coronary intervention (PCI) or intravenous coronary flow in only
thrombolytic therapy 45-60% of patients
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In the absence of PCI, thrombolysis is alternative, and the In the acute management of acute coronary syndromes, please
following should present for the patient to be a candidate of take note of the following:
thrombolysis:
If the patient is in shock, always look for precipitating causes:
• Typical chest pain of AMI
1. Do a gentle rectal examination to look for gastrointestinal
• ST-segment elevation fulfilling the criteria stated above bleeding.
• Chest pain <12 hours from onset 2. Is the patient bradycardic? Treat according to ACLS guidelines.
• Patients <75 years of age 3. Is the patient tachycardic? Treat according to ACLS guidelines.
Table 4.4 Contraindications Of Intravenous Thrombolysis 4. Does the patient have a right ventricular infarct?
213
5. Is the patient in cardiogenic shock because of mechanical
complications, e.g., papillary muscle dysfunction or rupture,
septal rupture or cardiac tamponade from free wall rupture?
214
Section 3
Case Presentation
by Walid Hammad An ambulance crew rushes into your emergency department
(ED) with a 56-year-old man. He is severely short of breath,
sitting upright on the stretcher, using his accessory respiratory
muscles, and gasping for air. You find that he is diaphoretic,
tachypneic, and in severe respiratory distress. You ask him,
“What’s going on?” He replies: “I…can’t…(pauses and inhales
a shallow breath)…breathe!”
The paramedics inform you that they received a call from the
patient’s wife about 6:30 that morning, saying that her
husband was short of breath and sweaty and that he had
vomited once. The wife told them that she and her husband
had returned from a long trip the night before and that her
husband had not taken his “water pills” because he did not
want to stop for frequent restrooms breaks during their drive.
Audio is available here
When they got home, he still did not take his pills because he
215
wanted to sleep through the night. His breathing Critical Bedside A c t i o n s a n d G e n e r a l
problems woke him during the night, and he tried Approach
The first step in managing such a patient, as for most ED
to get more comfortable by adding pillows under patients, is measuring vital signs. This information will help you
his head to the point that he was almost sitting identify a part of the pathology. For example, if the patient is
up in bed. hypertensive, he could be in acute heart failure; on the other
hand, if the patient is hypotensive, he could be in shock. Similarly,
You thank the paramedics and turn back to the if the patient is tachycardic, his symptoms could be caused by
the very fast heart rate; conversely, if he is bradycardic, he could
patient, who now looks even worse. He is more
have symptomatic bradycardia. The vital signs will guide your
short of breath, and you sense that he is getting treatment options. When you examine the patient described in
tired, about to give up. He looks like he is about this case report, you find his blood pressure (BP) to be 265/145
to collapse. What is your next step? mm Hg, his heart rate (HR) to be 138 beats/min, his respiratory
rate at almost 40 breaths/min, and his pulse oximetry reading is
92% on 4 liters of oxygen delivered by nasal cannula. (Note: A
patient who is severely short of breath might be breathing through
his or her mouth, so a nasal cannula may not be of great benefit;
in these patients, the use of a face mask might be prudent.)
216
On the other hand, a patient who presents with the same clinical by the increased systemic vascular resistance (SVR) that is
picture but with a low BP instead of a high one could have APE or generating an extremely high BP in the aorta. With such elevated
acute LVF secondary to cardiogenic shock. In this scenario, your BP, the left ventricle is unable to offload the suitable amount of
treatment choices will change, and your strategy will be directly blood with each stroke, i.e., stroke volume (SV) is decreased,
opposite that for a patient with elevated BP. It is crucial to make leading to a decrease in cardiac output (CO). With time, if the
this distinction early because the administration of vasodilators in preload does not decrease and the afterload continues to
high doses to a patient in cardiogenic shock could have a increase, the blood will back up behind the left ventricles (in the
devastating outcome. lungs), causing the lungs to become engorged with accumulated
blood and thus increasing transudation of protein-poor fluid into
The second step in management is the clinical examination. In a
the interstitial space and the alveoli. This cascade compromises
patient with AHF with consequential severe APE, the clinical
the air exchange mechanisms, causing the patient to manifest
picture might resemble severe Stage D congestive heart failure
signs and symptoms of respiratory failure, presenting clinically as
(CHF), but with a swifter, more acute onset. Generally, the patient
tachypnea and hypoxia.
is in moderate to severe distress, is uncomfortable, and is usually
diaphoretic, with jugular venous distention (JVD) and bilateral The First 5 to 10 Minutes
rales on lung examination. Depending on how long the patient The main pathology in AHF is the extremely high SVR in the heart,
has been in severe CHF, the rales might be basal initially but then so the treatment modalities should focus on decreasing the
heard in all lung fields, up to the apices, in late stages or even resistance, i.e., decreasing the blood pressure (afterload) or
audible without a stethoscope. decreasing preload. The mean arterial pressure (MAP) can be
used as a treatment guideline. It is determined by the cardiac
Hepatic engorgement, a positive abdominojugular test, and
output (CO) and SVR: MAP=CO x SVR. Note that about 50% of
bilateral lower extremity edema are signs of chronic CHF and
patients presenting with APE are euvolemic rather than
might not have developed yet in a patient with acute left heart
hypervolemic and that the treatment options should focus on
failure. These signs start to manifest when the pulmonary arterial
volume redistribution rather than volume removal.
wedge pressure increases. Think about the pathology: the heart
(the pump or engine), specifically the left ventricle, is unable to Since you do not want to decrease CO in a patient who is barely
pump the blood against the overwhelming resistance generated perfusing because of the elevated BP, your best bet is to work on
217
decreasing preload and/or SVR and thus decrease the MAP. This • Myocardial Infarction
can be achieved by several means. However, in this scenario, in
• Nephrotic Syndrome
which the patient is extremely ill and needs the MAP to be
dropped quickly, we head directly to the rapid-onset options— • Neurogenic Pulmonary Edema
nitro derivatives (fast-acting nitroglycerin derivatives) and BIPAP
or CPAP. • Pneumothorax
• Pulmonary Embolism
Differential Diagnoses
• Acute Kidney Injury • Respiratory Failure
• Goodpasture Syndrome • Bilateral pulmonary rales are typical of APE but not specific.
Rales on only one side could suggest other causes such as
• Idiopathic Pulmonary Fibrosis
pneumonia or emphysema (dry crackles).
• Interstitial (nonidiopathic) Pulmonary Fibrosis
218
• APE can also present as bilateral wheezing (cardiac asthma); output (CO=HR X SV). The ECG could also reveal a left
however, this presentation should not be confused with the ventricular strain pattern.
wheezing associated with pure reactive airway disease or
3. With proper training, emergency physicians can reliably obtain
asthma.
the following information with an ultrasound examination
• If the patient presents with altered mental status or has an performed at the bedside:
abnormal neurologic exam, the APE might be neurogenic
• Determine left ventricular ejection fraction as a broad
pulmonary edema.
categorization (normal, moderately reduced, severely
• If the patient is receiving dialysis or has nephrotic syndrome, reduced) – link
cirrhosis, or other causes of volume overload, the backbone of
• Check for pulmonary congestion/edema – link
treatment will be diuresis rather than redistribution (preload or
afterload reduction). • Evaluate volume status by examining the inferior vena
cava – link
• If lung sounds are unequal, the patient might have a
spontaneous pneumothorax. If the patient is as sick as the one
Laboratory Tests
in our scenario, he or she could be experiencing cardiac 1. Complete Blood Count (CBC): May show an elevated white
tamponade (pay attention to the position of the trachea). blood cell (WBC) count, which may indicate an infectious
cause rather than a cardiac cause. However, stress in itself can
Emergency Diagnostic Tests and induce hypoxia and shortness of breath, which can cause
Interpretation margination of WBCs, leading to an elevated WBC count. A
Bedside Tests patient with severe chronic obstructive pulmonary disease
1. By placing the head of the stretcher at a 45-degree angle, you (COPD) or Goodpasture syndrome is likely to be taking
should be able to assess the patient for JVD. corticosteroids, which can raise the WBC count.
2. An electrocardiogram (ECG) might show sinus tachycardia, 2. Comprehensive Metabolic Panel (CMP): May indicate renal
atrial fibrillation, or another arrhythmia (tachycardia or failure if the SVR is so high that it is causing severe spasm in
bradycardia), suggesting the reason for a decrease in cardiac the renal artery and thus impairing kidney function, especially if
219
the patient has other comorbidities that predispose him/her to
Image 4.5
kidney injury. The patient might be alkalotic in response to
tachypnea, which presents as low CO2. He may also present
with acidosis due to elevated lactate levels resulting from
tissue hypoxia. Liver function test results could be elevated,
especially if the patient has long-standing CHF that is causing
hepatic engorgement.
Imaging Modalities
A chest x-ray (obviously a portable frontal view in our patient)
would show pulmonary congestion, with cephalization of the Emergency Treatment Options
pulmonary vessels, Kerley B lines, peribronchial cuffing with air Initial Stabilization
bronchograms, a “bat wing” pattern, and possibly, though not 1. If the patient is lying down flat, move him/her into a sitting
always, an increase in cardiac shadow size. Note that not all position, which should lessen the pooling of blood in the lungs
these findings may be present on the chest x-ray. and allow the utilization of the superior lung fields for aeration
and gas exchange.
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Non-invasive positive pressure ventilation (NIPPV) • N i t r o g l y c e r i n might cause hypotension, which is
usually temporary and associated with overall clinical
NIPPV for cardiogenic pulmonary edema is an effective and safe
improvement. However, the persistence of the
modality in adult patients with APE. There is a potential benefit of
hypotension after the nitroglycerin is stopped might
NIPPV in reducing mortality.
indicate a right ventricular malfunction, e.g., right
ventricular MI or volume depletion.
Medications
• Nitro derivatives: Nitrogen inhibits the motor function of the • Intravenous nitroglycerin can be administered, starting
smooth muscles in the systemic vasculature, leading to as a drip at 0.5‒0.7 mcg/kg/min and then increased by
vasodilation and a decrease in SVR. 10‒20 mcg/min q3-5 minutes up to 200 mcg/min. The
BP must be monitored closely during administration.
• Nitroglycerin: Reduces preload.
• Nitroglycerin has been found to be safe for use in • Transdermal nitroglycerin (1‒5 cm) can be applied to the
patients with acute heart failure and improves short- chest wall.
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• Dosage: 0.3–10 mcg/kg/min doses, is more helpful than the oral route; diuresis will begin
within 15 to 20 minutes after administration.
• Pediatric dosing: 0.25‒4 mcg/kg/min to a maximum
dose of 10 mcg/kg/min • The dose in emergency circumstances can be up to 2.5
times the patient’s regular dose. If the patient is loop diuretic
• Safety profile: Class C in pregnancy. Possibly unsafe
naïve; give 40 mg IV of furosemide or the equivalent of
during lactation
another loop diuretic.
• Nesiritide:
• Check the safety profile for each individual medication that is
• Has not been found to increase or decrease the rate of considered or administered.
hospitalization or death. It might have a negative effect,
• Inotropics:
causing hypotension. Its use in acute heart failure is still
being investigated. • Severe left ventricular dysfunction or acute valvular problems
may cause hypotension in some patients. Therefore, using
• Dosing: 0.01 mcg/kg/min IV to a maximum of 0.03 mcg/
the above agents can be harmful to these patients.
kg/min
Therefore, inotropic medications such as dopamine and
• Safety profile: Class C in pregnancy. Safety during dobutamine can be inevitable to preserve normal blood
lactation is unknown pressure.
222
intensive care unit or an intermediate care unit based on the
institution’s ability to handle the necessary therapeutic
modalities, especially drips and noninvasive positive-pressure
ventilation (NIPPV).
223
Section 4
Aortic Dissection
Case Presentation
by Shanaz Sajeed A 56-year-old male presented to the emergency department
with sudden onset of severe tearing chest pain radiating to the
back. He had a history of hypertension and hyperlipidemia. He
was a smoker. Upon arrival, he appeared to be diaphoretic
and in severe pain. He denied any prior history of chest pain.
He had been without any infective symptoms lately. He was
compliant with his medications, namely, amlodipine and
simvastatin. At triage, his blood pressure was noted to be
80/60 mmHg with a pulse rate of 130 bpm. His oxygen
saturation was 95% on room air, and his respiratory rate was
22 breaths per minute. On examination, he had muffled heart
sounds, jugular venous distention, and radio-radial pulse
delay.
224
Introduction Illustration 4.1 De Bakey and Stanford classification of
Aortic dissection carries high morbidity and mortality. Although aortic dissection.
patients generally present with acute symptoms and classic
signs, a subset of patients may present with syncope, GI
bleeding, and neurological deficits. The clinician needs to remain
vigilant for such atypical presentations. There are two standard
anatomical classifications – Stanford and De Bakey. Stanford type
A dissections (De Bakey I and II) involve the ascending aorta.
Stanford type B (De Bakey III) dissections arise distal to the left
subclavian artery (Illustration 4.1). Stanford A dissections are
more common than Stanford B dissections (62% vs. 38%). The
aortic wall consists of 3 layers – the intima, media and an outer
layer known as the adventitia. Classic nontraumatic aortic
dissection is usually due to a tear in the intimal layer of the aorta,
leading to an intimal flap. The bridge between the media layer and
the aortic lumen causes a subintimal hematoma. Then intima gets
separated from the underlying media and adventitia. This false
lumen of varying size may result in complete occlusion of major
arteries that branch from the aorta leading to major ischemic
complications such as limb ischemia, paralysis, stroke, renal
failure as well as cardiac events. Critical Bedside Actions and General
Approach
The initial management of a patient with chest pain and
hypotension warrants observation in a monitored area with
continuous SpO2 and cardiac documentation. The physician
needs to assess airway, breathing, and circulation. A compromise
in any of these necessitates immediate action. In this case
225
scenario, for example, the next priority History Taking and Physical Other symptoms include dyspnea,
would be to determine the etiology of this Examination Hints dysphagia, focal weakness and altered
patient’s hypotension and to initiate mental status. Type B dissections present
resuscitative and stabilizing measures. History Taking Hints s i m i l a r l y. O c c l u s i o n o f t h e m a i n
The physician should As initial resuscitation is going on, a abdominal aortic branches may lead to
focused history should be obtained at the mesenteric and solid organ ischemia.
• Administer supplemental oxygen and bedside. Inquire about the site, onset, Patients may present with gastrointestinal
assess the patient’s airway, breathing, nature, duration, radiation as well as bleeding, oliguria or anuria. Therefore,
and circulation to determine the need aggravating and relieving factors of the asking about gastrointestinal symptoms
for any immediate critical interventions. chest pain. Patients with acute Type A is an essential part of the history. Risk
dissection classically present with : factors for aortic dissection should be
• Secure venous access by inserting two
large bore IV cannulas into the assessed. These are;
• Sudden onset of ‘ripping’ or ‘tearing’
antecubital fossa. chest pain (85%) and/or interscapular • An aortic aneurysm
back pain (46%)
• In the hypotensive patient, administer
• Atherosclerosis
an initial IV fluid bolus of 20 ml/kg • Pain is usually maximal at onset, unlike
crystalloid. MI where pain usually gradually • Chronic Hypertension
increases in intensity.
Note: A small initial bolus of fluid would • Coarctation of the aorta
not be harmful. Even in cardiogenic • Pain may migrate distally to the
• Congenital aortic valvular defects (e.g.,
shock, it is likely to improve cardiac abdomen as dissection progresses
bicuspid aortic valve)
output and blood pressure transiently.
Thus, one should not be hesitant to give • However, a minority of patients may
• High-intensity weight lifting
an initial bolus of fluid in the hypotensive present atypically with abdominal pain
patient even if the etiology of shock is not (22%), syncope (13%) and stroke (6%). • Increasing Age
immediately apparent.
• Patients often describe the pain as • Infection leading to aortitis
knife-like.
226
• I n fla m m a t o r y p ro c e s s e s d u e t o • Vasculitis facilitate diagnosis as soon as
vasculitis. e.g., Takayasu’s aortitis possible. Assess for pulse deficits. Pulse
The physician should also assess the
deficits are diminished or absent pulses
• Inherited connective tissue disease patient’s anticoagulants use for increased
caused by compression of the true lumen
(e.g., Marfan’s, Ehlers Danlos Syndrome bleeding risk, such as Warfarin/Novel Oral
by the false lumen. Blood pressure
Type IV, familial forms of a thoracic Anticoagulants or antiplatelet agents,
difference between the left and right arm
aneurysm and dissection) which would increase their bleeding risk.
suggests aortic dissection. BP difference
It is also vital to elicit any specific
• Male gender >20 mmHg between the two limbs is
allergies that may affect therapy or
significant. Data analysis from the
• Substance abuse such as cocaine, prohibit the use of IV contrast for imaging
International Registry of Acute Aortic
methamphetamine, MDMA purposes. Elicit any relevant social history
Dissection (IRAD) revealed that fewer
including questions about illicit drug use.
than 20% of patients with proven acute
Past medical history findings that should Note: Cocaine use is associated with
aortic dissection had reported pulse
prompt consideration of aortic dissection acute dissections.
d e fic i t s . T h e c a r d i o p u l m o n a r y
include:
examination should focus on signs of
Physical Examination Hints
• A family history of aortic dissection, As initial stabilizatio n and initial cardiac ischemia, aortic insufficiency,
aneurysm, or sudden death resuscitation take place, a focused cardiac tamponade and cardiogenic
clinical examination should shock. When listening to the heart
• Chronic hypertension (most common
simultaneously be performed. The sounds, listen for:
predisposing factor)
physician should assess for signs of
• Distant/muffled heart sounds suggest
• Documented aortic pathology shock (e.g., cold extremities, delayed
pericardial effusion.
capillary refill, weak, thready pulse.) and
• History of tuberculosis or syphilis
aim to determine the etiology of • Gallop rhythm, S3, S4 suggestive of
• Known connective tissue disorder hypotension if present. The physician heart failure.
should always consider bedside
• Previous cardiac surgery (especially ultrasonography (RUSH protocol) to
valve repair) or vascular surgery
227
• Diastolic murmur indicating aortic insufficiency. It is seen up to • Acute coronary syndrome
75% of Type A dissections.
• Pericarditis/Myocarditis
In the setting of the hypotensive patient, pulsus paradoxus and
• Pulmonary embolism
distended neck veins suggest cardiac tamponade. Examine for
pulmonary findings of: • Pneumonia/Pleural effusion
228
• Chest X-ray – Abnormalities suggestive of dissection are
Image 4.6 Chest x-ray showing aortic dissection findings.
present between 60-90% of cases.
These are;
Imaging Modalities
• Contrast-enhanced CT aortogram (Figure 2 and Figure 3) is
usually the investigation of choice. In cases where CT poses a
significant risk (e.g., pregnancy), MR Angiography of the aorta
can be done.
229
• Transesophageal echocardiogram (TEE) can be done at the
Image 4.8 CT scan - Stanford Type B dissection
bedside where there is a risk of contrast-induced nephropathy
(Patients with impaired renal function) or contrast allergy, or in
unstable patients.
230
Administer IV crystalloid bolus of 20 ml/kg blockers or Calcium Channel Blocker therapy. Avoid using
as sole therapy as it can cause reflex tachycardia.
Consider vasopressors (if needed) to maintain a MAP:
70-80 mmHg Practical Point: Hypotensive and drowsy patients need secured
airway or intubation before any advanced imaging. Induction
If pericardial tamponade is present, emergent
agents with cardiovascular stability are advised. Push dose
pericardiocentesis is indicated
vasopressors should be available in case of a precipitous drop in
Blood transfusion is indicated if the hypotension is due to blood pressure. Investigations and diagnostic workup should be
internal bleeding done in parallel with the resuscitation of the patient. Emergent
surgical/interventional consult should be sought for definitive
Hypertensive Patient management.
Aggressive blood pressure control is essential to reduce shear
stress: • Type A dissections are usually managed surgically. The principal
objectives are 1) relieve the symptoms, 2) reduce the
Target a systolic pressure between 100-120 mmHg or complications, and 3) prevent aortic rupture and death. The
MAP 70-80 mmHg. Heart rate should be between 60-80. affected layers of the aorta are sutured together, and the aorta
is reinforced with a graft. Endovascular therapy is now
IV ß-blockers are the first-line therapy.
becoming increasingly popular.
• Labetalol: 20 mg IV slow injection, then 40-80 mg IV
• Type B dissections are usually managed medically with
q10 min PRN, up to 300 mg IV total. An infusion of 0.5
aggressive blood pressure and pain control as well as continual
to 2.0 mg/min can also be run.
monitoring for signs and symptoms of complications. Surgical
Calcium channel blockers such as diltiazem or verapamil management indications include:
may be used in patients with contraindication to ß-
• Signs of bowel ischemia, limb ischemia or solid organ
blockers
ischemia
Sodium Nitroprusside may be added as adjunctive
• Persistent pain
therapy for elevated blood pressure refractory to ß-
231
• Expanding hematoma or impending rupture
Disposition Decision
Patients with acute aortic dissection should be managed in a high
dependency or intensive care unit. The overall in-hospital
mortality of aortic dissection is 27%. 30-day mortality of type A
dissection with and without surgery is 26% and 58%,
respectively. Type B dissection treated medically has 11% and
surgically has 31% 30-day mortality.
232
Section 5
Case Presentation
by Elif Dilek Cakal An 85-year-old woman, with a history of congestive heart
failure, presented with right leg pain and swelling of 2 days’
duration. She had been hospitalized for pneumonia one week
earlier. Her vitals on arrival were: Blood Pressure: 138/84
mmHg, Pulse Rate: 65 beats per minute, Respiratory Rate: 14
breaths per minute, Body Temperature: 37°C (98.6°F), Oxygen
Saturation: 96%. On examination, her right calf was reddish,
tender, edematous and 4 cm greater in circumference than the
left when measured 10 cm below the tibial tuberosity. Her
Wells’ Score for deep vein thrombosis (DVT) was 4 and
suggested high-risk for DVT. Compression ultrasonography
showed a thrombus in the popliteal vein. Enoxaparin (1 mg/kg,
twice a day, SC) was started. No signs and symptoms of
pulmonary embolism were observed. The patient was referred
Audio is available here to a cardiovascular surgeon as an outpatient after discussion
233
and confirmed understanding of discharge Introduction
The annual incidence of DVT is 92 cases per 100000 persons.
instructions.
The rate steadily advances with increased age (32/100000 if age
< 55 years, 282/100000 if age 65-74 years, 555/100000 if age
>74). While 90% of DVT occurs in lower extremities, 10% of DVT
occurs in upper extremities. Up to more than 40% of patients
with lower extremity DVT have concomitant pulmonary embolism
(PE), whether they may have related complaints or not.
235
History and Physical ankle. It is insensitive and • Prothrombin mutation
Examination Hints nonspecific, therefore, useless.
• Hyperhomocysteinemia
• Neither medical history nor physical
• Because only history and
examination is specific to DVT. Clinical • Deficient levels of clotting factors
examination are indeterminate, risk
presentation may range from nearly
factors for DVT are essential to • Congestive heart failure
asymptomatic to severely symptomatic
predict clinical probability. Known
or limb- or life-threatening. • Chronic obstructive pulmonary
risk factors for DVT are as follows:
disease
• As a general rule, unilateral limb pain
• Previous history of PE or DVT
and swelling imply DVT. • Air travel
• Recent Trauma or surgery
• Lower extremity DVT • Obesity
• Cancer
• Unilateral leg pain and swelling are • Phlegmasia alba dolens and
indicators of lower extremity DVT. • Central or long-term vascular phlegmasia cerulea dolens are vascular
Some patients may define fullness or catheter surgical emergencies. The features of
cramping in the posterior aspect of these conditions are summarized in
• Age
t h e l o w e r e x t re m i t y. B i l a t e r a l Table 4.6.
symptoms are more likely in the • Oral contraceptives
course of other diseases. However,
simultaneous bilateral DVT or • Hormone replacement therapy
Mechanism Massive iliofemoral Arterial flow disruption • Catheter-associated DVT is the predominant secondary
venous thrombosis and due to venous
associated arterial congestion and upper extremity DVT. Indwelling central venous lines, port
spasm increased tissue pressure
systems and pacemaker or defibrillator are leading
Thrombus location In major veins (collaterals In major veins and
are generally spared) collaterals predisposing factors in descending order. Cancer, surgery,
trauma, immobilization, pregnancy, oral contraceptive use
237
Emergency Diagnostics Tests and Emergency Treatment Options
Interpretation • The mainstay of medical therapy in ED is anticoagulation.
• Approximately 90% of DVTs occur in lower extremities.
• Possible anticoagulation options are summarized in Table 4.7.
Determination of pretest probability (PTP), D-dimer testing and
bedside compression ultrasound are the milestones of
management in ED.
Table 4.7 Medication For Anticoagulation in DVT
• Wells’ Criteria for DVT (link) stratifies patients according to their
CLASS OF
DVT risk. Scores ≥2 qualify a patient as “High Risk.” DOSE COMMENTS
AGENT
• A diagnostic algorithm is shown here (accessed at 10.05.2016) Unfractionated heparin 80 U/kg IV bolus, then Consider in inpatient therapy
18 U/kg/h IV infusion and in severe renal failure
(Dose adjustment based on APTT)
• D-dimer is useful for its negative predictive value. When
negative, it rules out DVT in the low-risk group. It does not Low Molecular Weight
Heparins
confirm DVT when positive.
Dalteparin 100 IU/kg, twice a day, SC A standard treatment for DVT,
200 IU/kg, once a day, SC preferred in outpatients as a
first line therapy if not
• Many ultrasound protocols for DVT are available. Related contraindicated
ultrasound videocasts can be found here (accessed at Enoxaparin 1 mg/kg, twice a day, SC A standard treatment for DVT,
1.5 mg/kg, once a day, SC preferred in outpatients as a
10.05.2016) first line therapy if not
contraindicated
• Upper-extremity DVT is diagnosed by Doppler ultrasonography. Tinzaparin 175 IU/kg, once a day, SC A standard treatment for DVT,
preferred in outpatients as a
first line therapy if not
Watch - A tutorial about diagnosing DVT with US. contraindicated
Factor Xa inhibitors
Watch - Normal and Abnormal US findings for DVT Fondaparinux < 50 kg - 5 mg, once a day, SC Do not use in renal failure
50-100 kg - 7.5 mg, once a day, SC
> 100 kg - 10 mg, once a day, SC
238
The indications for more advanced therapies like catheter- • <2 months: 1.5 mg/kg/ dose SC, twice a day
directed thrombolysis, percutaneous mechanical thrombectomy,
• >2 months: 1.0 mg/kg/dose SC, twice a day
conventional surgery or systemic thrombolysis are as follows:
The pain medication is advised for patients who are suffering from Patients With Isolated Calf Vein Thrombosis
severe pain. The need for treatment is controversial.
239
3. Is the patient at high risk for anticoagulant-related bleeding? • No contact telephone
4. Does the patient have major comorbidity or other factors that • Geographic location (too far from the hospital)
warrant in-hospital care
• Patient/family resistant to outpatient therapy
One or more positive answers should lead EP to admission.
Discharge Criteria
Consider admission if any is present: All patients lacking admission criteria may be treated as
outpatients after a confirmed understanding of discharge
• Suspected or proven concomitant PE
instructions. Several discharge instructions are available online.
• Significant cardiovascular or pulmonary comorbidity
Referral: Patients must be referred to cardiovascular surgeons.
• Iliofemoral DVT
References and Further Reading, click here
• Contraindications to anticoagulation
• Pregnancy
• Homeless patient
240
Section 6
Hypertensive Emergencies
Case Presentation
by Sadiye Yolcu A 68-year-old man with tearing chest pain presented to the
emergency department. He had a history of coronary artery
disease and hypertension. BP: 220/160 mmHg, HR: 105 bpm,
RR: 20/min, T: 37, SpO2: 96% in room air. In the initial
evaluation, airway and breathing were intact. Diastolic murmur
was heard on cardiac auscultation, and pulses were positive in
all extremities. He has a normal mental state (GCS 15) and no
lateralized motor deficit. A difference in systolic blood
pressure was measured between upper extremities (220/160
vs. 180/140 mmHg). ECG showed nonspecific ST-T changes
and sinus tachycardia.
241
Introduction urgencies are defined as situations •M a l i g n h y p e r t e n s i o n w i t h o u t
Systemic hypertension is a common requiring actions within 24 hours and yet complication
medical problem. It affects over 1 million do not compromise the risk of developing
• Perioperative hypertension
people worldwide. ER clinicians complications within that period.
commonly encounter this problem. Rapid • Pheochromocytoma,
Hypertensive emergencies include
diagnosis, evaluation, differentiation of
• Sympathomimetic drug use (cocaine,
hypertensive emergencies and • Acute aortic dissection
etc.)
hypertensive urgencies, and appropriate
treatment of these conditions are required • Acute coronary syndrome
Critical Bedside Actions and
to prevent morbidity and mortality.
• Acute heart failure General Approach
The levels above 180 systolic BP and 110 The priority should be given to initial
• Acute renal failure
diastolic BP are considered very stabilization of the patient (C-A-B) as
dangerous which may cause end-organ • Eclampsia other critically ill patients. Depending on
damage such as intracranial bleeding, patients’ symptoms in addition to high
• Hypertensive encephalopathy
aortic dissection, renal failure, etc. Having blood pressure, the cardiac
end-organ damage is the hypertensive • Intracerebral/subarachnoid hemorrhage monitorization, oxygen (if necessary), two
emergency. Having high blood pressure l a rg e b o re I V a c c e s s s h o u l d b e
• Pheochromocytoma, established and blood samples (CBC,
without any signs of end-organ damage
is the hypertensive urgency. Retinal BUN, Cr, coagulation, cardiac markers,
• Sympathomimetic drug use (cocaine
hemorrhage or exudates/papilledema type, and cross-match) sent to the
etc.),
associated with hypertension is defined laboratory. ECG and chest x-ray should
as malignant hypertension. • Stroke be ordered.
Hypertensive emergencies require action Hypertensive urgencies include Lowering BP should be balanced with the
within one hour to abolish the risks of level of BP, patient’s symptoms as well as
• Diastolic tension ≥140 mmHg without
developing complications. Hypertensive harm-benefit situation.
complication
242
Differential Diagnosis Each of these hints was g i v e n i n t h e s p e c i fic d i s e a s e
The most critical step in the differential diagnosis is the definition chapters. Therefore, we advise you to review those chapters too.
of the hypertensive situation (emergency or urgency). Suspicion
of hypertensive emergencies aligns with hypertension and end- Emergency Diagnostic Tests and
organ damage. Depending on patient symptoms and findings, Interpretation
An electrocardiogram (ECG) and chest X-ray should be
hypertensive emergencies differentials include severe problems
performed. ECG may show arrhythmias, nonspecific ST-T
such as intracranial hemorrhage, ischemic stroke, aortic
changes or obvious acute MI findings. The chest x-ray may give
dissection, acute MI, AAA rupture, heart failure, renal failure, limb
hints about aortic dissection, aneurysm, pulmonary edema.
or organ ischemia, etc. In addition to these end-organ damages,
other differentials (seizure, brain tumor, encephalitis, What is your opinion about the chest x-ray (Image 4.9)?
encephalopathy, drug overdose, etc.) should also be considered.
Bedside ultrasonography may help to diagnose some critical
History and Physical Examination Hints pathologies timely. These are pulmonary edema, aortic aneurysm
The previous medical history of the patient (chronic diseases, or dissection, heart failure, and increased intracranial pressure.
antihypertensive drugs usage, previous end-organ compromise,
What is your opinion about the transthoracic ultrasound here?
etc.) should be taken. Chest pain for myocardial infarction, aortic
dissection, dyspnea for pulmonary edema, headache, mental Blood urea nitrogen (BUN), electrolytes, complete blood count
status, seizure for hypertensive encephalopathy should be asked. (CBC), liver-renal function tests, coagulation parameters, cardiac
enzymes and urine analyses should be checked. BUN and Cr
The patients present mostly with ischemic stroke, pulmonary
may show renal impairment. Hematuria and proteinuria in the
edema, hypertensive encephalopathy, or congestive heart failure.
urine should also be checked.
Therefore, history and physical exam should be focused on these
problems during the initial and secondary evaluation. In the Some patients may require further investigations with CT or MRI
physical examination, measure the blood pressure from both depending on their symptoms and findings.
arms and assesses the patient for end-organ compromise
(neurologic-ophthalmologic-cardiac). What is your opinion about the CT (Image 4.10)?
243
Image 4.9
Image 4.10
245
Asymptomatic Situations Discharge Criteria
Hypertensive urgencies (Absence of end-organ damage
Oral antihypertensives (hydrochlorothiazides 25 mg/day,
symptoms and findings, known to have hypertension, reversible
Metoprolol 25 mg/day, angiotensin receptor blockers, ACE
causes, etc.)
inhibitors) should be given in the ED and prescribed to the
patients whose systolic blood pressure is higher than 180-200 Referral
mmHg and the diastolic blood pressure higher than 110/120 Patients should refer to their primary care physician or
mmHg. hypertension clinic in 7 days.
Disposition Decisions
Admission Criteria
All patients with hypertensive emergencies, signs of end-organ
damage are admitted to the intensive care or high dependency
care unit.
246
Section 7
Pulmonary Embolism
Case Presentation
by Elif Dilek Cakal A 45-year-old female with no prior medical history presented
to the emergency department (ED) with three days of constant
shortness of breath. She was suffering from left-sided sharp
chest pain, which is stronger during inhalation. She had felt
breathless while she was climbing upstairs during the previous
week. She had no cough or expectoration. She was a non-
smoker; her only drug was daily oral contraceptive. Vitals at
arrival were as follows: Blood Pressure: 116/72 mmHg, Pulse
Rate: 102 beats per minute (bpm), Respiratory Rate: 18
breaths per minute, Body Temperature: 37°C (98.6°F), Oxygen
Saturation: 95%. Physical examination revealed no
abnormality except for the left-sided basilar crackles. Chest X-
ray was unremarkable. The emergency physician (EP)
proceeded to investigate differential diagnoses. Her Well’s
Audio is available here Score for pulmonary embolism was 4.5 (moderate) because of
247
increased heart rate and lack of alternative Introduction
The incidence of pulmonary embolism (PE) is approximately 1.5
diagnosis. The laboratory results showed
new cases per 1000 persons. Patients with chest pain, shortness
negative β-HCG, normal renal function test, of breath and syncope should have pulmonary embolism
platelet number and a D-dimer measurement of excluded. Atypical presentations include mental deterioration in
751 ng/ml (cutoff = 550 ng/ml). EP explained patients with prior dementia. EP must maintain a high index of
suspicion as the potential outcome of a misdiagnosis is
these results to the patients and suggested a
catastrophic. The mortality of untreated PE is estimated to be
computed tomographic pulmonary angiography 30% whereas the all-cause 30-day mortality of diagnosed PE is
(CTPA). CTPA showed filling defects within the only 8%.
left pulmonary artery, left anterior and lateral Critical Bedside and General Approach
segmental artery associated with pulmonary First, the EP must determine whether the patient is stable or
unstable. Instability and shock warrant stabilization in addition to
embolism. Enoxaparin, 1.0 mg/kg, twice a day
simultaneous diagnostic and therapeutic effort. If the patient is
(80 mg = 0.8 ml, each dose for approximately 80 hypoxic, administer oxygen. Severe hypoxemia or mental
kg patient), was started. Her Pulmonary deterioration necessitate intubation. If the patient is hypotensive,
Embolism Severity Index (PESI) was 65 (class I) administer only 500 mL IV bolus saline. Aggressive IV fluid may
increase the right heart strain and shock. If hypotension persists,
and implied a very low risk. As a shared decision
give IV vasopressors, particularly norepinephrine or epinephrine.
with the patient and respiratory physician, the
Obtain an ECG to exclude STEMI and dysrhythmia. Perform a
patient was referred to the respiratory physician
thorough bedside ultrasound. EP can rapidly exclude pericardial
as an outpatient after discussion and confirmed tamponade, pneumothorax, and intraabdominal bleeding via
understanding of discharge instructions. bedside ultrasound. Right ventricular enlargement or the
presence of deep venous thrombosis (DVT) gives hints of
pulmonary embolism (please check RUSH Protocol chapter).
248
What is your diagnosis in US given here? presentation. Even highly qualified EPs may miss the diagnosis
because of vague signs. Previously healthy young patients tend
• If the patient is stabilized, the patient should directly undergo
to be mildly symptomatic with normal vital signs. Prior
CTPA.
cardiopulmonary disease and cognitive dysfunction generally
• If the patient remains unstable or CTPA is unavailable, bedside obscure the diagnosis. Therefore, atypical presentations are
ultrasound is the only diagnostic tool. frequent in elderly patients. Proximal clots cause dyspnea via
ventilation-perfusion mismatch. Pneumonia-like presentation
• If CTPA confirms or bedside ultrasound strongly suggests and pain due to pulmonary infarction are more often in distal
pulmonary embolism, thrombolysis is indicated. clots. The presence or absence of sudden onset symptoms
neither increase nor decrease the probability of PE. Fewer than
• If the patient is stable with high suspicion of PE, but the
half of patients describe sudden onset.
diagnostic measures are expected to delay, administering of
one dose low molecular weight heparin (LMWH) is • Most patients with PE complain of dyspnea (82-85%), chest
recommended. pain (40-49%), pre-syncope or syncope (10-14%), and
hemoptysis (2%). Other PE-related signs and symptoms include
Differential Diagnosis functional or mental deterioration, arterial hypotension, cough,
Potentially life-threatening differential diagnoses of pulmonary
flank pain, abdominal pain, dizziness, light-headedness,
embolism are summarized in Table 4.8.
tachypnea (30-60%), fever, diaphoresis, and anxiety. DVT-
Non-Life-Threatening Causes are Bronchitis, Chest wall pain/ related symptoms may accompany. Some cases are
Costochondritis, Pleuritis/Pleurisy, GI Abnormalities (GERD, asymptomatic and diagnosed incidentally.
Peptic Ulcer, Gastritis), Panic Attack/Anxiety Disorder, Rib
• Shortness of breath, vague or apparent, is the most common
Fracture.
symptom. A patient with PE typically presents with 2 to 3 days
of new-onset shortness of breath that is not explained by a
History and Physical Examination Hints
• The character and severity of the clinical presentation may vary known medical condition, now worsened enough to seek care.
tremendously from being asymptomatic to sudden death. The Because the embolic burden is loading gradually, most patients
patient’s prior condition, clot’s size, and localization affect describe dyspnea on exertion days to weeks before dyspnea at
249
Table 4.8 Potentially Life-Threatening Differential Diagnoses Of Pulmonary Embolism
ACS – NSTEMI Typical chest pain ECG Troponins Troponins may be elevated
in PE.
Cardiogenic Shock/ History of CHF Bed-side ultrasound Pulmonary edema on chest BNP BNP and pro-BNP may be
Congestive Heart Failure (e.g. RUSH protocol) X-ray Pro-BNP elevated in PE.
Pneumonia Cough with sputum, fever, Bed-side ultrasound Pneumonic infiltration on WBC
immunosuppression chest X-ray CRP
Procalcitonin
Asthma History
Bronchospasm on
examination
The most helpful diagnostic ways to establish the diagnoses are in bold. Original by author.
250
rest. secondary to PE or other diagnoses may cause crackles.
Bronchospasm primarily dictates other diagnoses. However, the
• Contrary to common misbelief, PE may cause both pleuritic and
EP must consider that underlying PE exacerbates Chronic
angina-like chest pain. Distal emboli induce atypical, pleuritic,
Obstructive Pulmonary Disease (COPD). Treatment-resistant
stabbing-like chest pain due to pleural irritation. Central emboli
COPD exacerbations may imply PE.
may present as typical angina-like chest pain, possibly
associated with RV ischemia. Thus, exclusion solely based on • The combination of history and physical examination is
the quality of chest pain is impossible. frequently insufficient to diagnose. Thus, the EP must
investigate risk factors to determine the likelihood of PE. The
• The frequency of syncope and pre-syncope among the ED
risk factors in the emergency setting differ from the general
patients with confirmed PE remains highly variable in different
population or longitudinal risk factors.
studies (4-22%). On the other hand, only in a minor group of
patients presented with pre-syncope and syncope, the final
Table 4.9 Selected Risk Factors of Pulmonary Embolism In
diagnosis is PE. Yet, patients with PE who present with syncope The ED Setting
tend to have major PE.
INDICATORS OF PE IN THE ED MAY BE LESS SIGNIFICANT IN
• Haemoptysis is not common but is more specific to PE. SETTING THE ED POPULATION
• Vital signs are variable. Most patients have relatively normal Age > 50 Pregnancy
Recent Surgery Smoking
vitals. Some are in shock and shock is a predictor of bad Recent Major Trauma Family History of VTE
outcome. Heart rate > 100 bpm and oxygen saturation <95% Immobilization Inactive cancer
Estrogen Travel
increase the probability. Fever does not exclude PE, though an Prior VTE
oral temperature >39.2°C (102.5°F) greatly decreases the Postpartum
Inherited Thrombophilia
possibility. Mild or severe increase in respiratory rate may be Active cancer
present. Normalization of vital signs with treatment or time does
Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do
not change the likelihood of PE.
tempor incididunt ut labore et dolore magna aliqua.
• No single examination sign confirms or excludes PE. DVT-
related signs increase the possibility. Pulmonary infarction
251
Table 4.9 summarizes selected common risk factors in the ED • B e d s i d e E C G s h o w s tachycardia and non-specific ST-T
setting. For a more detailed discussion, please refer to the changes in most of the cases. Acute S1Q3T3 finding in the ECG
relevant sections of “Emergency Evaluation For Pulmonary is seen only increased right ventricle enlargement and pressure
Embolism, Part 1: Clinical Factors That Increase Risk” at this link which seen massive emboli. These finding can also be seen in
and “Clinical Features From the History and Physical Examination core pulmonale.
That Predict the Presence or Absence of Pulmonary Embolism in
Symptomatic Emergency Department Patients: Results of a Image 4.11 ECG shows S1Q3T3
Prospective, Multicenter Study” at this link.
• Wells’ Criteria for PE – link • Pulmonary embolism should come to mind in a large number of
patients because of the changeable and vague nature of its
• Revised Geneva Score (RGS) – link presentation. Proper assessment of clinical probability, D-dimer
testing and CTPA are cornerstones of management. Other
• Experienced physician’s gestalt and clinical prediction rules
d i a g n o s t i c t o o l s l i k e l u n g s c i n t i g r a p h y, b e d s i d e
showed similar performance in some studies, but the use of
echocardiography and compression venous ultrasonography of
clinical prediction rules are strongly recommended for
bilateral lower extremities may prove useful in special
inexperienced physicians.
circumstances such as pregnancy, unavailability of CTPA,
• Pulmonary Embolism Rule-Out Criteria (PERC) is recommended instability or shock.
for the bedside exclusion of low-risk patients – link
What is your diagnosis in CT given here?
253
risk and intermediate-low risk • Intubate, if necessary. Beware of dobutamine/dopamine, except for
groups, according to RV function and high intrathoracic pressure for it may a selected group of patients with
cardiac biomarker values. Lastly, a worsen the right ventricular failure. known congestive heart failure.
PESI class I-II or sPESI class 0 Therefore; aim:
• Confirm PE with whether CTPA or
normotensive patient is defined as a
• Low tidal volumes (about 6 mL/ bedside ultrasound as the patient’s
low-risk patient. The proposed risk
kg lean body weight) status permits. Prepare for thrombolytic
stratification (link) and risk-adjusted
treatment.
management strategies in acute PE • limited positive end-expiratory
is demonstrated at this link as part of pressure Medications
2014 ESC Guidelines on the Parenteral anticoagulation for stable
diagnosis and management of acute • to keep end-inspiratory plateau
patients remains the mainstay of therapy
pulmonary embolism. pressure < 30 cm H20
in ED. Low-Molecular-Weight Heparins
• Use non-invasive mechanical ventilation (LMWHs) and fondaparinux are preferred
Emergency Treatment over unfractionated heparin (UFH)
with caution.
Options because of lower major bleeding and
• Mental deterioration and coma may heparin-induced thrombocytopenia risk.
Initial Stabilization
dictate intubation.
Stabilizing interventions, diagnostic and
• LMWHs
therapeutic effort must begin immediately • If the patient is hypotensive
and continue till admission for an • Enoxaparin: 1.0 mg/kg, every 12
unstable patient. Development of shock, • Give 500 mL normal saline IV hours, SC
hypotension or hypoxemia in the course bolus. Avoid excessive IV fluids for
of ED stay warrants prompt stabilization. it may increase right ventricular • Tinzaparin: 175 U/kg, once daily, SC
strain.
• If the patient is hypoxemic • Dose reduction is required in renal
• If fluid bolus does not help, start impairment.
• Administer oxygen vasopressors. Norepinephrine and
• Fondaparinux
epinephrine are preferred over
254
• 7.5 mg, body weight 50-100 kg, Thrombolytic treatment must be reserved Pediatric, Geriatric,
for unstable patients. Streptokinase, Pregnant Patient, and Other
• 5 mg, body weight <50 kg
urokinase and recombinant tissue
Considerations
• 10 mg, if body weight >100 kg, once p l a s m i n o g e n a c t i v a t o r ( r T PA ) a re
daily, SC) approved thrombolytic agents for PE. As Pediatric considerations
a general rule, LMWHs, fondaparinux and The pediatric pulmonary embolism is
• C o n t r a i n d i c a t e d , i f c re a t i n i n e UFH infusion must be stopped during relatively rare, but widespread use of
clearance <30 mL/min t h r o m b o l y t i c t h e r a p y. C u r r e n t l y, CTPA showed that it is more frequent
recombinant tissue plasminogen activator than previously thought.
• Dose reduction by 50%, creatinine
(rtPA) is the most widely used agent and
clearance is 30-50 mL/min. Up to 30% of adult patients have no
its dose is 100 mg over 2 hours OR, 0.6
identifiable risk factors. Unlike adults,
• UFH mg/kg over 15 minutes, the maximum
96-98% of pediatric patients have
dose of 50 mg.
• 80 Units/kg IV bolus, then 18 Units/ identifiable risk factors, 88% have two or
kg/h continues IV infusion. Vitamin K antagonists (VKAs, e.g., more. Infants and neonates bear the
warfarin) and new oral anticoagulants highest risk. In all age groups, a central
• Recommended, if the patient is venous catheter is the most common risk
(NOACs, e.g., dabigatran, rivaroxaban)
should be started in the inpatient setting factor. Other common risk factors include
• a candidate for thrombolytic
after initial therapy. dehydration, septicemia, peripartum
treatment
asphyxia in neonates. Malignancy, lupus
• severely obese Surgical embolectomy, percutaneous erythematosus, renal disease, congenital
catheter-directed treatment, and venous thrombophilia, surgery and major trauma
• Recommended, if creatinine filters are rarely applied after admission to are common predisposing factors in older
clearance <30 mL/min ICU. c h i l d re n . O v e r a l l , i m m o b i l i z a t i o n ,
• Advantages: The ease of hypercoagulability, central venous
monitoring and reversal of effects catheter, excess estrogen state, and
by protamine. concurrent deep venous thrombosis are
255
associated with pediatric PE. Deep • >2 months: 1.0 mg/kg/dose SC, from ionizing radiation, the fear of
venous thrombosis in children is twice a day missing a life-threatening diagnosis and
predominantly associated with upper the need for quick decisions harden the
extremity and central venous catheter Geriatric considerations management of a pregnant woman with
The management and treatment do not
rather than lower extremity as in adults. suspected PE. A clinical pathway is
change in geriatric patients. However, the
recommended at this link as a part of
Pleuritic chest pain (84%), hemoptysis EP should consider a few issues. The
“Emergency Evaluation For Pulmonary
and shortness of breath are the main incidence of PE increases with age.
Embolism, Part 2: Diagnostic Approach.
symptoms. D-dimer and prediction rules Atypical presentations are common;
are not studied in children. CTPA remains comorbid illnesses and dementia obscure The first step is bilateral lower extremity
the primary diagnostic tool in the the diagnosis. The treatment does not venous ultrasound. If the ultrasound is
emergency setting. The segmental change, but complications of positive, the treatment starts without
arteries are affected 52%. The main or anticoagulation occur more frequently. further investigation. If the ultrasound is
central arteries are affected 6%. Children The EP must adjust dose according to negative, the EP must assess the pretest
tend to compensate for relatively large comorbid situations like renal dysfunction p r o b a b i l i t y ( P T P ) . T h e t r i m e s t e r,
clots well out of their cardiopulmonary of cachexia. physician’s gestalt or clinical prediction
reserve. rules are available methods to assess
Pregnant patient considerations PTP. Note that no prediction rule is
LMWH is the mainstay of the therapy. PE and pregnancy form an ominous validated in pregnant. In the non-high risk
Hemodynamically unstable patients couple for apparent reasons. Pregnant group, PERC negative patients are further
should receive thrombosis. The prognosis and postpartum women are susceptible stratified with D-dimer. If D-dimer is under
is generally good. Shock is the predictor to PE. Peak times are the third trimester cutoff values according to trimesters, PE
of an adverse outcome. and the first 4 weeks following the labor, can be excluded to a reasonable degree
particularly after cesarean section. of medical certainty. High risk, PERC
• Enoxaparin
Moreover, breathlessness is a common positive or D-dimer positive patients
• <2 months: 1.5 mg/kg/dose SC, c o m p l a i n t d u r i n g p re g n a n c y. T h e should undergo imaging. On the imaging
twice a day potential harm to fetus and woman breast
256
branch, shared decision-making should be pursued between Referral
CTPA and ventilation-perfusion scan. • Patients must be referred to respiratory or internal medicine.
LMWH is safe during pregnancy [Pregnancy Category (PC) B] and Pearls And Pitfalls
lactation and so is standard treatment and is preferred over Use validated clinical prediction rules to estimate pretest
heparin (PC C). Fondaparinux (PC B) is not recommended due to probability in patients with suspected PE.
lack of data. VKAs (PC X) and new oral coagulants are
contraindicated in pregnancy. Pregnancy does not alter the Do not proceed to D-dimer measurements or imaging
dosage. studies in patients with a low PTP and negative Pulmonary
Embolism Rule-Out Criteria.
Disposition Decisions
A high sensitivity D-dimer is the initial test in patients with
Admission Criteria intermediate PTP or low PTP but a positive Pulmonary
• All high-risk patients, including those in shock, who are Embolism Rule-Out Criteria. Imaging studies are not the
hypotensive, post-CPR, intubated, or who have received initial test in patients with low or intermediate PTP.
thrombolytic treatment must be admitted to ICU.
Use age-adjusted D-dimer thresholds in patients older
• Intermediate-high risk patients should be observed in monitored than 50.
beds and possibly in ICU
CTPA is the initial test in patients with high PTP.
• Intermediate-low risk and low-risk patients should be admitted Ventilation-perfusion scans are alternative if CTPA is
to the ward. contraindicated or unavailable. D-dimer cannot exclude
PE in patients with high PTP.
Discharge Criteria
• A very selected group of low-risk patients may be treated as
outpatients. A proposed algorithm for outpatient management
References and Further Reading, click here
of PE is available at this link
257
Chapter 5
Selected Endocrine,
Electrolyte
Emergencies
Section 1
Acid-Base Disturbance
Case Presentation
by Lamiess Osman, Qais Abuagla A 15-year-old female presented with dyspnea, polyuria, and
polydipsia for the last 3 days. She was slightly lethargic with
dry oral mucosa. Vitals were BP 92/45mmHg, RR 27/bpm,
HR119/bpm, Temp 37°C, SpO2 99% on INO2 1L/min.
Physical examination revealed normal findings except there
was a mild abdominal tenderness without guarding.
A bedside arterial blood gas revealed the following:
• pH: 7.19
• PaO2: 105mmHg
• PaCO2: 19mmHg
• HCO3: 7mmol/L
• Na: 124mmol/L
• K: 3.4mmol/L
259
• Cl: 91mmol/L Introduction
• Gluc: 310 mg/dL Definitions
Acid: a substance that is capable of donating a hydrogen ion to
• BUN: 13mmol/L
another substance
The patient was put under close monitoring, and Base: the substance that is capable of receiving a hydrogen ion.
intravenous fluids were initiated. Urine dipstick
Acidemia is serum pH < 7.35.
showed glucose 4+ with ketones. A diagnosis of
diabetic ketoacidosis was made. The arterial Alkalemia is serum pH > 7.45.
blood gas (ABG) was evaluated at the end of the Acidosis refers to physiologic processes that cause acid
chapter for this case. accumulation or alkali loss.
Defense Mechanisms
The body has three defense mechanisms to maintain normal pH:
262
• Pneumonia • Post-hypercapnia Step 2: Evaluate the primary process
that accounts for the deranged pH.
• Pulmonary edema • Diuretics*
• The low HCO3 with a low PaCO2
• Hemo/pneumothorax (* associated with high urine Cl level)
indicates that the main primary disorder
• Myopathy is metabolic acidosis.
remember the following mnemonic: actual PaCO2 (19mmHg) lies within this
• Anxiety
range. This means that the respiratory
“CLEVER PD”
• Mechanical ventilation compensation is appropriate and there
• Contraction (due to blood loss) was no concurrent respiratory acid-
• Progesterone
based disorder.
• Licorice *
• Salicylates
Step 4: Calculate the Anion Gap, Anion
• Endocrine (Conn’s/ Cushing’s/ Batter’s)*
• Sepsis Gap and delta HCO3
• Vomiting/nasogastric suction
Looking Back To Our Case AG = Na – (HCO3 + Cl) ±4). The patient’s
• Excess Alkali* Step 1: Interpretation of pH AG is 26±4 {i.e. 124 – (7 + 91 ) ±4}.
• Refeeding Alkalosis* • The pH <7.35 indicating acidosis AG = AG-12. The patient’s AG is 14±4
{i.e.26-12(±4)}.
263
Delta HCO3 = 24-HCO3. The patient’s delta HCO3 is 17 {i.e.
24-7}
264
Section 2
Hyperglycemia
Case Presentation
by Toh Hong Chuen A 58-year-old lady presented with right foot pain for 3 days,
associated with high fever, lethargy, polyuria, and polydipsia.
At triage, air hunger was noted. Her vital signs were: BP 82/46
mmHg, PR 131/min, RR 28/min, T 38.7 and SpO2 98%. She
was brought to the resuscitation room for further
management.
265
A diagnosis of septic shock Image 5.1 Critical Bedside Actions
secondary to gas gangrene and General Approach
Diabetic ketoacidosis (DKA) and
complicated by diabetic hyperosmolar hyperglycemic state (HHS)
ketoacidosis was made. She are potentially life-threatening diabetic
was aggressively resuscitated emergencies. In acutely ill patients with
hyperglycemia, blood and urine tests
with fluid and started on IV
must be performed, preferably at the
insulin infusion. Potassium point of care, to evaluate for the presence
replacement was withheld as K of DKA or HHS (Table 5.1).
tetanus toxoid were given. X- vital signs, mental status and biochemical
The patient was sent directly to response to therapy (glucose, ketones,
ray (Image 5.1) of right foot Na and K) and input-output must be
the theatre and underwent
confirmed subcutaneous air. closely monitored. As DKA and HHS
extensive debridement for the resolve, overlap with s/c insulin prior to
gas gangrene. She had an stopping the insulin infusion. See
appendix 1 for management details.
uneventful recovery and was
discharged 1 week later.
266
Differential Diagnoses D K A a n d H H S a r e distinguished as follow:
pH 7.25-7.30 7.00-7.24 <7.00 >7.3 • Up to 10% of DKA are “euglycaemic” (glucose <14). They can
HCO3 be seen in pregnant patients, those with restricted food intake,
15-18 10-14 <10 >18
(mmol/L) or had initiated insulin therapy (though insufficient) prior to
Anion gap presentation.
>10 >12 >12 Variable
(mmol/L)
Serum Hallmarks of HHS are profound hyperosmolality, hyperglycemia,
ketone ≥0.6 ≥0.6 ≥0.6 Small/none and dehydration.
(mmol/L)
Urine • Associated with type 2 diabetes; can occur with type 1 as a
Positive Positive Positive Small/none
ketone simultaneous occurrence with DKA.
Effective
serum
Variable Variable Variable >320
• Like DKA, the circulating amount of insulin is inadequate to
osmolality
prevent hyperglycemia. Unlike DKA, this amount is sufficient to
(mOsm/kg)
prevent lipolysis and ketoacidosis.
Adapted from Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN.
Hyperglycemic crises in adult patients with diabetes. Diabetes Care.
2009;32(7):1335-1343. doi:10.2337/dc09-9032. Please read the article for • Without significant ketoacidosis, HHS develops slowly and
more information. subtly over several days, contributing to more severe water
deficit at around 7-12 L, compared to 4-6 L in DKA.
267
• The older terms “hyperglycemic • Bleeding GI • DKA patients often present with
hyperosmolar nonketotic coma” (HHNK) a i r h u n g e r a n d k u s s m a u l ’s
and “hyperglycemic hyperosmolar History and Physical breathing secondary to acidosis,
nonketotic state” (HHNS) should not be Examination Hints unlike HHS.
used. Patients often present without 1. DKA and HHS can present similarly
with malaise, anorexia, thirst, polyuria, 4. Abdominal symptoms
coma, and ketonemia may found in
some. and polydipsia. In addition, they can
• In DKA, nausea, vomiting and
be triggered by similar precipitants.
abdominal pain are associated
Up to 1/3 of patients have an overlap of D i ffe r e n c e s i n c l u d e a l o n g e r
with the severity of ketoacidosis.
DKA and HHS. presentation and more severe
dehydration in HHS. • Conversely, an acute abdominal
Any significant stress can precipitate
process such as pancreatitis can
DKA/HHS, remembered as “7 ‘I’s have 2. Neurological symptoms
precipitate DKA. Search for
bled!”.
• HHS patients often have some intraabdominal precipitants if
• Iatrogenic (drug interaction, e.g. degree of altered mental state or abdominal pain when DKA is mild,
steroids) other neurological disturbances. persistent pain despite
These are related to the severity improvement of acidosis or signs
• Idiopathic (new onset DM)
and rate of development of of peritonism.
• Illegal (substance abuse) hyperosmolality.
• HHS (no significant ketoacidosis)
• Infarction (e.g. AMI, stroke, bowel • Conversely, since hyperosmolality is not associated with abdominal
ischemia) is absent or insignificant, DKA pain. Evaluate for an abdominal
patients have normal neurological precipitant if there are abdominal
• Infection (e.g. pneumonia, UTI, cellulitis) symptoms.
status. Only severe DKA presents
• Infraction (i.e. noncompliance) with coma.
5. Physical findings may be unreliable for
3. Respiratory symptoms estimating the degree of dehydration,
• IUP (i.e. pregnancy)
particularly in children
268
• In DKA, patients may appear more • Note that the severity of metabolic •AAc and BHB fully dissociate in
dehydrated from the drying of oral acidosis can be masked by metabolic physiological pH and contribute to
m u c o s a d u e t o K u s s m a u l ’s alkalosis from vomiting. HAGMA. Ac, which does not dissociate,
respiration. does not.
• Interestingly, most patients change from
• Hyperosmolality in HHS may HAGMA to NAGMA while recovering • BHB is the most abundant ketone in
“preserve” intravascular volume from treatment. This is due to urinary DKA, with a ratio of 10:1 compared to
(even though it leads to urinary loss of ketones earlier during osmotic Aac, and Ac is least abundant.
losses) and mask signs of volume diuresis. Ketones can be metabolized to
• Insulin reduces overall ketone level but
depletion until hemodynamic bicarbonate when adequate insulin is
also converts BHB AAc. As
deterioration suddenly occur. provided; hence the loss of urinary
nitroprusside-based urine test detects
ketones is equivalent to losing
Emergency Diagnostic Tests only Ac and AAc, urinary ketones may
bicarbonate, resulting in NAGMA.
and Interpretation not improve or paradoxically worsen
Ketosis with treatment. Therefore, serum BHB
High Anion Gap Metabolic • The small amount of ketones is should be used to monitor resolution of
Acidosis (HAGMA) normally present (<0.6 mmol/L) acting ketosis.
• The most important feature of DKA. as an alternative energy source if
• Note that blood test for ketones can be
• Anion gap = Na – (Cl + HCO3). Use glucose is not available.
falsely positive in a patient taking
measured sodium in the calculation of sulfhydryl drugs.
• In DKA, relative or absolute insulin
anion gap.
d e fi c i e n c y a n d t h e s u r g e o f
counterregulatory hormones (especially Serum osmolality
• pH in venous blood gas is sufficient as
• The effective serum osmolality should
it correlates with arterial pH. Perform glucagon and catecholamines) cause
be used in the diagnosis of HHS, not
arterial blood gas only if concomitant unrestrained ketogenesis. All three
measured osmolality. Measured Na
respiratory failure is suspected. ketones, acetone (Ac), acetoacetate
should be used to determine the
(AAc) and beta-hydroxybutyrate (BHB)
osmolality.
are elevated.
269
• Effective serum osmolality = 2 x Na low normal or mild hyponatremia Emergency Treatment
(mmol/L) + Glucose (mmol/L). (dilutional). Hypernatraemia, therefore, Options
signifies severe dehydration.
• Urea travels freely across a cell Fluids
membrane and does not contribute to • Use the measured Na when calculating • Patients with DKA and HHS are
osmolality in vivo. the anion gap and serum osmolality. invariably volume depleted. Start IV
0.9% NaCl at 10-20 mmol/kg/hr during
Serum potassium • Corrected Na = serum Na + 2 [ (serum
the first hour.
• Check K before and after starting glucose – 5.5)/5.5 ]
insulin. • After BP and perfusion normalizes,
• After the initial fluid challenge with 0.9%
continue infusion at a rate of 250-500
• Total body potassium depletion occurs NaCl, use corrected sodium to decide
ml/hr with 0.45% NaCl if the calculated
through urinary (and occasionally on the choice of saline for infusion.
Na is normal or high; or 0.9% NaCl if
gastrointestinal) loss. Serum K,
Others the calculated Na is low
h o w e v e r, m a y b e n o r m a l o r
• Leukocytosis is present due to the
paradoxically elevated due to • The total body fluid deficit should be
elevated levels of stress hormones. Up
transcellular shift (acidosis, insulin slowly corrected over 24 hrs.
to 15K may be expected for DKA.
deficiency), volume contraction and
reduced renal function. • Serum amylase, lipase, hepatic
IV insulin
• Mainstay treatment of DKA and HHS.
enzymes, creatinine kinase and CRP,
• Hypokalemia at presentation signifies
can be mildly elevated. These are • Before initiating IV insulin,
profound K loss. This generally worsens
nonspecific findings.
with treatment and may precipitate
• Initiate fluid replacement. With
threatening arrhythmia and profound
insulin, glucose is taken up by cells,
respiratory muscle weakness.
drawing fluid out of intravascular
space and can cause hypotension.
Serum sodium
• As hyperglycemia draws fluid into the
intravascular space, most patients have
270
• Correct hypokalemia, if present, with • Add D5% to replacement fluid, •Add 20-30 mmol of K in each liter of
IV KCl at 20-30 mmol/hr until K>3.3 keep serum glucose between 8-11 fluid to maintain normokalemia.
mmol/L. mmol/L until ketoacidosis
• Withhold K is elevated above the
resolves.
• Give as a continuous infusion of 0.1 U/ upper limit (or >5.2 mmol/L).
kg/hr, and not as a bolus as this may • Once resolved and the patient is
• Check K 2 hourly after initiating fluid
cause severe hypokalemia and may risk a b l e t o t a k e o r a l l y, s t a r t
and insulin therapy
hypoglycemia. subcutaneous rapid-acting insulin
at 0.1 U/kg around 30-60 min
• Resolution of DKA as indicated by Phosphate
b e f o re s t o p p i n g t h e i n s u l i n • DKA patients have total body
serum glucose <11 mmol/L plus any 2
infusion, given the delayed onset phosphate though serum levels may be
of the following:
of the s/c preparation, to prevent normal or elevated. Treatment with
• pH >7.3, rebound hyperglycemia. insulin drives phosphate intracellularly
and worsens hypophosphatemia.
• HCO3 >18 mmol/L • Similarly in HHS, when capillary glucose
reaches 16 mmol/L: • However, routine phosphate
• Anion Gap ≤ 12 mmol/L
replacement is not indicated as no
• Reduce IV insulin rate to 0.02-0.5
• As the resolution of ketoacidosis in DKA studies demonstrated benefit.
U/kg/hr, keep serum glucose
often lack behind hyperglycemia (mean Treatment could also precipitate
between 11-16 mmol/L.
duration of 12 hours versus 6 hours hypocalcemia.
respectively), IV insulin should be • IV insulin can be stopped once the
• Consider phosphate replacement (IV
continued with dextrose replacement to patient is alert, taking orally and
K2PO4 at 4.5 mmol/hr) in DKA if:
clear the ketones. When capillary started on their oral hypoglycemic
glucose reaches 11 mmol/L: or subcutaneous insulin. • Cardiac dysfunction
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Section 3
Hypernatremia
Case Presentation
by Vigor Arva, Gregor Prosen A 79-year-old man was brought to the emergency department
(ED) by his wife. She complained that the patient had general
weakness and was feeling ‘unwell’ for the last two days. He
had a history of dementia, diabetes, renal failure, and
hypertension. He was on diabetic and antihypertensive
medication.
273
patient’s wife reported that he had not been Critical Bedside Actions and General
drinking much for the last few days, even though Approach
Hypernatremia should be excluded in any patient who presents
he did not complain about thirst. with altered mental status, particularly, the very young or old and
those with abnormal basal cognition.
Once diagnosed, the next step is to assess for volume status and
acuity of symptoms, as they influence treatment plan. It is
considered acute if symptoms develop within 48hrs, and chronic
if it is longer. Then, the cause should be determined and treated.
Differential Diagnoses
Hypernatremia usually results from relative water losses, and
rarely secondary to sodium overload. The causes can be
categorized into the following three groups:
274
saline, or large volumes of sodium bicarbonate), ingestion of salt History and Physical Examination
water or large amounts of salt, Cushing’s and Conn’s syndrome Hints
The signs and symptoms of hypernatremia are nonspecific
Diabetes insipidus (DI) refers to an absolute or relative antidiuretic
including lethargy, irritability, restlessness, hyperactive reflexes,
hormone (ADH) deficiency. Absolute ADH deficiency occurs in the
and increased muscle tone. Severe symptoms usually occur after
setting of inadequate ADH secretion and is called central DI.
the serum Na has risen acutely above 158 mEq/L, and may
Relative ADH deficiency occurs in lack of renal response to ADH
include seizures, coma or even death.
and is called nephrogenic DI.
Rapid and severe hypernatremia developing over minutes and
Malignant diseases, trauma or surgery on the pituitary, infiltrative
hours can result in brain hemorrhage, due to the accompanying
diseases, familial diseases or idiopathic conditions may cause
rapid decrease in brain volume causing ruptures of cerebral veins.
central DI. Chronic renal insufficiency, tubulointerstitial diseases,
It is also associated with hypocalcemia, for unclear reasons.
polycystic kidney disease, hypercalcemia, hypokalemia, lithium
toxicity, or familial diseases may cause nephrogenic DI. If the hypernatremia is chronic, the brain can adapt by generating
intracellular osmogenic compounds, or idiogenic osmoles, which
Symptomatic hypernatraemia (e.g., polyuria and polydipsia,
increases the osmolality in the cells and thus maintaining brain
lethargy and weakness) with an inappropriately low urine
volume by resisting shrinkage.
osmolality (<300 mOsm/kg) should suggest DI in the ED. The
formal diagnosis requires a water deprivation test, which is often Patients should be asked about their fluid and salt intake, urine
not performed in the ED given the long duration required. output, and concurrent medical and medication history. The
patient’s caregiver should be interviewed, especially if the patient
Central and nephrogenic DI are further distinguished by the
is mentally altered, to see if there are mental or behavioral
response to desmopressin (synthetic ADH). With desmopressin,
changes (e.g., excessive water intake).
urine osmolality will rise to more than 800 mOsm/kg in patients
with central DI, while this rise is absent in nephrogenic DI. Patients should be examined for their volume status by checking
skin turgor, capillary refill, looking for edema and raised jugular
Psychogenic polydipsia can be distinguished from DI by water
venous pressure, measuring heart rate, blood pressure and
restriction. Following water restriction, urine osmolality will rise in
looking for a postural drop, mental and neurological status.
psychogenic polydipsia and remain unchanged in DI.
275
Emergency Diagnostic Tests and After stabilizing the patient, proceed to evaluate for and treat the
Disposition Decisions
Patients with symptomatic hypernatremia should be admitted for
evaluation and treatment, as the free water deficit is generally
replaced gradually. Those with severe neurological symptoms will
require admission to a closely monitored unit.
277
Section 4
Hyponatremia
Case Presentation
by Vigor Arva, Gregor Prosen A 72-year-old man was brought to the emergency department
(ED) by his daughter. She reported that he had nausea,
vomiting, and confusion and had been unwell for the last few
days. He had hypertension and heart failure for the previous
ten years and was on ACE-inhibitor, beta-blocker and thiazide
diuretic.
278
Critical Bedside Actions and changes of sodium concentration usually Isotonic hyponatremia (osmotic
General Approach present more dramatically with more pressure 275-295 mOsm/L) (Also known
Hyponatremia is the most frequent neurologic involvement. The management as pseudo-hyponatremia) occurs with
electrolyte disturbance and refers to differs based on the rate of change. high levels of osmotically inactive
when the serum Na is <135mEq/L. The substances.
management principles are as follow:
Differential Diagnoses
The type of hyponatremia has to be • Hyperlipidemia
1. Assess severity and acuity determined to narrow down the
• Hyperproteinemia (multiple myeloma
differential diagnoses. Based on serum
2. Determine type (based on plasma etc.)
osmolality, we distinguish between
osmolarity and volume status)
hypertonic, isotonic, and hypotonic Hypotonic hyponatremia (osmotic
3. Identify and treat the underlying cause hyponatremia. pressure < 275 mOsm/L) is subdivided
based on clinical evaluation of volume
4. Prevent complications Hypertonic hyponatremia (osmotic
status and urine sodium concentration.
pressure > 295 mOsm/L) occurs when a
Hyponatremia can be classified as large concentration of osmotically active A. Hypovolemic
substances pull additional water and
• mild (125-134 mEq/L), • Urinary sodium > 20mEq/L:
dilute sodium concentration.
renal losses (diuretics, salt-
• moderate (120-124 mEq/L)
• Hyperglycemia (for each 1mmol/L rise w a s t i n g n e p h r o p a t h y,
• severe (<120 mEq/L) in blood glucose, the serum sodium mineralocorticoid deficiency)
decreases by 0.3mmol/L)
The physician should carefully evaluate • Urinary sodium <20mEq/L:
the underlying cause before attributing • Administration of osmotic agents, such extrarenal (hypotonic fluids,
the symptoms to hyponatremia alone as as mannitol, glycerol, sorbitol, and GI, and third space loss,
mild and moderate hyponatremia are radiocontrast infusion sweating in CF patients)
often asymptomatic. Determining the rate
of change is important since rapid B. Euvolemic
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• Syndrome of inappropriate • Hormone deficiency (hypothyroidism, develop acutely (<24h) or may
ADH secretion (SIADH) adrenal insufficiency) develop gradually and subtly over days.
Osmolality (in mmol/L) = 2 Na + Glucose + Urea If the patient is stable, evaluate the patient’s volume status to
determine the management strategy.
After the type of hyponatremia, Checking the urine sodium and
osmolality to evaluate the etiology further. Note to monitor these Hypovolemic patients benefit more from increasing volume rather
values after treatment for hyponatremia is initiated. than sodium correction per se. If the patient’s serum sodium is
<130 mEq/L, Ringer’s lactate solution (sodium concentration =
If pseudohyponatremia is suspected, verify if the serum sodium 130mEq/L) may be used. It has the advantage of treating
measure is affected by protein and lipid concentration. If this is concurrent hypokalemia if present – correcting this often
the case, add serum protein and lipid levels to exclude improves serum sodium. Otherwise, use Normal Saline (sodium
pseudohyponatremia. concentration = 154 mmol/L) for volume correction.
Exclude other electrolytes abnormalities, especially potassium. Sodium concentration in different solutions
These disorders often co-exist in conditions such as adrenal
insufficiency. • 0.9% NaCl: 154 mmol/L
Point of care ultrasound can be used to evaluate volume status. • Ringer’s Lactate: 130 mmol/L
Nerve sheath diameter can be measured using ocular ultrasound
• 0.45% NaCl: 77 mmol/L
if cerebral edema is suspected.
• 5% Dextrose in water (D5W): 0 mmol/L
Emergency Treatment Options
Initiate therapy with 100 mL of 3% NaCl over 10-15 minutes in In general, patients with euvolemic and hypervolemic
patients with severe acute hyponatremia (sodium < 120 mEq/L) hyponatremia should be fluid restricted. For patients with SIADH
and neurological symptoms, such as seizures, confusion or and congestive heart failure, consider adding loop diuretics. For
coma. At this point, recheck the serum sodium. Give a second those with glucocorticoid deficiency, hydrocortisone should be
dose of 3% NaCl if hyponatremia is still severe and the patient administered. In these three conditions, a vasopressin receptor
281
antagonist may be considered in consultation with the inpatient presentation can take place a f t e r 2 - 6 d a y s a n d m a y b e
specialists if the hyponatremia is refractory. irreversible. Symptoms range from ataxia and paresis to the
“locked-in syndrome.” As the prognosis is poor, care should be
The amount and speed at which sodium is corrected must be
taken to avoid this complication in the first place when correcting
determined before initiating replacement therapy. This can be
hyponatremia.
calculated manually or via several online calculators, such as
Medcalc. Diagram 5.1
• Rule of 6s:
• Rule of 100s:
282
Pediatric, Geriatric, Pregnant Patient, and Asymptomatic patients with mild hyponatremia from benign
Other Considerations causes can be discharged with advice. They should be followed
The most common cause of hyponatremia in the pediatric up by their primary physicians or referred to a specialist.
population is the gastrointestinal fluid loss (emesis or diarrhea)
and inappropriate rehydration with a hypotonic solution. Ingestion
of overly diluted formula and excessive water are other causes. References and Further Reading, click here
Diagnosis and treatment are as described above.
Disposition Decisions
Patients with neurologic symptoms should be admitted to the
ward or the ICU. Patients requiring excessive sodium correction
should be placed under close monitoring.
283
Section 5
Hypoglycemia
Case Presentation
by Rok Petrovčič A 75-year-old woman was brought to the emergency
department (ED) by her relatives for “not being her usual self”
for a day. She was on insulin therapy for her diabetes, but
otherwise healthy.
284
last two days. In addition, Critical Bedside Actions and •Cardiogenic Shock
286
25g of dextrose) over a few minutes. A Pediatric, Geriatric, monitored area. Consider
second dose can be administered if the Pregnant Patient, and Other consultation with toxicologist and
patient’s mental status does not psychiatrist for patients who overdose on
Considerations
improve. Children should receive 5 mL/kg of 10% their diabetic medication.
glucose or 2.5mL/kg of 25% dextrose.
• If intravenous access is not available, Discharge criteria
Avoid using 50% dextrose in this
IM/SC glucagon 1mg can be given. The patient should only be discharged if
population as it may easily result in
Glucagon takes a longer time to the cause of the hypoglycemia is
thrombophlebitis.
normalize mental status (around identified and deemed benign, have fully
7-10mins), and its effect tends to be Up to half diabetic pregnant patients on recovered, taking well orally and have no
short-lived. As glucagon raises blood insulin will experience an episode of recurrence of hypoglycemic episodes
glucose by releasing the hepatic severe hypoglycemia during pregnancy. after a period of observation. Discharge
glycogen reserve, it is not helpful in Careful titration of insulin is paramount to advice should be given.
patients with depleted glycogen stores prevent recurrence of hypoglycemia while
(e.g., liver failure or chronic alcoholism) Referral
attempting to achieve optimal sugar
If discharged from the ED, the patients
control.
• For patients with sulfonylurea overdose, should be referred to their primary
commence therapy with IV dextrose physician or specialist to follow up.
Disposition Decisions
until the patient can tolerate orally. If
episodes of hypoglycemia recur despite Admission criteria
glucose therapy, consider the addition Patients with hypoglycemia generally
References and Further Reading, click
of SC octreotide 50-100 micrograms. require admission to an observation unit
here
Note that octreotide should only be or the general ward, for evaluation and
used for recurrent sulfonylurea-induced treatment of underlying cause and
hypoglycaemic episodes despite titration of diabetic medication.
glucose therapy.
Patients with unexplained or recurrent
hypoglycemia should be admitted to a
287
Section 6
Thyroid Storm
Case Presentation
by Shabana Walia A 68-year-old female with hypertension presented to the
emergency department (ED) with worsening of lower extremity
swelling for the last few months. She appeared to be
confused over the last three days according to her husband.
He also noted that she had a fever. She had intermittent chest
discomfort and was feeling “anxious.” She was compliant with
the prescribed antihypertensive (lisinopril and
hydrochlorothiazide). She used no tobacco or illicit drug. She
had a family history of hypertension and hyperthyroidism.
288
were 3+. The rest of the physical examination Free T3: > 30 pg/ml (2.5- 3.9)
was unremarkable.
Free T4: > 6 ng/dL (0.58-1.64)
Bedside ECG is below
Troponin: 0.10 (<0.04)
Image 5.2
Pro-BNP: 3,000 pg/mL (0-100)
289
Introduction Initiate aggressive supportive care, •Encephalitis/meningitis
Thyrotoxicosis occurs when there is an including temperature control. Treatment
• Heat stroke
excess of circulating thyroid hormone in of the thyrotoxic state is aimed at
the body, whereas hyperthyroidism refers inhibition of thyroid hormone release, • Hypertensive encephalopathy
to thyrotoxicosis that arises from a inhibition of new hormone synthesis,
inhibition of peripheral conversion of T4 • Malignant hyperthermia
hyperfunctioning thyroid gland. Thyroid
storm, a true endocrine emergency, is the to T3, and lastly blockage of peripheral
• Neuroleptic malignant syndrome (NMS)
most extreme form of thyrotoxicosis. It beta-adrenergic receptors.
consists of a triad of severe hyperthermia, • Sepsis
Evaluate the patient for precipitants (e.g.,
cardiovascular dysfunction and altered
sepsis, noncompliance of anti-thyroid • Serotonin syndrome
mental state. Although it occurs in less
medications, trauma to the thyroid,
than 2% of patients with thyrotoxicosis, • Sympathomimetic overdose
radioactive iodine therapy, chemotherapy,
Emergency Physicians must maintain a
recent surgery, and molar pregnancy) and
high index of suspicion for thyroid storm History and Physical Exam
complications of the thyroid storm (e.g.,
because mortality approaches 80-100% Hints
high output cardiac failure, atrial As thyroid hormones act on almost every
if untreated. Prompt identification and
fibrillation). The underlying precipitant has cell in the human body, thyroid storm will
appropriate treatment can reduce the
to be addressed early and concurrently result in multi-organ dysfunction.
mortality to 15-50%.
with treatment for complications of the
thyroid storm. A thorough history and physical exam are
Critical Bedside Actions
keys to diagnosing thyroid storm.
A patient with suspected thyroid storm
Differential Diagnosis Patients often have a personal or family
should be placed in the resuscitation
Differentials of thyroid storm include: history of thyrotoxicosis. Initial symptoms
area. Evaluate the patient’s ABCs and
m a y b e v a g u e a n d n o n s p e c i fic .
establish intravenous access. Vitals signs, • Acute psychosis
Symptoms of weight loss, ravenous
including temperature, must be closely
• Alcohol or benzodiazepine withdrawal appetite, emotional labiality or irritation,
monitored.
and heat intolerance suggest
• Anticholinergic overdose
290
thyrotoxicosis. In a patient with prequel symptoms, Table 5.2 Criterion for Diagnosing Thyroid Storm
hypermetabolic state, and deranged vital signs, the diagnosis of
thyroid storm should be considered. CATEGORY SITUATION SCORE
becomes excessive and unregulated. Temperature above 38.5°C CNS Effects Absent 0
Mild-Agitation 10
is common, and can even exceed 41°C. Patients also present Moderate-Psychosis, 20
Delirium, Fatigue
with altered mental state and severe cardiovascular dysfunction. Severe-Seizures/Comatose 30
Precipitant History 0
Negative 10
Positive
Criterion for diagnosing thyroid storm, Modified from the original Burch HB,
Wartofsky L. Criteria: Life-threatening thyrotoxicosis: Thyroid storm.
Endocrinol Metab Clin North Am 22:263-277, 1993. Please read the article
for more information. 291
SCORING SYSTEM adds total points Emergency Diagnostic Tests consider a head CT scan to rule out a
based on patient’s history and physical and Interpretation precipitating or concurrent intracranial
exam: The following investigations are indicated process.
in patients with suspected thyroid storm:
• >45: Highly suggestive of thyroid storm Use the Burch and Wartofsky criteria to
CBC, renal function test, liver function
evaluate for the likelihood of thyroid
• 25-44: Suggestive of an impending test, thyroid function tests, metabolic
storm. If the diagnosis is suspected,
thyroid storm or thyrotoxicosis panel (including calcium), ECG, CXR.
treatment with the medications listed in
• <25: Unlikely thyroid storm based on While confirming the presence of Table 2 should be initiated. The primary
presentation thyrotoxicosis, thyroid function tests goals are blocking the peripheral effects
alone cannot be used to rule in or rule out of thyroid hormone, preventing the
The patient in our case presentation synthesis of T3 and T4, and inhibiting the
thyroid storm reliably. Thyroid stimulating
above hormone (TSH) will be low or release of preformed thyroid hormone.
u n d e t e c t a b l e , w i t h e l e v a t e d f re e
• Temp: 30 Emergency Treatment
triiodothyronine (T3) and its prohormone,
• CNS effects: 10 thyroxine (T4). Hypercalcemia, elevated Options
Initiate supportive care expeditiously.
alkaline phosphatase, and hyperglycemia
• GI-Liver: 0 Administer intravenous fluid to correct
are other common lab abnormalities seen
volume depletion, supplemental oxygen
• Tachycardia: 20 due to bone resorption, bone remodeling,
for hypoxia and exter nal cooling
a n d g l y c o g e n o l y s i s , re s p e c t i v e l y.
• CHF: 5 measures for severe hyperthermia.
Abnormalities on ECG include premature
Acetaminophen alone is not helpful as the
atrial, premature ventricular contractions,
• Atrial Fibrillation: 10 hyperthermia in thyroid storm is not a
atrial fibrillation, or atrial flutter The CXR
central, hypothalamic regulatory problem.
• Precipitant History: 0 may show cardiomegaly and pulmonary
Cooling blankets, ice packs or even cold
vascular congestion – indicating heart
• TOTAL POINTS: 75 intravenous fluids can be used. In
failure. If global or focal neurological
patients with airway compromise, rapid
deficits are found, it is reasonable to
292
sequence intubation and paralysis should be considered with a
Table 5.3 Medical Treatment for Thyroid Storm
secondary aim of temperature control. Aspirin and other non-
MECHANISM EXTRA
steroidal anti-inflammatory drugs (NSAIDs) should be avoided as GOAL MEDICATION
OF ACTION CONSIDERATIONS
they can increase peripheral free T3 and T4 due to their protein
STEP 1: Block Propranolol: Beta blockade, Use propranolol
binding properties. peripheral 60-80mg PO q4hrs shorter half life with with caution in
adrenergic effects or 0.5-1 mg IV q1h esmolol those with signs
of thyroid hormone (slow infusion) and symptoms of
Propranolol has the congestive heart
Esmolol: additive mechanism failure, as this can
250-500micrograms of blocking cause cardiogenic
/kg IV bolus, then conversion of T4 to shock and collapse
50-100micrograms/ T3 in peripheral
kg infusion tissues Esmolol is a
selective B-1
blocker, thus can be
used in patients
with bronchospasm
or asthma
293
Pediatric, Geriatric, Pregnant Patients And Admit the patients with partially-controlled thyrotoxicosis
Other Considerations symptoms for further management. Patients with mild controlled
Pediatric patients may not present with the classic symptoms of symptoms and stable vital signs may be discharged with close
hyperthyroidism. They may only demonstrate jitteriness, agitation, follow up with the primary care physician or endocrinologist.
restlessness without typical ophthalmologic or other systemic
References and Further Reading, click here
findings.
Disposition
Admit all patients with thyroid storm to the ICU or high
dependency unit for ongoing monitoring and treatment.
294
Chapter 6
Selected
Environmental
Emergencies
Section 1
Burns
296
• Estimation of the area can be • Genital bur ns – fertility
Image 6.1
done in the following ways: consequences
297
• Glove or stocking
Table 6.1 Burn Degrees
distribution indicating
forced immersion EXAMINATION FINDINGS
DEGREE EXAMPLE
OF SKIN
• C i g a re t t e m a r k s o r
other implement 1st degree or Red, painful Sunburn
contact marks superficial
2nd degree is divided into: Sometimes blistered, painful, Scald or flash burn
Management - superficial partial thickness moist
1. First aid – the primary treatment is - deep partial thickness
cooling the burn area with running 3rd degree or Dry, white, insensate, leathery Flame or immersion
water. This not only gives pain relief full thickness and decreased sensation
but also halts the thermal coagulative
4th degree or Damage extends to fat, Chemical or electrical
process and prevents more area of deep full thickness muscle or bone
skin being damaged. Following this,
burns should generally be wrapped in treatments, applications, and • Give 1/2 of the total in 1st 8 hours,
dry cling film or dressing before dressings available. and then give 2nd half over next
transport to a medical facility. This 16 hours
reduces pain from surrounding clothes 3. Fluids – When skin is lost, a large
and wind. The author was once asked amount of fluids may leak into the • Hartmann’s solution is the ideal
to explain minor injuries including injured space and also evaporate. replacement fluid
burns and this is the video for it. Regimens may vary but a good rule to
• Pediatric patients require even
follow is the Parkland formula. Here is
2. Analgesia – simple oral analgesia more specific control of fluid
an online calculator for this. In
(paracetamol or NSAID) followed by replacement and have their own
essence, give in mls:
opioids if need be. This is the most formulae.
298
4. Specific dressings and burns ointments have changed over the • Airway burns (if the unit has an ICU built in)
last decade. Here’s a good, updated site for such information.
Examples of units are in these links (1, 2)
5. Blister management – whether to remove or puncture the
blister or leave it alone has been controversial for a long time. Electrical Burns
The current consensus is to de-roof them. Electricity contains a large amount of energy, and when passing
through the body, it causes damage along its path and usually
6. ATT – Anti-tetanus toxoid for anyone not immunized or whose manifests itself as a burn at the entry and exit points.
last dose was more than 10 years ago.
Referral to the Burn Unit Image 6.2 Image shows the entry wound of an electrical
The burn unit is a specialized unit which deals specifically with injury
burns patients’ needs (dressing changes, escharotomy,
debridement, physio, etc.). They are essential units which provide
specialist care and dedicated rehabilitation.
• Scrotal/genital burns
299
the body at small points but does
Image 6.3 Image shows the exit Image 6.4 Image shows urine of
wound on the leg. tremendous damage along the route of the patient who has
the current all the way to the exit point. rhabdomyolyis after electrical
Thus a careful scan of the body and an burn.
ECG must be done to elicit damage.
Muscle damage leads to breakdown
called rhabdomyolysis and this, in turn,
leads to renal failure and multi-organ
failure if not treated promptly. Shoulder
dislocations from being jolted from the
There are a few modes of injury: electricity and head injuries are also
common.
• Power points – The amount of damage
caused by home/industrial mains Lightning strikes have far more energy
depends on contact time, voltage and transmitted than household mains.
current. Lichtenberg flowers are classically (but
rarely) seen in lightning strike burns. Here
• Lightning strikes, on the other hand, are
rare but cause devastating injuries. lies a good write-up and picture of it.
300
3. Bicarbonate – in cases of rhabdomyolysis, alkalinization of the Chemical/ Radiation Burns
urine will help draw products of muscle break down out of the
body. Image 6.6 Image shows chemical burn on the hand.
4. Treat other injured joints or organs sustained from the jolt when
shocked (e.g., shoulder dislocations)
301
Like most toxic ingestions and lamps. A good explanation of radiation Management
exposures, the extent of injury depends damage and risks can be found in this Probably the most important
on: pdf. interventions to get right are the first aid
processes:
• Type of toxin Assessment
A similar calculation for TBSA burned can • Removal of offending agent
• Concentration of toxin
be used as in thermal burns shown in the
• Irrigation with water to dilute and
• Length of exposure to it section above. However, the location of
neutralize
the burn and concentration of the agent
• Immediate decontamination and first have far more impact. • Transport to a medical facility
aid
For example: ED management includes;
A good explanation of chemical burns
from common household items can be • Alkali burns of the cornea can result in 1. Analgesia – IV opioids most commonly
found here. permanent blindness as they are deep dermal burns
Although radiation burns sound very • Hydrofluoric acid burns can result in 2. More irrigation of the affected area if
ominous, they are handled similarly as all systemic fluorosis which is life- symptoms or pain persists
other burns. The myth that exposed threatening
3. Irrigation of the eyes is of utmost
patients can contaminate the whole
• Corrosive burns to the esophagus can importance and the only way of
hospital is unjustified and applies to only
cause permanent swallowing difficulties removing the offending agent.
a specific scenario involving “dirty
bombs.” Hence a thorough examination is more 4. Local anesthetic also helps during
important than any lab or imaging test. irrigation. A good video of this is here.
Most common radiation burns are
Geiger counters can be used to detect
actually from medical facilities such as 5. Anti-tetanus toxoid
contaminated patients exposed to
cancer treatment or x-ray imaging
radionuclides. This needs to be done by
centers as well as tanning booths and 6. Specific antidotes:
experts in the field.
302
• Hydrofluoric acid – this acid is one Inhalation injuries •A c u t e R e s p i r a t o r y D i s t r e s s
of the most corrosive known and Syndrome (ARDS) or acute lung injury
its systemic effects lower calcium
Image 6.8 Smoke inhalation
to a life-threatening level. Hence
• Particulate matter in smoke causes
calcium is essential not only for
airway and bronchial inflammation
cardiac stability but also for
which can lead to pulmonary edema,
analgesia. Calcium can be given in
bronchospasm, and even ARDS. Signs
oral, topical gel and IV forms.
of such injury include soot in the
• Radionuclide poisoning – oropharynx, singed nasal hairs,
decontamination is once again hoarseness, stridor or confusion/
dealt very comprehensively in this agitation. Watch this video.
pdf.
Chemical inhalational injury
6. Referral to the burn unit When patients are thermally injured, the
environment they were in can cause harm
as well. Here are two of the most
common inhalation injuries that patients
trapped in burning environments receive.
Thermal inhalational injury
• Airways can become swollen due to • CO poisoning – This gas is a by-
inflammation. Prompt airway protection product of combustion. Symptoms can
measures need to be initiated before range from confusion to coma. The only
the swelling becomes too severe way to detect it is a high degree of
(impairs breathing) suspicion and via arterial blood gas.
The treatment is 100% oxygen. In some
• Tracheobronchial edema / inflammation
cases with neurological symptoms and
303
coma, hyperbaric oxygen therapy is recommended.
304
Section 2
Drowning
Case Presentation
by Ana Spehonja A 6-year-old previously healthy male was brought to the
emergency department (ED) after he fell into a freshwater lake
while playing on the dock. Eyewitnesses found his body
floating face down in the water. He was unaccounted for
10-15 minutes. They started basic life support right after they
pulled him out of the water. He was cyanotic, apnoeic,
pulseless with fixated and dilated pupils and tympanic
temperature of 26,7 at arrival to ED. CPR was continued. After
established airway and assessment for other injuries, they
began to warm him up. ABG showed combined respiratory
and metabolic acidosis with severe uncorrected hypoxemia.
15 minutes post mechanical ventilation and the return of a
spontaneous heart rate with adequate blood pressure 110/67,
SpO2 was 96%, pupils small and reactive to light and the
tympanic temperature was 32,2°C. There was no spontaneous
305
respiratory effort. ABG analysis showed d r o w n i n g a s t h e ˝ t h e process of experiencing respiratory
impairment from submersion/immersion in liquid. Drowning
uncompensated metabolic acidosis with
outcomes are defined as death, morbidity, and no morbidity.˝
corrected hypoxemia. He was stable enough for
transfer to Paediatric ICU. After two days, ICU Drowning happens due to closed glottis, hypoxia,
reported him to be stable with normal and cardiac arrest.
temperature. People don’t inhale water; it gets into the lungs
Definition and Terminology later.
306
both cases, the effect of the osmotic gradient on the very delicate I f t h e p a t i e n t i s n o t breathing give 5 rescue breaths
alveolar-capillary membrane increases its permeability and immediately, followed by 30 chest compressions and continuing
exacerbates fluid, electrolyte shifts and plasma. with 2 rescue breaths and 30 compressions until signs of life
reappear. Positive pressure bag-valve-mask ventilation should be
Rapid CNS cooling before significant cardiac dysrhythmia
administered.
provides cerebral protection in cold water submersion.
If the heart is beating give only breaths, not CPR. Victims with
In submersion victims amount of swallowed water is much
only respiratory arrest usually respond after a few rescue breaths.
greater than aspirated, as a consequence 60% of patients vomit
after a submersion event. Well-known complication with If the patient is spontaneously breathing, let him cough, place him
aspiration of gastric contents is pulmonary injury and increased in the recovery position and administer high-flow oxygen mask
possibility for acute respiratory distress syndrome. (15 liters of oxygen per minute).
Type of the water does not matter If it is possible, resuscitate in the water
When the patient is rescued alive is the clinical picture
(ventilation alone)
determined predominantly by the amount of water has been Endotracheal intubation and positive pressure ventilation are
aspirated and its effects. Osmotic gradient effects the very necessary if there is no recovery of spontaneous respiratory
delicate alveolar capillary membrane increases its permeability effort.
and exacerbates fluid, plasma and electrolyte shifts.
Obligatory transportation to ED is for the patients who have a loss
We should also consider the precipitants of submersion injury or depressed consciousness, an observed period of apnoea and
which may be drugs or ethanol intoxication, cardiac arrest, those who require a period of artificial ventilation.
hypoglycemia, seizure and attempted suicide or homicide.
Emergency Department Care
Prehospital Care First steps are assessing and securing the airway, providing
The most important thing is early CPR, as it optimizes the oxygen, determine core temperature and assisted ventilation as
outcome. This is the reason why there is a need to train necessary.
laypersons in CPR.
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If the patient is in cardiac arrest you should follow ACLS • A v o i d s u c t i o n a s i t disrupts oxygenation and do not
guidelines. extubate early (lung injury may present later). Medications
should not be administered through the endotracheal tube.
The following management shows the steps when the patient is
not in cardiac arrest: C. Circulation
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Risk Groups If ED resuscitation/CPR was required the patient should be
• Drowning is the leading cause of injury mortality in children 1 to a d m i t t e d t o t h e i n t e n s i v e c a re u n i t f o r c o n t i n u o u s
4 years of age. cardiopulmonary and frequent neurologic monitoring.
• Children can develop dilutional hyponatremia and seizures in The patient can be discharged after 4-6 hour observation period if
freshwater near-drowning. the Glasgow Coma Scale is 15, oxygen saturation over 94% on
room air and if pulmonary examination does not reveal rales,
• Children have hypothermia more quickly because of a lower rhonchi, wheezing, or retractions. We should warn the patient to
ratio of body mass to surface area. There was no shown benefit return if mental status changes, pulmonary symptoms or fever
in controlled hypothermia, barbiturate coma, and intracranial occur.
pressure monitoring.
Prognosis
There is no prognostic scale that accurately predicts long-term References and Further Reading, click here
neurologic outcome. There is documented normal neurologic
recovery even with fixed and dilated pupils, cardiovascular
instability, prolonged submersions and persistent coma.
Complete recovery within 48 hours is expected if there was no
need for cardiopulmonary resuscitation on the scene or in ED. If
there are no continuous neurologic and cardiovascular deficits
shown, the patients should recover completely. Those who
needed CPR in ED have a poor prognosis, because of significant
anoxic or ischemic insult to the brain and other vital organs.
Disposition Decisions
Apnoea, hypoxia, unconsciousness, dysrhythmia or abnormal
chest radiograph are signs for admission.
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Section 3
Heat Illness
Case Presentation
by Abdulaziz Al Mulaik A 57-year-old male is brought to the emergency department
by EMS during Hajj. The patient as stated by the paramedics
was “found face down” in the street under direct sunlight,
where outside temperature is 45°C. Initial vitals are BP: 91/55,
HR 130 . O2Sat 95% on room air, RR 25 , Axillary temperature
39°C, and his Glucose check was 8 mmol/l. On examination,
the patient is not oriented nor alert but he moans to painful
stimuli, and he is maintaining his airway with no drooling. You
ask a member of your team to repeat temperature
measurement rectally, and he finds it to be 42.3°C. The rest of
your physical examination is unremarkable. You remove all of
the patient’s clothes and spray him with lukewarm tap water,
you then turn on a fan and raise the head of the bed and the
side rails. A continuous temperature probe is inserted rectally.
A cardiac monitor with pulse oximetry is connected, and
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blood samples were drawn for laboratory testing. Basics of Heat Transfer is explained in this video.
After reaching a rectal temperature of 39°C, you Critical Bedside Actions and General
direct your team to dry him and cover him with a Approach
Heat stroke is a devastating disease that might have permanent
light bed sheet. On subsequent examination, the
sequelae if lifesaving interventions are delayed. It is defined
patient is conscious, alert and oriented. Vitals are simply as a failure of thermoregulatory mechanisms to cope with
HR 105, O2Sat 96% on room air, RR 20. Labs either internal heat production known as exertional heat stroke
reveal multiple abnormalities including respiratory (EHS) or external environmental heat, known as classic heat
stroke (CHS). Watch this video.
alkalosis and elevated liver enzymes. Your
disposition includes appropriate medical To diagnose a heat a stroke, the patient has to have a Central
Nervous System (CNS) impairment and core temperature of more
consultation and admission to a medical ward for
than 40°C. The spectrum of neurological abnormalities ranges
further management. from mild confusion to full-blown coma with GCS of 3. Core
temperature has to be measured and continuously monitored
using rectal or esophageal probes as peripheral measures of
temperature are unreliable and does not correlate with core
temperature.
Differential Diagnoses
In a febrile illness, be it infectious or otherwise, circulating
pyrogens resets the normal temperature in the thermoregulatory
control center to a new set point above normal. The entire
thermoregulatory pathways in the body will work to achieve the
new set point; hence febrile patients will have behavioral changes
where they will seek warmer environments. Cooling febrile
patients by cold towels or showers has a mild effect as the body
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by sweating is another risk factor for developing heat illness.
Table 6.2 The list of minor heat illnesses with their clinical
features and treatment Generally speaking, CHS is not common in geographical areas
where average temperature throughout the year is high, as
MOST PROMINENT
MINOR HEAT communities living in these places will develop behavioral tactics
CLINICAL TREATMENT
ILLNESS
FEATURES to avoid the heat.
Prickly heat Very pruritic vesicular Chlorhexidine lotion
rash on an Intense exercise, military training, sports competitions or
erythematous base prolonged labor might induce another type of stroke known as
Heat syncope Standing in heat for No specific treatment exertional heat stroke (EHS), which differs from CHS in laboratory
long time with no required
previous indices and long-term complications. A third less common type of
acclimatization to heat stroke is confinement hyperpyrexia where the patient is
heat
exposed to moderately high ambient temperatures for a long
Heat cramps Muscular cramps Oral 0.1% salt time.
AFTER working in solution
heat
Measuring body core temperature is perhaps the most important
Heat edema Swollen feet and No specific treatment
ankles in healthy required physical assessment, whenever heat illnesses are considered in
patients after the differential diagnosis of a given patient. Peripheral
standing in heat for
long time temperature measurements correlate poorly with core
temperature. The two methods of measuring core temperature
are either through the esophagus or the rectum with the latter
History and Physical Examination Hints
representing the majority of clinical practice. A common pitfall in
Situational awareness is a vital skill to emergency physicians, as
using rectal temperature is inserting the probe to an insufficient
one should be aware of high ambient temperatures and high
depth which will render readings to be inaccurate in both
humidity days as they are perfect conditions for classical heat
directions especially if ice packs have been applied to the groin.
strokes. Lonely elderly community members with low
Rectal probes, in general, have to be inserted 15 cm inside the
socioeconomic status are particularly vulnerable to CHS as they
rectum to mitigate the effects mentioned above, but
have poor access to good air conditioning and ventilation. Usage
manufacturers may recommend different depths.
of some medications which impairs adrenergic response to heat
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Tachycardia and hypotension are Emergency Diagnostic Tests immersion can do this, and although
commonly seen and represent the and Interpretation this is theoretically the best cooling
physiologic response to heat, as E H S a n d C H S h a v e d i ffe r e n t method, it is clinically challenging as it
peripheral vascular resistance decreases derangements in laboratory studies with poses a risk of aspiration and renders
to allow the blood to be cooled at the some similarities. For instance, patient’s accessibility quite difficult.
surface of the skin, leading to a high respiratory alkalosis is a physiologic Convection, which is the thermal loss due
output status. This phenomenon might response to heat stress, which is to gas movement around the body,
explain other heat illnesses like heat profoundly represented in CHS, whereas combined with evaporation can achieve
syncope and heat edema. lactic acidosis is the prominent acid-base the similar speed of cooling to full body
disturbance in EHS. Moreover, liver immersion. This combination can be
Heat stroke is a multisystem disease
enzymes should be elevated in both EHS achieved by spraying the patient with
affecting almost every organ in the body.
and CHS with numbers in the tens of lukewarm water followed by fanning with
CNS effects might range from simple
thousands above normal cutoffs, to the warm air. Mist fans are very convenient
confusion to deep coma. Seizures, in
degree that their elevation is a cardinal and have the added benefit of their ability
general, are common and might be
diagnostic criterion, and their absence to fan multiple patients at once. Cooling
confused with shivering during cooling,
will render the diagnosis of heat stroke units with intermittent water sprays from
but both disorders need to be treated, the
unlikely. Another common difference all directions around the patient are costly
former for neural protection and the latter
between CHS and EHS is glucose level and not available in most hospitals, and
to prevent heat generation. Heat stroke
as it might be low in the latter but not the they have recently fallen out of favor,
patients might have derangements in
former. even in Hajj despite their availability,
their hemostasis represented clinically as
mainly due to safety concerns as they
melena, hemoptysis, conjunctival
Emergency Treatment limit access to patients.
hemorrhage or epistaxis. Prickly heat
Options
patients will have pruritic vesicles on an Invasive cooling procedures such as cool
The fastest way to transfer heat and to
erythematous base. These vesicles are IV fluids have not been proven to change
cool patients is through conduction,
sweat glands with blocked pores by the outcomes as their evidence remains
which is the direct transfer of heat
macerated stratum corneum. to be weak. On the other hand, thoracic,
between molecules. Full body water
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bladder, rectal and peritoneal lavage and should take priority on any other A mass casualty incident of heat stroke
should only be used when all other diagnostic or therapeutic procedures. and heat exhaustion patients should be
measures fail. We suggest abandoning expected in preparing for a mass
Peripheral blood pooling is in the heart of
them even in the very sickest of patients, gathering event and mitigation measures
heat stroke pathology, so hypotension is
as a neurologically meaningful recovery is should be sought in advance. Public
common in these patients and fluid
highly unlikely. education to seek shade, drink enough
administration should be very judicious
fluids, use umbrellas and installing mist
as the blood pressure usually will pick up
Image 6.9 monitor showing the as the core temperature drops down. Image 6.10 The row of beds with
current vitals while the patient is Aliquots of 250 cc of crystalloids should mist fans in a sunstroke unit. A
cooled. cooling unit can be seen at the far
be used when fluids are needed, and
right.
repeated dosing should take place after
volume status assessments.
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pipes, venting fans, cooling stops in a path of a riot or a race are
few examples.
Disposition Decisions
Heat stroke patients usually require higher care upon admission
as their stability is not certain and further assessment of heat
stroke complications should take place in the hospital. Stable,
conscious heat exhaustion patients may be discharged with
education and close follow up. Minor heat illnesses should be
treated as a case by case scenario, but they rarely require
inpatient care.
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Section 4
Hyperthermia
317
• Seizures • Status epilepticus, linked to the RYR1 gene located on
chromosome 19q. Triggering drugs cause
• Agitation • Stroke,
a release of sarcoplasmic reticulum Ca2+.
• Uncoupling of oxidative • Brain trauma, Resulting ca2+ stimulated glycolysis,
phosphorylation- e.g., Salicylate muscle contraction, uncoupling of
• Neoplasms, oxidative phosphorylation leading to
overdose.
hyperthermia. Drugs causing MH are
• Acute intermittent porphyria,
• Hepatic Metabolism stimulation-e.g - volatile inhalation halogenated
sympathomimetic drugs • Tetanus, a n e s t h e t i c s a n d m u s c l e re l a x a n t
suxamethonium.
Hyperthermia secondary to • Thyroid Storm
other processes Pathophysiology
• Neuroleptic Malignant Syndrome(NMS) • Heat stroke,
– link The usual body temperature of humans is
• Sepsis.
between 36° C and 37.5°C.
• Serotonin Toxicity/syndrome(SS) –
• SSRI toxicity and other drug toxicities,
Serotonin TOXICITY – link When Core Body temperature (Rectal
• pheochromocytoma. temperature/esophageal temperature) is
• Malignant Hyperthermia (MH) – link greater than about 41.5°C it results in:
Malignant Hyperthermia (MH)
Differential Diagnoses Incidence is about 1:10000-15000. All • Progressive denaturing of number of
There are multiple differentials to the races are affected. vital cellular proteins.
cause of hyperthermia. A good history
from the patient (if possible), carers or Mortality rates have fallen from 70-80 % • Failure of vital energy-producing
relatives is crucial to the diagnosis. Few to 2-3 % due to increase awareness, process in the cells like oxidative
important differentials to consider in ED monitoring standards, and Dantrolene. phosphorylation and failure of enzyme
are: function.
Genetically inherited disorder (autosomal
• Central nervous system infections, dominant). About 70% of families are
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• Loss of cell membrane function with • Failure to achieve muscle relaxation There is Dopamine depletion/
increasing permeability. following succinylcholine, e.g., master dopamine receptor (D2) blockade in the
spasm impeding intubation and hypothalamus, nigrostriatal pathways and
Tissues most at risk are:
persisting for 2 minutes. spinal cord which leads to increased
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• Agitation, anxiety, confusion, decreased picture, and exclusion of alternative AKI(Acute Kidney Injury) and
level of consciousness, seizures diagnoses. Drug history is very important rhabdomyolysis.
and clinical suspicion is paramount.
• Clonus, Hyperreflexia, Hypertonia, • Cardiac enzymes.
Investigations are directed towards the
Incoordination, Myoclonus, Tremor
exclusion of other causes of pyrexia, e.g., • C h e s t X - r a y - To i n v e s t i g a t e
• Diaphoresis, Diarrhoea, Hypertension, sepsis and other disorders complications and rule out the
Hyperthermia, Tachycardia differential diagnosis.
Investigations are done to rule out
• mydriasis, piloerection, and muscular complications and guide treatment. • Specialist investigation:
rigidity
• Serum electrolytes- to check imbalance • Muscle biopsy using in-vitro
• CVS features include sinus tachycardia, and supportive treatment contracture test (IVCT) which is
flushing, hypertension, and hypotension the gold standard for MH
• Creatinine Kinase – Guides treatment of
(rare). diagnosis. This is done in
Rhabdomyolysis.
specialized MH centers. 8 to 10
• Citalopram causes dose-dependent QT
• Serum Glucose – Rule out hypo/ muscle specimens are taken and
prolongation.
hyperglycemia as the cause of altered considered positive if muscle
Develops after a latent period, ranging mental state. contracts to halothane and/or
from few hours to several days. Most caffeine
• ECG- arrhythmia, electrolyte
patients are mildly affected, but the
abnormalities. Treatment
disease spectrum is very broad. Most
cases resolve within 24-48 hours after • Urine- Toxins Supportive and cooling
withdrawal of the precipitating agent. measures for hyperthermia in
• Multiorgan dysfunction workup
general
Workup • Clotting screen- coagulopathy • Evaporative cooling- Remove all
Diagnosis of hyperthermia disorders is clothing, and spray the patient with
(DIC)LFT’s, Renal functions-
based on a detailed history, clinical tepid water while blowing air with a fan.
detect complications such as
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Areas with increased vascular beds, • Severe SS: Neuromuscular •Bromocriptine as dopamine agonist
e.g., neck, axillae, groins should be paralysis should be considered can be given orally/NG tube, 2.5-10mg
asked with ice packs. early especially in cases with a TDS.
low GCS.
• Iced water immersion: – Can cause Malignant Hyperthermia
awkward patient access and difficulty in • Antiserotoninergic drugs: • Avoiding the triggering agents prevents
monitoring. Not very practical in the MH.
• Chlorpromazine- 12.5-50mg
Emergency Department.
IM/IV • Using inhalation agent free machines
• Invasive methods: Cold IV fluids, urinary during anesthesia.
• C y p ro h e p t a d i n e - 4 - 8 m g
bladder lavage, peritoneal/pleural
orally 8 hourly. • Dantrolene Sodium- Inhibits the release
lavage with cold fluid.
of calcium from the sarcoplasmic
Neuroleptic Malignant
Serotonin Syndrome( SS) reticulum.
• Mild cases- May need observation in
Syndrome
• Benzodiazepines for anxiety and • 2.5mg /kg IV initially repeated
ED for a few hours and safely
agitation. every 15 minutes to maximum
discharged if asymptomatic.
30mg/ kg.
• Stop all neuroleptics
• More serious cases would need
• AAGBI guidelines for treatment of MH
supportive treatment and • Correct volume depletion and
poster link
pharmacological therapy with hypotension with intravenous fluids
observation and treatment for
• Reduce hyperthermia (see above)
Prognosis and Disposition
complications in ICU.
• Early intensive care referral is indicated.
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Chapter 7
Selected
Gastrointestinal
Emergencies
Section 1
Acute Appendicitis
Case Presentation
by Ozlem Dikme A previously healthy 22-year-old male was brought to the
emergency department (ED) with recently-started abdominal
pain. He had not eaten anything since that morning due to
loss of appetite. He was nauseated and vomited three times.
His abdominal pain started around the umbilicus and
epigastric area. His pain increased as it moved towards his
right lower quadrant (RLQ). The maximum pain was felt on the
right iliac fossa. He had not taken any medication. His social
history revealed that he was non-drinker, non-smoker and did
not use any illicit drugs. His diet mostly consisted of
carbohydrates. The past and family histories were
unremarkable. His blood pressure was 120/70 mmHg, pulse
rate was 100/min, the temperature was 37.8°C (100°F), and
respiration rate was 22/min. Physical examination showed
Audio is available here normal bowel sounds, tenderness and voluntary guarding,
325
particularly over the right iliac Can you name the finding in the given diffuse abdominal infection, systemic
ultrasound in this video? infection, even sepsis/septic shock can
fossa. The costa-vertebral
be another priority for the physician. After
angles were not tender. Oral Introduction the ABC evaluation, focused
About 7% of the population develops
intake was stopped, gastrointestinal and pelvic orientation
appendicitis in their lives. Males are follows. Depending on the patient needs,
intravenous (IV) catheter was affected 1.4 times higher than females, critical actions necessary in the initial
inserted, blood and urine tests and teenagers more than adults (3:2). The ABC evaluation can be applied. However,
were planned, and fluid therapy incidence rises gradually from birth, placing IV catheters, starting fluid therapy
peaks in the late teens, and declines in are the priority in most of the cases. Oral
was started. The urinalysis was
the elders. It occurs in all age groups but intake should be stopped. Pain
normal. White blood cell (WBC) most frequently between the age of 10 medication and application of antibiotics
count was 14,500 with 89% and 30. Prevalence is higher in countries may be considered in the early phase
with diet habits low in fiber and high in
polymorphous and 11% depending on the patient situation.
refined carbohydrates. Low dietary fiber
lymphocytes. The causes fecalith formation and obstruction The possibility of acute appendicitis must
ultrasonography (USG) showed of the appendicular lumen. be explained, and the patient’s approval
should be obtained for further steps. The
a non-compressible tubular
Critical Bedside Actions and evaluation should include laboratory tests
structure of 9 mm in diameter General Approach and imaging. Count blood cell (CBC) and
at RLQ. He admitted to the The general approach to a patient with c-reactive protein (CRP) are generally not
possible acute appendicitis must start specific to diagnose, but they may be
surgical ward with the
with the patient stabilization. Fortunately, useful to confirm or exclude the
diagnosis of acute the most of the patients come with stable differential diagnoses. USG or computed
appendicitis. clinical presentation except pain. Some tomography is possible imaging
patients may present late. In this situation modalities.
perforation is a possibility. Therefore
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History and Physical peritoneal irritation are triggered RLQ •Inflammatory Bowel Disease (Crohn
Examination Hints pain with palpation of the left lower Disease, Ulcerative Colitis)
Abdominal pain is the most common quadrant (Rovsing sign), with internal and
• Inguinal hernia
complaint. It typically starts periumbilical external rotation of the flexed right hip
or epigastric, then migrates to the RLQ. It (Obturator sign), with the extension of the • Intussusception
is the most discriminating feature of the right hip (Psoas sign), with cough
(Dunphy sign) or with dropping from • Meckel Diverticulum
patient’s history. Its’ sensitivity and
specificity are approximately 80%; the standing on toes to the heels (Markle
• Mesenteric adenitis
positive likelihood ratio is 3.18, the Sign).
negative likelihood ratio is 0.5. Patients • Mesenteric ischemia
typically avoid moving because it
Differential Diagnoses
Many different specific diseases cause • Omental torsion
worsens their pain. The classic history of
abdominal pain. The below list is given in
anorexia, periumbilical pain followed by • Pancreatitis
alphabetical order. We advise you that
nausea, RLQ pain, and vomiting occurs in
look for other specific disease entity • Perforated viscus
only 50% of cases. Nausea is present in
chapters to understand presentation,
61-92% of patients, anorexia in 74-78%. • Rectus sheath hematoma
diagnosis and treatment differences.
Vomiting almost always follows the pain.
Diarrhea or constipation is noted in as • Tubo-ovarian pathologies (Ectopic
• Acute Cholecystitis or Biliary Colic
many as 18% of patients. In up to 50% of pregnancy, Pelvic inflammatory disease,
cases, local tenderness of Mc Burney’s • Acute Gastritis or Peptic Ulcer Disease Abscess, Endometriosis, Ovarian cyst/
327
Emergency Diagnostic Tests T h e r e f o r e , i t i s n o t s p e c i fic t o more likely urinary tract infections.
and Interpretation appendicitis. Studies show that sensitivity Additionally, proteinuria and hematuria in
Appendicitis is a clinical diagnosis. of CRP is between 93% and 96.6% for urinalysis usually suggest genitourinary or
However, some laboratory tests may help acute appendicitis. A normal CRP level hematological disorders. Women of
emergency physicians in the decision- has a negative predictive value of childbearing age must have pregnancy
making process. Each test has some pros 97-100% for appendicitis in the patients evaluated. Ectopic pregnancy should be
and cons. Therefore, your clinical history with symptoms longer than 24 hours. in your mind always.
and exam should be the main part of your Investigators have also studied the
Computed tomography (CT) has 94%
decision-making process. Relying on combinations of WBC count, CRP and
sensitivity and 95% specificity and shows
laboratory tests may mislead you in some neutrophil count to reliably rule out the
higher diagnostic accuracy over USG
cases. diagnosis of acute appendicitis. Patients
(Sensitivity: 88%, specificity: 94%) for
with a WBC count below 10000/mm3 and
Count Blood Cell (CBC) is an easily acute appendicitis. A large, single-center
a CRP below 6 to 12 mg/dL are unlikely
accessible and inexpensive test, but it is study found that CT has a high rate of
to have acute appendicitis (Negative
nonspecific. Studies consistently show sensitivity and specificity (98.5% and
likelihood ratio: 0.09). Patients with a
that WBC count is greater than 10500/ 98%, respectively) for acute appendicitis.
WBC count above 10000/mm3 and a
mm3 of 80-85% adult patients with acute Though the use of IV and oral contrast
CRP above 8 mg/dL were likely to have
appendicitis. Also, the neutrophil count is may increase sensitivity, it may prolong
acute appendicitis (positive likelihood
higher than 75% in 78% of patients. CBC ED stays, cause allergic reactions and
ratio: 23.32).
shows different likelihood ratios (LR) for vomiting. Therefore, in adults, abdominal
different WBC levels. LR of WBC of Urinalysis may differentiate diagnoses and pelvic CT may be performed with or
9-11000 is 0.29. However, WBC of such as urinary tract infections. However, without contrast.
11-13000 has 2.8 LR. the appendix has a relationship with the
A healthy appendix usually cannot be
right ureter, and in some cases, pyuria
C-reactive protein (CRP) is useful, and it viewed by Ultrasonography (USG). In the
may not refer to only urinary infections.
usually is higher than 1 mg/dL. However, case of acute appendicitis, the USG
Pyuria may occur in cases of
it cannot detect the site of infection. typically demonstrates a non-
appendicitis, but severe pyuria marks
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compressible tubular structure of 7-9 mm in diameter in the RLQ. T h e u l t r a s o u n d v i d e o shows transverse and longitudinal
However, USG is not as accurate as CT. USG is the first choice, views of appendicitis in the same sequence. The appendix is
especially in pediatric patients, pregnant females, and slender located 3-4 cm deep from the skin surface. This video does not
patients. Additionally, if a gynecologic pathology is more likely include measurement. However, the reported diameter was 8 mm,
than acute appendicitis in females, USG can be the initial test to the diameter reaches more than 1 cm (10 mm) in some slices.
detect gynecologic pathologies such as ectopic pregnancy,
Plain radiographs are not specific or cost-effective. It may
ovarian cysts or other female reproductive system pathologies. If
visualize an appendicolith (It is highly suggestive of appendicitis
the operator is an experienced ultrasonographer, it may be the
but only seen in fewer than 10% of patients) or air-fluid level on
first imaging method. It is also important to emphasize that USG
RLQ location.
is an operator-dependent modality.
If USG is equivocal, magnetic resonance imaging (MRI) should be
Ultrasound images show the increased size of appendicitis
considered in pregnant patients. Its’ disadvantages are long scan
(below). More than 6 mm is considered abnormal (Image 7.1).
times, high cost, and limited availability. Some researchers
suggest MRI instead of USG in pediatric patients. MRI’s (100%)
Image 7.1 sensitivity is found higher than USG (76%) in pediatric patients
with acute appendicitis.
329
physician groups, especially emergency Elders initially relate their symptoms to and tenderness may occur in the first
physicians and surgeons in some their comorbidities. As a result, late trimester, but RUQ or flank pain may
facilities. 2011 Cochrane review reported presentation to ED may cause diagnostic dominate later. The symptoms are similar
that “The use of analgesia for acute delays. Additionally, ongoing drugs’ side t o t h e fir s t - t r i m e s t e r p r e g n a n c y
abdominal pain does not mask clinical effects may mask their acute condition. symptoms such as nausea, vomiting, and
findings, nor does it delay diagnosis.” Therefore, a late presentation or anorexia. The physicians should consider
However, only recommended analgesics insignificance of symptoms should not appendicitis if these symptoms reappear
are opioids in these patients. dissuade the clinician from the diagnosis. later in pregnancy. However, WBC count
The diagnostic delay relates to increased is not reliable in pregnancy because of
Pediatric, Geriatric, and mortality and morbidity. The mortality the physiologic leucocytosis. Imaging
Pregnant Patient rates range from 0.1% to 1% in children, modalities USG or MRI can use for the
Considerations and it rises above 20% in patients older diagnosis.
Appendicitis has relatively high than 70 years. Overall, the perforation
misdiagnosis rates at both extremes of rate varies from 16% to 40%. Younger Decision Making
age. In children, the misdiagnosis rate is children have a higher perforation rate Clinical findings guide risk stratification.
25-30%. The most common between 50-85%. Diagnostic delays may Risk stratification scores guide diagnostic
misdiagnoses are gastroenteritis and increase perforation rates up to 55-70% modalities and disposition decisions such
respiratory tract infections. The early in patients older than 50 years. as discharge, observation or surgical
symptoms like loss of appetite or consultation. The Alvarado score is a
vomiting are non-specific. They may The appendicitis incidence in the well-known classification for appendicitis
easily lead the physician to other pregnant remains unchanged compared (Table 7.1).
diagnoses such as gastroenteritis, urinary to the general population, but the
or respiratory infections. changes in the presentation may delay
the diagnosis. During pregnancy,
Ten percents of the appendectomies are appendix replaces toward the right
performed in the elderly. Misdiagnosis kidney and rises above the iliac crest at
rates are high in this age group too. about 4.5 months of gestation. RLQ pain
330
Score
Table 7.1 Alvarado Score In Acute Appendicitis
1-4 Appendicitis unlikely
CATEGORY EXPLANATION SCORE
5-6 Appendicitis possible
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Section 2
Biliary Disease
Case Presentation
by Dan O’Brien A 35-year-old woman presents to the emergency department
with right upper quadrant pain of two hours duration. She
awoke several hours after eating a large meal. Based on
increasing pain and nausea she presents for evaluation. She
denies vomiting, fever or dysuria. Her past history is notable
for diet-controlled type II diabetes, dyslipidemia, and essential
hypertension. Her BMI is 33. Her only medication is lisinopril
10 mg daily. She has never had surgery. Her social history is
unremarkable. She neither drinks alcohol nor uses tobacco.
She has begun to diet and reports recent weight loss.
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findings include: chest exam normal, cardiac Image 7.2
exam normal, abdominal exam demonstrates
normal bowel sounds and no rebound in any
quadrant. She has guarding to inspiration with
palpation over the gallbladder (positive Murphy’s
sign). Rectal exam normal, stool is hemoccult
negative for blood. Pertinent lab values: glucose
110 mg/dl, alkaline phosphatase 120 U/L, alanine
aminotransferase (ALT) 25 U/L, aspartate
aminotransferase (AST) 25 U/L, gamma glutamyl
transferase (GGT) 20 U/L, direct bilirubin 0.1 mg/
dL, total bilirubin 0.5 mg/dL, lipase 20 U/L.
return to the emergency addition, it is important to exclude the gallbladder wall, or cholangitis:
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History and Physical are at increased risk for pancreatitis as described as colic, the pain may be
Examination Hints well. Diets low in fiber and high in more constant as it is caused by an
“A 35-year-old woman presents to the carbohydrates and fat have been obstruction of bile flow with subsequent
emergency department with right upper associated with gallstone formation. This distention. Patients may appear restless
quadrant pain of two hours duration. She may, in part, explain regional differences and unable to find a comfortable position.
awoke several hours after eating a large in gallstone formation. Murphy’s sign (the sudden cessation of a
meal. Based on increasing pain and deep inspiration when the inflamed
“ H e r t e m p e r a t u re i s 3 7 º C , b l o o d
nausea she presents for evaluation. She gallbladder descends and reaches the
pressure: 110/70 mmHg, pulse: 90 betas
denies vomiting, fever or dysuria.Her past examiners’ fingers palpating the right
per minute. Physical exam reveals an
history is notable for diet-controlled type subcostal area) is 65% sensitive and 87%
overweight female in mild distress
II diabetes, dyslipidemia, and essential specific for acute cholecystitis. Fever is
secondary to right upper quadrant pain.
hypertension. Her BMI is 33. Her only not typical, and jaundice is rarely seen
She cannot find a position of comfort and
medication is lisinopril 10 mg daily. She unless there is obstruction of the
describes the pain as similar to labor
has never had surgery. Her social history common bile duct from
pains. Pertinent exam findings include:
is unremarkable. She neither drinks choledocholithiasis or extrinsic
chest exam normal, cardiac exam normal,
alcohol nor uses tobacco. She has begun compression due to mass or
abdominal exam demonstrates normal
to diet and reports recent weight loss.” inflammation.
bowel sounds and no rebound in any
Gallstones are two to three times more quadrant. She has guarding to inspiration Emergency and Diagnostic
common in women, especially during with palpation over the gallbladder Tests and Interpretations
childbearing years. The risk of also (positive Murphy’s sign). Rectal exam
gallstones increases with age. Obesity or normal, stool is hemoccult negative for Laboratory Tests
blood.” “Pertinent lab values: glucose 110 mg/dL,
Body Mass Index (BMI) greater than 30 is
alkaline phosphatase 120 U/L, alanine
associated with increased gallstone
Patients with biliary colic have moderate aminotransferase (ALT) 25 U/L, aspartate
formation. Type II diabetes is associated
to severe right upper quadrant colicky aminotransferase (AST) 25 U/L, gamma
with obesity, hyperlipidemia, and
pain without peritoneal signs. Although glutamyl transferase (GGT) 20 U/L, direct
gallbladder hypomotility. Diabetic patients
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bilirubin 0.1 mg/dL, total bilirubin 0.5 mg/ cholangitis. ALT may briefly spike during gallbladder wall thickening or
dL, lipase 20 U/L.” acute obstruction, but it usually is not pericholecystic fluid. In addition, the
elevated unless there is secondary liver patient has a “sonographic Murphy sign”:
Alkaline phosphatase (ALP) is
parenchymal damage. An AST level there is maximal abdominal tenderness
synthesized by the bile duct epithelial
greater than the ALT level suggests when the ultrasound probe is pressed
cells. Its production is stimulated by bile
alcoholic liver disease, cirrhosis or over the visualized gallbladder.”
duct obstruction and is elevated in a
metastatic disease.
majority of patients with cholestasis. Plain radiography is often not helpful in
However, isoenzymes are found in the Gamma-glutamyl transpeptidase (GGT) is assessing biliary stones as most do not
liver, bone, placenta, small bowel and a membrane-bound peptidase that contain enough calcium to be visible on
leukocytes; it is therefore not specific for hydrolyzes peptides to amino acids and plain x-ray. Plain imaging may be useful
the biliary tract. smaller peptides. Although serum activity to identify gas in the biliary tree or
is primarily from the liver, it is found in the evidence of intestinal obstruction.
Bilirubin is a breakdown product of heme.
renal proximal tubule, pancreas, and
Unconjugated bilirubin is hydrophobic X-ray (Image 7.3) shows relatively normal
intestine. Its circulating half-life is usually
and is transported in the blood bound to findings in a RUQ and abdominal pain
7-10 days but may increase to 28 days in
albumin. It is taken up by the hepatocyte, patient. The CT scan of the same patient
alcohol-associated liver disease. The
conjugated, and actively secreted into the is shown below. It revealed cholecystitis
cholestatic disease may elevate GGT
biliary tract. Cholestasis may elevate (Image 7.5).
significantly. A complete white blood cell
serum bilirubin.
count, serum electrolytes, glucose renal
The aminotransferases; aspartate function studies, and urinalysis, may
aminotransferase (AST) and alanine assist in diagnosis and management.
aminotransferase (ALT) are found in the
liver, cardiac and skeletal muscle, and
Imaging Modalities
“The emergency physician performs a
cerebral nerve cells. Levels of these
focused right upper quadrant ultrasound
enzymes are typically only mildly elevated
and finds gallstones without associated
but may be markedly increased in
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pericholecystic fluid, C T imaging (Image 7.5) is not nearly as
Image 7.3
helpful as the right upper quadrant
sonographic Murphy’s sign,
ultrasound in evaluating the biliary system
common duct dilatation. for evidence of cholecystitis. Gallstone
sensitivity is about 75%, and common
In acute cholecystitis, gallstones are duct stones may be missed. It may be
present in 95-99% of cases. Emergency helpful to reveal complications of
physicians, performing focused, limited cholecystitis such as gangrenous or
bedside ultrasound and taking into emphysematous cholecystitis as well as
account the context of the patient’s to exclude other pathologies in the
h i s t o r y a n d c l i n i c a l p i c t u re h a v e abdomen.
documented a sensitivity of 90-96%, a
specificity of 88-96% as well as a positive Image 7.5
predictive value of 88-99% and a
negative predictive value of 73-96% for
cholecystitis. (Image 7.4)
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Emergency Treatment inflammatory drugs (NSAIDs) are first-line o f metronidazole and a fluoroquinolone.
Options therapies. In fact, studies suggest that Most patients will improve over 24 to 72
“An IV was established, and the patient NSAIDs have similar efficacy as opioids hours before surgical intervention.
received an isotonic fluid bolus. In with fewer complications. Opioids may be
Cholangitis, an infection of the bile duct,
addition ketorolac, 30 mg IV and used to control pain. Although there were
is a life-threatening disease that requires
ondansetron 4 mg IV were administered. historical concerns about morphine
aggressive resuscitation, timely
Over the course of an hour symptoms causing greater sphincter of Oddi spasm
antibiotics, and early drainage via either
resolved. Absent evidence of gallbladder relative to other opioids, all opioids to
endoscopic retrograde
inflammation or infection she was some degree increase sphincter of Oddi
cholangiopancreatography (ERCP)
discharged from the emergency pressure and biliary pressure. If a
guided sphincterotomy or stent
department and referred to a general patient’s pain is resolving and controlled
placement or percutaneous drainage to
surgeon for elective cholecystectomy. with oral agents, they may be discharged
stabilize the patient prior to definitive
She was advised that her pain might and referred to a general surgeon for
surgery.
return but if it is prolonged, is associated consideration of elective laparoscopic
with fever or jaundice she is to return to cholecystectomy.
Pediatric, Geriatric,
the emergency department.” Pregnant Patient and Other
Acute cholecystitis is best managed in
Asymptomatic gallstones do not require the hospital with surgical consultation. Considerations
Early laparoscopic cholecystectomy is None other than mentioned above.
any treatment. Most remain
asymptomatic for years after diagnosis. often the treatment of choice. Patients
should be given nothing by mouth. About
Disposition Decisions
About 1-2% may become symptomatic
annually. 20% of patients develop gallbladder or Admission
biliary duct infection. Appropriate Patients with suspected cholecystitis or
Biliary colic or biliary pain typically has a antibiotics regimens include second- and cholangitis should be admitted to the
definitive onset with a duration ranging third-generation cephalosporins, hospital. For suspected cholangitis,
from 15 minutes to up to four hours. carbapenems, ß-lactam/ß-lactamase emergency consultation, and if need be,
Antiemetics and nonsteroidal anti- inhibitor combinations or a combination transfer to a facility that can emergently
339
establish biliary drainage either via ERCP-guided sphincterotomy
or percutaneous stenting.
Discharge
Patients with biliary colic may be discharged once their
symptoms have resolved with follow up with a general surgeon.
They should be informed that there may be symptom recurrence
and should be instructed to return if they experience prolonged
pain, fever or jaundice.
Referral
Asymptomatic gallstones need not be referred to a general
surgeon. The patient should be informed of their findings and
instructed to follow up with their primary care physician.
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Section 3
Case Presentation
by Dan O’Brien A 68-year-old female presents to the emergency room at
midnight, with a chief complaint of vomiting “coffee grounds”
earlier that evening. She has a history of congestive heart
failure, hypertension, and a mild stroke. Her medications
include lisinopril 20 mg, Lasix 20 mg, aspirin 325 mg, and
clopidogrel 75 mg daily. Recently, she has taken ibuprofen
several times daily for arthritic pains. Family history is
significant for peptic ulcer in her mother and a brother.
Pertinent Exam: blood pressure is 98/65 mmHg, heart rate
110 bpm and regular, respiratory rate 14, non-labored, and
temperature 37 ºC. She appears pale, has a poor capillary refill
and is mildly confused but oriented to person, place and time.
Heart and lung sounds are normal; her abdomen is soft, non-
tender, without organomegaly, and without bruits. She has
Audio is available here trace pedal and pretibial edema. Her neurological exam is
341
grossly normal. While being examined, she asks hemoglobin of 11 g/ dL and creatine of 1.0 mg/
for a bedpan and vomits a cup full of bright red dL.
blood. Her blood pressure systolic is now 85 mm
Initial resuscitation is successful. Upper
Hg.
endoscopy reveals a bleeding duodenal ulcer that
She has hemodynamically significant upper GI is successfully stopped with hemoclips. The
bleeding. Her hypotension and tachycardia patients H. pylori stool antigen is positive.
indicate loss of more than 20% total blood Cardiology and Neurology agree to stop aspirin
volume. The most likely working diagnosis is and clopidogrel. Oral iron was started, and the
active upper GI bleeding likely from peptic patient was discharged. With the avoidance of
ulceration secondary to nonsteroidal anti- NSAIDs and with H. pylori eradication the risk of
inflammatory drugs (NSAIDs) with likely rebleed is less than 5%.
Helicobacter infection.
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Introduction • Hematochezia from upper GI source history of liver cirrhosis also give one
Despite advances in diagnosis prevention gram IV Ceftriaxone or 400 mg
• Hemoglobin <8 g/dL
and treatment, nonvariceal upper norfloxacin orally twice daily. Antibiotics
gastrointestinal bleeding is still a serious • Liver cirrhosis, coagulopathy are of benefit in cirrhosis by decreasing
problem in clinical practice. The infectious sequelae as well as the
• Orthostatic incidence of encephalopathy. The
incidence ranges from 48 to 160 cases
per 100,000 population per year. Upper reduction of bacterial products in the
• Resting tachycardia (>100 bpm)
GI bleeding causes mortality ranges from p o r t a l c i rc u l a t i o n re s u l t s i n l e s s
5% to 14%. • Syncope (systolic < 90 mmHg) vasodilation, which lowers the rebleeding
risk. After initial stabilization efforts,
• Transfusion > 1 unit/8hrs or 6 units total
Critical Bedside Actions and consult an endoscopist.
General Approach Initiate resuscitation: insert two large bore
“She has hemodynamically intravenous catheters infuse lactated
“The most likely working
significant upper GI bleeding.” ringers, type and crossmatch, obtain diagnosis is active upper GI
complete blood count with platelets, PT, bleeding likely from peptic
Indicators of Major Blood Loss and INR, as well as routine blood
ulceration secondary to
• Acidosis chemistries to assess for renal and
hepatic function. Start intravenous nonsteroidal anti-inflammatory
• Anticoagulation
octreotide, a somatostatin analog, at 50 drugs (NSAIDs) with likely
• Antiplatelet medications mcg/hour. Proton pump inhibitor by
Helicobacter infection.”
continuous drip, as a pH of 7 or greater is
• Azotemia (BUN > 40 mg/dL needed for platelet function and clot
adherence.
• Chest pain or dyspnea
Intravenous erythromycin 250 mg if given
• Continued bleeding or re-bleeding
within 30 minutes of planned endoscopy
• End stage renal disease can improve visualization. If there is a
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The goal of therapy is to stop bleeding to
Figure 7.1 Figure 7.2
prevent end organ ischemic damage.
Medical treatment alone is successful for
most cases of lower GI bleeding with a
third of upper GI bleeding cases requiring
emergent endoscopic therapy.
UPPER GI LOWER GI
BLEEDING BLEEDING
Differential Diagnosis Table 7.2 Comparison of Upper and
Abdominal pain may or may Large volume hematochezia
While it is important to know what is Lower GI Bleeding not be present in peptic or maroon stool with
ulcer orthostasis indicates
bleeding to determine prognosis and bleeding from right sided
UPPER GI LOWER GI Chest pain with esophageal diverticulae or ateriovenous
guide management, it is most crucial to BLEEDING BLEEDING ulcer malformations
think of anatomy and pathophysiology: Sudden fullness with nausea Small volume hematochezia
larger vessels bleed faster and more often 35% present with 19% present with due to blood in GI tract without orthostasis indicates
hemorrhoidal bleeding
shock shock Hematemesis or coffee (usually painless) if painful
require urgent intervention. The internal ground emesis followed by with dyschezia indicates
melena anal fissures or proctitis
diameter and pressure in vessels above 65% require 36% require
the ligament of Treitz are greater than transfusion transfusion Hematochezia in 10% of Bloody loose stools with low
rarpidly bleeding upper abdominal pain present in
lesions infectious colitis,
vessels associated with lower GI inflammatory bowel disease
30% require >90% stop Coughing followed by or ischemic colitis
bleeding. intervention to stop spontaneously hematemesis in Mallory
Weiss tear
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Upper GI bleeding represent 65 to 80% • gastric antral vascular ectasias (GAVE Lower GI bleeding is most often
of all GI bleeding, and includes or “watermelon stomach”) or caused by right-sided diverticula,
arteriovenous arteriovenous malformations, colonic
• esophageal or gastric varices,
adenocarcinoma, ischemic colitis,
• malformations above the ligament of
• duodenal or gastric ulcer, inflammatory bowel disease, infectious
Treitz.
colitis, or anorectal lesions including
• erosive gastritis, hemorrhoids, fissures, and proctitis.
Worldwide, upper GI bleeding from peptic
• erosive or ulcerative esophagitis, ulcer is most prevalent, although persons
with portal hypertension may represent
History and Physical
• Mallory Weiss tears, the majority who present with massive Examination Hints
Elderly patients and those with valvular
upper GI bleeding. With advanced age
• gastrointestinal cancers, heart disease or renal failure have an
and atherosclerotic disease, more
increased risk for arteriovenous
Rarer causes are patients are using anticoagulants or
malformations anywhere in the GI tract.
antiplatelet medications that impair clot
• hemobilia, Chronic NSAID use causes gastric
formation, and augment bleeding.
mucosal erosions in at least one-third of
• splenic artery pseudoaneurysms, Gastrointestinal bleeding from non-
daily users or significant ulceration in 2%.
steroidal induced peptic ulcers is on the
• Dieulafoy lesions, Alcohol consumption, chronic viral
rise, with up to 1 in 2 adults taking these
hepatitis, non-alcoholic hepatitis (NASH)
medicines. Although with industrialization
• gastrin-secreting tumors (Zollinger- can result in cirrhosis with portal
Ellison syndrome), and improved hygiene the prevalence of
hypertension. A family or prior history of
Helicobacter pylori has declined, the
peptic ulcer suggests Helicobacter pylori
• arteriovenous fistulae, infection and associated conditions are
infection. H. pylori is a spiral-shaped
still major causes of upper GI bleeding in
• penetrating foreign bodies, flagellated bacterium that lives in the
many parts of the world including the
human stomach and interrupts the
Middle East, Asia, and South America.
protective mucous bicarbonate layer, thus
exposing the epithelium to hydrochloric
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acid leading to chronic inflammation. Most persons with duodenal
Image 7.6
ulcer report sharp epigastric pain worsened by eating while less
than 50% of patients with gastric ulcer report abdominal pain that
improves post meals, as the acid is then buffered by the food and
duodenal bicarbonate secretion. The color of vomitus or stool is
also predictive of severity: hematemesis suggests ongoing
bleeding, whereas “coffee grounds” indicate partially digested
hematin or “old blood.” Abrupt symptom onset associated with
hypotension suggests acute bleeding whereas a history of weeks
of intermittent dark melanic stools suggests chronic blood loss.
Presenting vitals signs are most predictive of the magnitude of
blood loss; other important physical clues for portal hypertension
include abdominal ascites, enlarged liver or splenomegaly.
Evidence of hyperestrogenemia in males with cirrhosis includes
gynecomastia, testicular atrophy, and spider telangiectasias on
the chest or upper body. Palmer erythema and bounding pulses
in the fingers from peripheral vasodilation are indicators of
advanced cirrhosis. The bedside physical exam is unreliable in
females as palmer erythema and telangiectasias are normal Emergency Diagnostic Tests and
findings. Ascites determination is difficult in every patient unless it Interpretation
is massive. If available, a bedside ultrasound may confirm When abdominal pain is present, a plain film with upright chest x-
suspected ascites, coarse echotexture of the liver, or show ray may reveal significant atherosclerotic disease, ingested
reduced or reversed (hepatopedal) flow in the hepatic veins in foreign bodies, or subdiaphragmatic free air from a perforated
advanced cirrhosis. ulcer.
347
aspirate does not affect the timing of Colonoscopy is used less often as an
Figure 7.3
endoscopy or additional interventions. interventional therapeutic technique to
Gastric lavage is no longer considered stop bleeding from hemorrhoids, fissures,
useful. Consider endotracheal intubation arteriovenous malformations or diverticuli.
to decrease aspiration risk before elective
endoscopy for any patient with upper GI Figure 7.4
bleeding who is unconscious, in
significant respiratory distress, or with
recurrent witnessed hematemesis.
348
therapy for select patients with high risk of variceal bleeding.
Table 7.5 Glasgow-Blatchford Risk Score
Emergency Surgery for GI bleeding is required in less than 1% of CATEGORY SCORE
all cases including surgery for a peptic ulcer, and total or subtotal
BUN in mg/dL
colectomy for shock associated with bleeding diverticuli.
18.2 to 22.4 2
Emergency shunt surgery for liver cirrhosis is almost never
22.5 to 28 3
performed, as the mortality is unacceptably high compared to
endoscopic and angiographic techniques. 28.1 to 70 4
70.1 or greater 6
Pregnant Patients and Other Considerations Hemoglobin, men g/dL
In pregnant patients with GI bleeding, monitor for fetal distress,
12 to 13 1
and consult Obstetrics. Avoid erythromycin in the third trimester
10 to 11.9 3
otherwise treat the same as any other adult with GI bleeding.
Emergency upper endoscopy is safe in all trimesters. Lower 9.9 or less 6
endoscopy may be difficult depending on the size of the fetus/ Hemoglobin, women g/dL
uterus but is not contraindicated. The endoscopist will use safe 10 to 12 1
sedation medications for pregnancy. For GI bleeding in patients 9.9 or less 6
with acute MI, significant heart disease, stroke or significant
Systolic Blood Pressure, mmHg
neurovascular disease consult cardiology or neurology for help
100-109 1
with management. Often they will agree to urgent endoscopy to
90-99 2
clarify and treat bleeding lesions without interruption or reversal
of anticoagulation. <90 3
Heartrate >100 peats per minute 1
Disposition Decisions Melena 1
There are several valuable bleeding scoring systems help to
Syncope 2
guide disposition.
Hepatic Diseases 2
Heart failure 2
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Glasgow-Blatchford Risk Score is useful for predictive of inpatient AIM65 GI Bleeding Score is practical, easy to remember, assists
mortality, blood transfusions, re-bleeding, ICU monitoring, and with level of care, and timing for endoscopy. Scores less than 1
hospital length of stay. Patients with a score of zero may be predict good outcome, scores above 2 require hospitalization and
discharged home, those with score 2 or higher are usually treatment.
admitted, and those with score of 10 or more are at highest risk
for morbidity and resource utilization. Maximum score is 23. Admission Criteria
Patients with GI bleeding presenting in shock, requiring
transfusion or with bleeding scores (AIM65>2 or Glasgow-
Table 7.6 AIM65 Bleeding Score
Blatchford (GB) >10) have significant predictable morbidity and
RISK FACTOR SCORE mortality requiring ICU admission and treatment. Patients with
AIM65 of 1 or less or GB score 2 or less have predictably mild GI
Albumin <3.0 1
bleeding (melena without hematemesis and who are
INR > 1.5 1
hemodynamically stable) and may be cautiously admitted to a
Altered mental status 1
medical floor.
SPB < 90mm Hg 1
Age > 65 1 Discharge Criteria
Patients with AIM or GB score of zero may be discharged home
MAXIMUM SCORE 5
without outpatient gastroenterology evaluation within two weeks.
Prescribe twice daily PPI, avoidance of NSAIDS and alcohol for
Point Mortality %
those with upper GI symptoms. Instruct them to return
0 0% immediately for syncope or signs of bleeding. Those with history
1 0.9% and findings consistent with minor lower GI bleeding and stable
2 7.4% hemoglobin should also be referred for outpatient consultation
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Section 4
Case Presentation
by Rabind Antony Charles A 75-year-old woman presents to your Emergency
Department (ED) with diffuse abdominal pain for the past day,
associated with diarrhea and vomiting. She says the pain is
increasingly worse and has failed to respond to paracetamol
and charcoal tablets. She has a history of hypertension,
hyperlipidemia, and atrial fibrillation. She has no history of
laparotomy. She is alert and oriented. However, she is in
distress because of her abdominal pain. The pain score is 9
out of 10. Blood pressure: 96 over 56 mmHg, pulse rate: 125
(irregularly, irregular), respiratory rate 20, pulse oximetry: 98%
on room air, tympanic temperature: 37.5 degrees Celsius.
Heart sounds: (irregular) S1S2 positive. Lungs sounds are
bilateral equal and clear. Abdominal exam reveals diffuse
tenderness; it is worse in periumbilical region, no guarding,
Audio is available here
352
bowel sounds are sluggish. No scars or hernias Introduction
Acute mesenteric ischemia is a life-threatening cause of acute
noted. Per rectal exam: brown stool.
abdominal pain which occurs predominantly in patients over 50
What do you think about patient’s ECG? years old with the underlying cardiovascular disease. It is caused
by inadequate flow through the mesenteric vessels resulting in
Image 7.7 bowel ischemia and eventually gangrene of the bowel wall.
Mortality rates can be between 60-80% especially in patients with
greater than a 24-hour delay in diagnosis or presentation. This
underscores the importance of early detection in the ED, and the
need for aggressive management to reduce morbidity and
mortality. Surgical intervention in 6 hours of symptoms increases
survival rate.
Imaging Modalities
Erect Chest x-ray/Abdominal x-ray series used mainly to exclude
other causes of abdominal pain or look for complications of acute
mesenteric ischemia (e.g., free gas/bowel obstruction). They are
often normal in the early stages of acute mesenteric ischemia.
However, there are some early and late findings in the X-rays.
Early findings are adynamic ileus, distended air-filled bowel loops
and bowel wall thickening from submucosal edema or
hemorrhage. Pneumatosis of the bowel wall and gas in the portal
venous system strongly suggest bowel infarction as late findings.
355
diagnostic laparotomy depending on monitoring. IVC assessment with bedside decompress stomach and bowel is
institutional practice. U l t r a s o u n d c a n g u i d e t h e flu i d often necessary. Correct any electrolyte
resuscitation before invasive procedures abnormalities and acidosis.
Ultrasound has a limited role in the
(RUSH protocol).
diagnosis of acute mesenteric ischemia. Urgent surgical consultation should be
It is more useful for ruling out other A quick tutorial on IVC measurement with obtained in the ED as this is a time-
causes of abdominal pain, e.g., ultrasound (video) sensitive condition. Delays to definitive
cholecystitis, acute abdominal aneurysm treatment will result in increased
The ultrasound video shows collapsible
rupture, ureteric colic. morbidity and mortality. It is best to get a
and non-collapsible IVC. If the IVC
surgical consult when suspicion is high
Emergency Treatment collapse, this means the patient may
for acute mesenteric ischemia even
Options benefit from fluid resuscitation. (video)
before a CT angiogram has been done.
357
As a summary, the role of the ED physician is
to
• resuscitate the patient as needed,
358
Section 5
Perforated Viscus
Case Presentation
by Ozlem Dikme A previously healthy 42-year-old male presented to the
Emergency Department (ED) with a 3-day history of worsening
abdominal pain. He felt nauseated and vomited twice. His
pain started around the umbilicus, moved to the left side of his
abdomen and then become generalized. It peaked the last few
hours, and the painkillers did not work. His social history
revealed that he was non-drinker, non-smoker and did not use
any illicit drugs. The past and family histories were
unremarkable. His blood pressure was 100/60 mmHg, pulse
rate 120/min, the temperature 37.8°C (100°F), and respiration
rate 24/min. Physical examination showed diffuse abdominal
tenderness and voluntary guarding. Bowel sounds were not
heard. Bedside ultrasonography (USG) exhibited increased
echogenicity of the peritoneal stripe, with corresponding
Audio is available here horizontal reverberation artifacts over the liver. Plain chest
359
radiographs confirmed the presence of free Critical Bedside Actions and General
abdominal air. Oral intake was stopped, Approach
All critically ill patients with acute severe abdominal pain is a
intravenous (IV) catheter was inserted, fluid candidate to have a viscus perforation. The first step is always
therapy was started, and cefoperazone sodium patient evaluation with ABC approach and stabilization. These
was administered intravenously. Blood type and patients present to the ED with a severe abdominal pain and
discomfort. Because of the pain severity, they may not let you
cross, complete blood count and coagulation
touch their abdomen. They prefer to stand still because of any
were ordered. He transferred to the operation movement trigger pain. They look sick. Our first priority is to
theater with the diagnosis of the perforated ensure there is no immediate life or organ-threatening situation. If
so, immediate actions should be done at the bedside during the
viscus.
initial evaluation. Airway, breathing, and circulation evaluations
Can you identify free air on the X-ray? are completed. However, quick, focused abdominal examination
can be done before the full secondary evaluation. Opening two
Image 7.9 large bore IV lines, fluid therapy, stopping oral intake are some of
the routine actions. Patients are attached to the cardiac monitor.
Necessary blood samples are collected and sent. The pre-
diagnosis of perforated viscus must be explained to the patient,
and his approval should be obtained for further evaluation and
treatment. The US can be used at the bedside as an adjunct to
focused history and physical exam.
Differential Diagnoses
During the initial evaluation, emergency physicians try to
understand possible differential diagnoses in a patient with
severe abdominal pain. The below list is given in alphabetical
order.
360
• Abdominal Aortic Aneurysm Abscess, Endometriosis, Ovarian cyst/ o f pain helps to diagnose. Typical pain
torsion, Uterine leiomyomata) starts around a limited location, then
• Acute Cholecystitis or Biliary Colic
expands to all abdomen in a short time. A
• Acute Gastritis or Peptic Ulcer Disease
History and Physical history of frequent abdominal pain may
Examination Hints suggest the patient has a predisposing
• Acute MI Thorough medical history usually reveals condition. Free air under the diaphragm
predisposing factors or possible etiology may cause referred pain to the either or
• Acute Pancreatitis
of perforation. Predisposing chronic both shoulders. Vomiting is present in
• Aortic Dissection conditions include peptic ulcer disease, 50% of patients. Shock, sepsis,
inflammatory bowel disease, malignancy. gastrointestinal or intraabdominal
• Appendicitis Acute conditions like acute appendicitis, bleeding may accompany perforation.
acute diverticulitis, infections (e.g.,
• Diabetic Ketoacidosis
typhoid fever), intestinal ischemia, Ulcer perforation refers to when the ulcer
• Diverticulitis necrotizing vasculitis and penetrating or erodes through the wall and leaks air and
blunt injuries may cause perforation. peptic contents into the peritoneal cavity.
• Gastrointestinal carcinoma The anterior wall of the duodenum is the
Additionally, caustic substance and
foreign body (e.g., toothpicks) ingestions, most common site. Approximately 2 to
• Inflammatory Bowel Disease (Crohn
Disease, Ulcerative Colitis) endoscopic interventions and some 10% of patients with peptic ulcer
m e d i c a t i o n s a re a s s o c i a t e d w i t h undergo perforation once in their lives.
• Mesenteric ischemia perforation. Most common medications
Contamination of the sterile peritoneal
are aspirin, nonsteroidal anti-
• Omental torsion cavity with the chemical and bacterial
inflammatory drugs (NSAIDs) and
intestinal content causes inflammation,
• Rectus sheath hematoma steroids.
infection, and sepsis. Therefore, patients
• Tubo-ovarian pathologies (Ectopic The patient typically presents with may become tachypneic, tachycardic and
pregnancy, Pelvic inflammatory disease, sudden and severe abdominal pain. hypotensive in short time.
Asking patients about the characteristics Immunocompromised or critically ill
361
patients with other comorbidities pose a to diagnose but may exclude the other gas analysis, lactic acid, liver and renal
greater risk for perforation. Obscure differential diagnoses. function tests, lipase/amylase and
presentations in these patients may delay urinalysis can guide to diagnose and
the diagnosis. Bedside Tests post-surgical care. WBC count usually
The US is a highly sensitive modality in
elevated owing to peritonitis. Amylase
Fever and tachycardia are common. scanning for peritoneal free air. Recently
may be elevated; liver function test
Typically, initial low-grade fever increases attention of this technique has been a
results are variable.
over time. Peritoneal findings are almost rise, and it became a popular rapid
always present. Diffuse guarding and diagnostic test in EDs. Characteristic US Imaging Modalities
rebound tenderness are likely. “Boardlike” signs of pneumoperitoneum are the ring Plain radiography has a sensitivity
abdomen is a late sign. Bowel sounds are down artifact and enhancement of the demonstrating pneumoperitoneum
found decreased in the majority of the peritoneal stripe over the liver often ranging from 30 to 80%, thus making it is
cases. caused by fluid trapped between gas a questionable initial study when a
bubbles. When experienced hands use perforated peptic ulcer is considered
Emergency Diagnostic Tests the US its sensitivity of likely. Free air rises to its highest elevation
and Interpretation pneumoperitoneum achieves an almost in the body when the patients sit upright
An essential step of the evaluation is 93%. The US video. or in positions of left lateral decubitis for
imaging and laboratory tests. Erect chest at least 10 minutes. Thus it results in
or left lateral decubitus radiographs may Laboratory Tests increased sensitivity of the radiography.
reveal pneumoperitoneum. Bedside US Laboratory studies are generally not
Perforation suggestive findings include
may shorten the time to diagnosis and specific to diagnose. Use of these tests is
subdiaphragmatic free air, visible
surgical consultation. If these methods do valuable for the preparation before the
falciform ligament and air-fluid level.
not confirm pneumoperitoneum, the surgery and information about the patient
Radiography can be used as an initial
physician should proceed with b a s a l s t a t u s . Ty p e a n d c r o s s ,
screening exam. Thus, a patient may
computerized tomography (CT) or hemoglobin/hematocrit, platelet and
more expediently go to surgery with
laparotomy options by discussing with coagulation studies are the minimum
positive plain radiography. It also has the
surgery. Laboratory tests are not specific tests for this purpose. Additionally, blood
advantage of being obtainable portably at
362
the bedside with little interruption in contrast CT scans has shown as 95
Image 7.10
patient monitoring or care. On the other to 98% sensitivity in many protocols.
hand, free air cannot be identified in 30%
Can you identify free air on the CT?
of patients approximately. Thus plain
radiography is not sufficiently sensitive to
rule out perforation. Image 7.11
363
viscus should be in the ED resuscitation area with two large IV Pediatric, Geriatric, and Pregnant
line, oxygen, and close monitoring. Crystalloid fluids and Patient Considerations
antibiotics are medical treatment essentials. In the emergency In the pediatric population, two etiologies of perforation are
setting, antibiotics should cover gram-negative, gram-positive prominent: Blunt trauma and intussusception. Vehicle-related
and anaerobic pathogens. Two sample regimens are below. Fore trauma, bicycle handlebar injuries, and seatbelt syndrome are
more regimens, and please visit given links under the references common causes of perforation secondary to blunt trauma in
and further reading. children. Intussusception refers to invagination or “telescoping” of
a part of the small intestine into itself. Most cases are children
Table 7.7 A Sample Antibiotic Regimen In Perforated Viscus younger than two years. It leads to venous and lymphatic
ANTIBIOTIC PREGNANCY congestion and subsequent intestinal edema. As a result,
DOSAGE
REGIMEN CATEGORY intestinal ischemia and perforation may occur.
Ceftriaxone B Adult: 1-2 gr IV (bid)
Pediatric: 50-75 mg/kg/day IV Perforated viscus incidence increases with advancing age.
and (bid) History of peptic ulcer disease or diverticular disease is common
Metronidazole B Adult: Loading dose: 15 mg/kg IV in elderly. Medicine-related perforation is common in the geriatric
(max: 4 grams), 7.5 mg/kg IV (bid
or tid) population. NSAIDs increase the risk of colonic perforation in
Pediatric: 15-30 mg/kg/day IV patients with diverticular disease. In an elderly with lower
(bid or tid) (Check dosage for
neonatal of children <2 kg) abdominal pain, the physician should suspect perforated
diverticulitis or appendicitis.
Meropenem B Adult: 1-2 gr (tid)
Pediatric: 20 mg/kg – 1 gr (tid)
(Check dosage for children <3 Disposition Decisions
months)
All patients require intensive care unit admission. The majority of
patients with perforated viscus require laparotomy to explore the
whole gastrointestinal system, remove spilled ingredients and
repair the lesion. Selected self-closing lesions such as a duodenal
perforation covered by omentum may be an exception. They may
not need emergent laparotomy but close monitoring and
364
intravenous large-spectrum antibiotics treatment. Alternative
methods of source control such as the use of endoscopic clips
for iatrogenic colon injury during colonoscopy are under
investigation.
365
Chapter 8
Selected
OB&GYN and
Genitourinary
Emergencies
Section 1
Ectopic Pregnancy
Case Presentation
by Dan O’Brien A 24-year-old woman presents to the emergency department
with the complaint of lower abdominal pain and vaginal
spotting. She has never been pregnant. Her last normal
menstrual period was two months ago. She had light spotting
last month and states that her period this month is late.
367
Hg and a pulse of 90 bpm. An examination of her consulted. Treatment options were
abdomen reveals normal bowel sounds, no discussed.
masses, distension, organomegaly or rebound
tenderness. She is mildly tender to palpation in
the left lower quadrant. Pelvic exam reveals left
adnexal tenderness without palpable masses.
The rectal exam is normal with hemoccult
negative stool.
368
Introduction excluded. Once the diagnosis is It is important to determine the Rh factor
An ectopic pregnancy occurs when a entertained, the first step is to determine status of the mother. An ectopic
fertilized egg implants somewhere other whether the patient is hemodynamically pregnancy can sensitize an Rh factor
than the main cavity of the uterus. The stable. Most ectopic pregnancies are negative mother to Rh-positive fetal
true incidence worldwide is uncertain; stable on presentation. Alternatively, any blood. Obtaining a type and screen on a
however, in the United States, the woman of childbearing years with stable patient is the most efficient
incidence ranges from 2.7 to 6 deaths per abdominal or pelvic complaints and method. A baseline complete blood count
10,000 live births. Approximately 1%-2% unstable vitals should be considered to is warranted.
of pregnancies in the United States are have a ruptured ectopic pregnancy.
Other causes of abdominal or pelvic pain
ectopic and ectopic pregnancy accounts
An essential step is to determine if the with vaginal bleeding in the first twenty
for 3%-4% of pregnancy-related deaths.
patient is pregnant. The easiest method is weeks of pregnancy include abortion,
Ectopic pregnancy remains the leading
to determine the presence of the ß implantation bleeding, and gestational
cause of maternal death in the first
subunit of human chorionic gonadotropin trophoblastic disease. Abdominal or
trimester of pregnancy and is the second
(ß-hCG) in the urine or serum. Qualitative pelvic pain causes without bleeding may
leading cause of maternal mortality. Early
urines tests can be easily performed at include gallbladder disease, appendicitis,
diagnosis and appropriate management
the bedside. Urine testing is positive and hyperemesis. Urinalysis, electrolytes,
may prevent serious adverse outcomes
when ß-hCG is greater than 20 mIU/mL in and liver function studies should be
and potentially improve subsequent
the urine. Although dilute urine may considered.
fertility.
reduce sensitivity, at this level of
detection, the false negative rate will be Differential Diagnosis
Critical Bedside Actions and Abdominal or pelvic pain is a common
less than one percent. Quantitative serum
General Approach complaint in the emergency department
testing should be obtained as well since
Given the consequences of missing an
the serum ß-hCG level may assist with an extensive differential. All patients
ectopic pregnancy, all women of
subsequent disposition. who are in childbearing age should be
childbearing years with abdominal or
suspected and investigated for
pelvic pain with or without vaginal
appendicitis, endometriosis, ovarian cyst,
bleeding must have ectopic pregnancy
369
ovarian torsion, pelvic inflammatory From the emergency physician sounds, no masses,
disease, renal colic, and urinary tract perspective, the differential diagnosis of a
distension, organomegaly or
infection. In the pregnant patients, woman with a positive pregnancy test
however, intrauterine pregnancy, and abdominal or pelvic complaint is rebound tenderness. She is
implantation bleeding, threatened broad and will require, in almost all mildly tender to palpation in the
abortion, inevitable abortion, corpus instances in the first trimester, an
left lower quadrant. Pelvic
luteal cyst, molar pregnancy, and abdominal and pelvic exam.
ectopic pregnancy possibilities should be exam reveals left adnexal
Although abdominal pain is reported in
evaluated. tenderness without palpable
90% of ectopic pregnancies, vaginal
bleeding in more than half and menstrual masses. The rectal exam is
History and Physical Exam
Hints irregularities in up to 70%, none of these normal with hemoccult
symptoms narrow the diagnosis enough negative stool.”
“A 24-year-old woman
to include or exclude the diagnosis of
presents to the emergency ectopic pregnancy reliably. The classic Unfortunately, the physical exam may not
department with the complaint triad of abdominal pain, vaginal bleeding be helpful in distinguishing the ectopic
370
fact, patients with unruptured ectopic pregnancies may present If the vaginal exam is delayed or the patient is judged low
identically as a healthy pregnancy. risk, a transabdominal exam to identify an IUP may suffice.
371
“Transvaginal ultrasound Video shows Ectopic Pregnancy –
Image 8.3 Evidence of living embryo
on M-mode. M-mode pictorially Transvaginal Ultrasound
performed by the emergency
describes temporal changes at a
physician during the pelvic given depth on one axis while
measuring time in the second axis. Image 8.5 A pseudo-gestational
exam fails to demonstrate an The fluttering noted is cardiac sac (red), is a collection of
activity. intrauterine fluid and may be
intrauterine pregnancy. There is confused with a true gestational
a small amount of fluid in the sac. A true gestational sac is
normally embedded in the
rectouterine cul-de-sac. 2 cm endometrium rather than in the
uterine cavity, contains a yolk sac
ectopic pregnancy was typically seen at 5.5 weeks and has
a characteristic double ring or
identified.” double decidual sign at 4-6.5
weeks.
372
Culdocentesis involves extracting fluid consulting OB-GYN physician may I f the serum ß-hCG is below 1500 mIU/
from the rectouterine pouch posterior to consider medical management with mL, the patient is at low risk, and with the
the vagina through a needle. It has been methotrexate. The surgeon, not the concurrence with OB-GYN consultant,
supplanted by the ß-hCG and ultrasound emergency physician, should decide the the patient may be discharged with
but may be useful when ultrasound is not treatment. follow-up in two days for reexamination
available. and repeat ß-hCG levels.
The Discriminatory Zone
Emergency Treatment If the urine ß-hCG is positive, but the ß-hCG levels rise rapidly during the first
Options transvaginal ultrasound does not ten weeks of pregnancy then plateau.
“Two large-bore IV’s were started, the demonstrate an IUP, the emergency Although pathologic pregnancies often
patient was cross-matched for blood and physician should consider a concept have lower ß-hCG levels than normal
OB-GYN was consulted. Treatment known as the “discriminatory zone.” The pregnancies, there is significant overlap,
options were discussed.” discriminatory zone is the level of serum and absolute levels are not helpful in
ß-hCG above which an examiner should distinguishing a normal from abnormal
Ectopic pregnancy requires consultation be able to see an IUP. With transvaginal pregnancy. A general advisory rule is that
with OB-GYN. If the patient is unstable; ultrasound, an IUP should be seen with a ß-hCG levels double every 48 hours in a
resuscitation, urgent consultation, and ß-hCG level above 1500 mIU/mL and normal pregnancy. However, even here
laparoscopic or open surgery are with transabdominal above 6000 mIU/mL. there is significant variation and some
indicated. In this instance, IV access was If the serum ß-hCG is above 1500 mIU/ controversy. In stable patients, serial
established, the patient was typed and mL and transvaginal sonography does measurements and repeated sonography
cross-matched for blood. The OB-GYN not identify an IUP, consultation with OB- may be used to raise or lower suspicion
surgeon elected laparoscopic surgery. GYN is essential. These patients should of an occult ectopic pregnancy.
Ectopic pregnancy was confirmed in the be presumed to have an ectopic
left fallopian tube which was successfully The ß-hCG level representing the
p re g n a n c y. A d d i t i o n a l d i a g n o s t i c
removed. discriminatory zone is dependent on the
techniques may include laparoscopy or
technique and capabilities of the
If the patient is stable and the ectopic is dilation and curettage.
examiner and equipment. The
early (ß-hCG levels < 3000 mIU/mL) the
373
discriminatory zone should not be used to determine viability or A pregnant patient with a ß- hCG below the discriminatory zone
treatment plan associated with an IUP. and without evidence of IUP may be discharged with the
concurrence of the consulting OB-GYN surgeon for close
Documented ectopic pregnancies have presented with a ß-hCG
outpatient follow up and serial exams. A portion of these patients
level below test resolution. Therefore do not forgo transvaginal
will subsequently be diagnosed as an IUP, an ectopic pregnancy,
ultrasound investigation in any pregnant patient with a serum ß-
or a threatened, incomplete or completed miscarriage.
hCG below 1500 mIU/mL.
Disposition Decision
If an ectopic is diagnosed in an unstable patient, that patient will References and Further Reading, click here
require resuscitation, urgent consultation, and surgical
intervention.
374
Section 2
Tubo-Ovarian Abscess
Case Presentation
by Matthew Lisankie, Charlotte Derr, Tomislav A 19-year-old female presents to the emergency department
Jelic
(ED) complaining of 48 hours of worsening, stabbing left lower
quadrant abdominal pain. The patient notes an intermittent,
foul-smelling vaginal discharge for the past week. She also
endorses fever, nausea, vomiting, dyspareunia, dysuria, and
generalized fatigue. The patient is sexually active with one
male partner and uses combination OCPs in conjunction with
inconsistent utilization of condoms. She denies vaginal
bleeding, fevers, jaundice, vomiting, constipation, or diarrhea.
Her last menstrual period (LMP) ended 16 days ago and was
typical of her usual menses. The patient has a history of
menarche at 14 and coitarche at 17. She denies any use of
tobacco but admits intermittent alcohol and marijuana use.
She has no past medical or relevant family history. There are
Audio is available here no known drug allergies.
375
Physical exam reveals a well- with no visible blood products. Introduction
Tubo-ovarian abscess (TOA) is a walled-
developed female in mild Cervical motion tenderness
off infection of adnexal structures,
discomfort but no acute and pain on palpation of typically the fallopian tubes or ovary and
distress. Her vitals are bilateral adnexa are present. occasionally adjacent intra-abdominal
unremarkable except for a Left adnexa is more tender and structures. It is a potentially life-
threatening progression of the pelvic
temperature of 38.5 and a has a palpable mass on it.
inflammatory disease (PID). Thus, TOA
heart rate of 102. Her and PID share a great deal of
abdominal exam reveals pathophysiology and clinical
manifestations. TOA is common in
moderate tenderness to
women of childbearing age, who have
palpation, worse in the left multiple sexual partners and a history of
lower quadrant, with no PID [3]. Transvaginal ultrasound is the first
choice to diagnose TOA. But, CT remains
rebound tenderness. There is
an important tool in determining further
no costovertebral angle management. [2] Up to 70-80% of
tenderness, Rovsing sign or appropriately selected TOA cases resolve
McBurney point tenderness. with appropriate antibiotics alone.
However, many patients require either
External genitalia is
image-guided drainage or surgical
unremarkable. A pelvic exam exploration for resolution.
demonstrates foul purulent
Critical Bedside Actions and
discharge in the vaginal vault
General Approach
emanating from the cervical os Assessment of the undifferentiated
patient with a high suspicion for tubo-
376
ovarian abscess begins with the Consider the following critical actions to catastrophes can often lead to severe
measurement of vital signs and make a diagnosis and initiate effective metabolic derangements.
establishment of vascular access. treatment:
• Consider checking hepatic and
Continuous cardiac and pulse oximetry
• Obtain a urine specimen to rule out pancreatic function assays. Abnormal
monitoring is often prudent, especially if
cystitis and pyelonephritis. It may values may suggest other etiologies
the patient appears distressed or toxic, or
provide evidence for or against including biliary obstruction,
has vital signs that fulfill Systemic
nephrolithiasis. It may determine pancreatitis, Fitz-Hugh-Curtis
Inflammatory Response Syndrome (SIRS)
pregnancy status and therefore, change syndrome, or hepatitis.
criteria.
the choice of radiologic modalities.
Next, prepare for the pelvic examination
Rapid determination of the patient’s
• Obtain basic lab work, namely by obtaining:
pregnancy status is critical. A positive
complete blood count (CBC), blood
result warrants immediate rule out of • A lighted speculum to inspect the
urea nitrogen (BUN) and creatinine.
ectopic pregnancy and septic abortion. vagina and cervix
CBC may provide information on the
Additionally, it determines the appropriate
infection and anemia. BUN and • Chlamydia/Gonorrhea PCR swabs
interventions and diagnostic modalities. A
creatinine determine if the patient can
thorough history and physical including
safely undergo contrasted imaging • Wet prep swab
pelvic exam are crucial to timely
studies if required.
diagnosis and intervention. If available, • Lubricant
bedside transabdominal and • Check serum lactate and venous blood
• Gloves
endocavitary ultrasound can be a gas if there is a concern for sepsis.
powerful adjunct to the initial assessment A chaperone/assistant is recommended
of the patient with undifferentiated low • Obtain blood and other indicated for both male and female examiners.
abdominal or pelvic pain. cultures if the patient is exhibiting signs
Always be sure to discuss the major
of SIRS
points of and rationale/risks/benefits/
• Check electrolytes as hemorrhage, alternatives for the exam with the patient.
intra-pelvic, and intra-abdominal
377
The initial pelvic exam is critical as it diagnose these may lead to increases in should bear a high index of suspicion
leads the investigation and provides morbidity and mortality. More common in females of reproductive age.
valuable information to consulting but less immediately-threatening
The emergency physician should inquire
physicians. At the minimum, the diagnoses include constipation,
about the sexual history of the patient.
emergency physician should note the gastroenteritis, colitis, diverticulitis,
Multiple sexual factors and non-safe sex
general appearance of external genitalia, ruptured ovarian cyst, uncomplicated
practices are among the risk factors.
any bleeding, discharge, or odors, the pelvic inflammatory disease,
appearance of the cervix and caliber of nephrolithiasis, urinary tract infection. Symptoms related to TOA are abdominal
the os, presence or absence of any Finally, consideration of pelvic pain, fever, vaginal discharge, nausea,
cervical motion tenderness, and malignancy, particularly in the post- and abnormal vaginal bleeding. Physical
characteristics of the bilateral adnexa, menopausal patient with suspicion for examination features related to TOA are
making note specifically of mass, TOA is recommended. mucopurulent discharge, cervical motion
unilateral tenderness, and description of tenderness, and uterine or adnexal
ovaries if palpable. History and Physical Exam tenderness.
Hints
Differential Diagnosis Presentation of the patient with TOA can Emergency Diagnostic Tests
A chief complaint of acute lower vary from the post-menopausal woman and Interpretation
abdominal pain in the female of with only vague GI complaints to the Ultrasound is the first imaging modality to
reproductive age necessitates a rapid rule teenage patient with septic shock and evaluate the female reproductory system
out of multiple surgical and gynecologic peritonitis from a ruptured abscess. due to low-cost and lack of ionizing
emergencies. The emergency physician radiation. Developing a facility with
The typical presentation of TOA consists
should consider ruptured ectopic bedside ultrasound can have a profound
of abdominal pain, pelvic mass on
pregnancy, appendicitis, and TOA in the impact on the patient’s course in the ER.
examination, fever, and leukocytosis.
undifferentiated patient. Likewise, A skilled operator with access to an
However, a significant portion of patients
diagnoses including bowel obstruction, endocavitary probe can incorporate
with TOA may lack one or more of these
ovarian torsion, urinary obstruction diagnostic imaging into the initial pelvic
features. Therefore, emergency physician
should be excluded early as failure to exam within the first minutes of
378
evaluation, and potentially shorten the Pregnancy testing is perhaps the most •Unasyn (cat B) 3g IV q6h +
time to effective antibiotics, definitive guiding first step in both diagnosis and Doxycycline (cat D) 100 mg IV/PO q12h
imaging, consultant evaluation, and treatment. A positive result limits the use
• Imipenem-Cilastatin (cat C) 500 mg 16h
disposition. of CT, raises the possibility of ruptured
ectopic pregnancy, and limits the
The computerized tomography (CT) with Procedures
clinician’s armamentarium of antibiotics. Evacuation of the abscess will typically
oral and IV contrast has improved
be performed by either an interventional
sensitivity. The other advantages of CT Medications
radiologist or gynecologist, depending on
are to show more detailed anatomy and The mainstay of the medical therapy is
abscess characteristics and specific
rule in or rule out other differential antibiotics. TOA is typically a
institutional policies.
diagnoses. polymicrobial infectious process and
necessitates initial broad coverage for
Emergency Treatment Disposition Decisions
anaerobes, aerobes, gram-positive, and Signs of peritonitis, sepsis, or toxic
Options gram-negative bacteria. appearance suggest ruptured abscesses.
Initial management of patients with TOA
A summary of common empiric antibiotic These unstable patients need immediate
includes stabilization and timely
regimens and respective pregnancy surgical intervention. Stable patients with
diagnosis. Access and frequently
categories is as follows: a high suspicion or radiographic evidence
reassess airway, breathing, and
of TOA warrants ward admission for IV
circulation (ABC). Establish IV access to
• Cefotetan (cat B) 2 g IV q12h + antibiotics and serial evaluation by a
draw blood, enable intravenous contrast
Doxycycline (cat D) 100 mg IV/PO q12h surgeon or gynecologist. Discharge from
CT and administer medications. Sound
the emergency department and
medical management is the primary • Cefoxitin (cat B) 2 g IV q6h +
outpatient follow up are not
concern of the emergency physician. Doxycycline (cat D) 100 mg IV/PO q12h
recommended because of the risk of
Medical management primarily includes
• Clindamycin (cat B) 900 IV q8h + sepsis, peritonitis, and loss of fertility.
supportive care (e.g., fluid resuscitation,
Gentamicin (cat D) 2mg/kg IV (load)
antiemetics, analgesics.) and broad- References and Further Reading, click
then 1.5 mg/kg q8h
spectrum antibiotics. here
379
Section 3
Testicular Torsion
Case Presentation
by Sujata Kirtikant Sheth A 16-year-old male was sleeping when he suddenly started to
feel left sided lower abdominal pain. He continued to bear
through the pain for another 30 minutes until he started to
vomit. At this time he decided to go to the nearest hospital,
which is about 15 minutes away. When he reached the
hospital his vital signs were as follows: BP: 120/60 mmHg,
HR: 120 bpm, RR: 20 bpm, Temp 36.5C, Pain 10/10 and
SpO2 was 100% on room air. Physical shows a swollen right
scrotum with significant tenderness. What is the next step?
380
Critical Bedside Actions and • W h a t a re t h e o t h e r a s s o c i a t e d Nausea or vomiting, pain duration of
382
Torsion of the appendix is more common the intervention in patients with high Referral
than torsion of the spermatic cord. clinical suspicion. The emergency If you have deemed the patient as not
Torsion of the appendix is managed physician may attempt a bedside having a testicular torsion you can refer
conservatively unlike the torsion of the ultrasound while waiting for the urologist. them to urology a week later to see if
spermatic cord. Torsion of the spermatic Consider drawing blood for operation. their symptoms have resolved. Please
cord requires early surgical exploration provide patients with strict information on
because this will result in ischemia, Disposition Decision when to return to the emergency
damage or loss. department. If they start having pain
Admission Criteria
Patient with testicular torsion present again, increased vomiting, inability to
Medications urinate, fever, any other worrisome
within 6 hours should undergo an
Testicular torsion is a painful condition.
emergent surgery. Patients with testicular symptoms they need to return.
Please do not ignore and treat the
torsion for more than 48 hours should be
p a t i e n t ’s p a i n w i t h p r o p e r p a i n
admitted to the urology ward unless the
medication, paracetamol, ibuprofen or
patient is hemodynamically unstable. References and Further Reading, click
with stronger alternatives. In a pediatric
here
patient, the physician may consider
Discharge Criteria
options such as intranasal fentanyl. Patients with testicular torsion should not
I d e a l l y, o r a l m e d i c a t i o n s a re n o t be discharged from the emergency
preferable as the operation is likely. department. In a patient with intermittent
symptoms and a negative ultrasound, if
Procedures
the urologist does not admit the patients
If the emergency physician suspects
for observation, it is safer to observe the
testicular torsion, an emergent urological
patient in the ED for repeating symptoms.
consult is indicated. The urologist
If the symptoms occur again, repeating
determines the need for ultrasound or
the ultrasound and urology consultation is
emergency surgery. Ultrasound or any
sensible.
other diagnostic tests should not delay
383
Chapter 9
Selected
Neurological
Emergencies
Section 1
Case Presentation
by Matevž Privšek and Gregor Prosen A 56-year old female is brought to the ED by the paramedics
due to weakness in her left arm and left leg. She is conscious,
GCS 15, painless, normal skin color. Vitals are: BP 132/84,
pulse 78/min, 14 breaths/min, SpO2 99 %, temperature 36,4
°C, blood glucose 5,4 mmol/L. She says that weakness
started about 2 hours ago, while she was watching TV when
she suddenly realized she was unable to pick up a glass of
juice. She wanted to stand up and almost fell because her
right leg did not move. She thought it would go away, but it
did not, so she called an ambulance. She denies dizziness,
vertigo, nausea, vomiting, headache, visual disturbances. She
is otherwise healthy, not taking any medications or drugs. She
smokes half a pack of cigarettes daily.
385
appropriate except slight drift of right mouth Introduction
Stroke or cerebrovascular accident (CVA) is a syndrome of any
angle. She also has decreased muscle power in
vascular injury that diminishes cerebral blood flow (CBF) to a
her left arm as well as slightly decreased muscle specific region of the brain, causing ischemia and thereby
power in her left leg. She denies any sensory consequently causing focal neurologic impairment. Emergency
deficits. The rest of physical exam is physicians’ main goals are early recognition of stroke symptoms,
objectification of complaints and prompt diagnostics and
unremarkable.
treatment.
You set up an intravenous cannula, draw some According to some data, stroke is the third leading cause of death
blood for testing, and order emergency non- and a leading cause of long-term disability in the United States.
Around 2-4 % of hospital admissions are due to potential strokes.
contrast head CT scan, due to a high suspicion of
Depending on the cause of stroke, in-hospital mortality rates vary
an acute CVA. The results of the CT scan are between 5-10 % for ischemic stroke and up to 45 % for
back in 35 minutes: radiologist describes no hemorrhagic stroke. Up to 50-70% of stroke survivors regain
functional independence, while 15-30% be permanently disabled
intracranial hemorrhage or ischemic areas. A
and another 30% eventually require institutional care.
neurologist is consulted; upon repeated
Etiopathogenesis. 80 % of all strokes are ischemic in origin; the
examination, he advises highly for acute ischemic
rest are hemorrhagic. In the ischemic stroke, a clot stops the
stroke, most likely due to occlusion of the right blood supply to a specific area of the brain. However, in
middle cerebral artery. You immediately start with hemorrhagic stroke, blood leaks into brain tissue. It is highly
thrombolysis and transfer her to the neurology important to differentiate between them since treatment is
completely different.
ward.
In the ischemic stroke, a causative clot can originate from large
blood vessels of the brain (thrombus) or elsewhere in the body
(usually from the heart due to atrial fibrillation; embolus). Rarely,
386
the cause of ischaemic stroke is irreversible changes have not yet should have their complaints
hypoperfusion of the brain, due to a o c c u r re d . W i t h f u r t h e r o c c l u s i o n objectified by a focused neurologic exam,
systemic problem (e.g., myocardial irreversibility and scope of cerebral and efforts should be made to perform
infarction, dysrhythmias). In hemorrhagic infarction increase. Studies have shown urgent diagnostics.
stroke, the main causes are intracerebral that occlusion longer than 6 hours leads
(ICH) and subarachnoid hemorrhage to irreversible neurologic deficits. Differential Diagnosis
(SAH). A physician must be well aware of “stroke
In hemorrhagic stroke, events beside mimics,” which are defined as non-
Brains are highly sensitive to any alterations in CBF, such as red blood cells vascular diseases that present with
alterations in the blood supply of oxygen lysis and increased permeability of the stroke-like symptoms. Since the majority
and glucose that are needed for their blood-brain barrier lead to brain edema of strokes are treated with thrombolysis,
metabolism. Immediate alterations in CBF and secondary injury. accurate diagnosis due to harmful effects
and cellular homeostasis follows a stroke. of thrombolytics (significant intracranial
A complete interruption of CBF (rare) Critical Bedside Actions And bleed in 1 %) is essential.
causes loss of consciousness within 10 General Approach
seconds and death of pyramidal cells Regardless of the patients’ chief Possible stroke mimics which may be
follows within minutes. More often, complaint emergency physicians’ first misdiagnosed as a stroke;
the brains with electrical silence but diagnoses, and diagnostic and treatment
• Brain tumor
viable cells is called penumbra; plan. All patients with a suspected CVA
387
• Metabolic P = Psychiatric R = Rhythm disturbance
• Labyrinthitis
Depending on the affected area of the HEAD HEART VESSELS: Vascular causes are VESSELS:
brain and type of stroke CVA can present Syncope causes, by system
V = Vasovagal
with a vast list of chief complaints: altered
mental status, confusion, syncope, E = Ectopic (reminds one of hypovolemia)
CNS causes include HEAD:
weakness, dizziness, vertigo, ataxia,
aphasia, diplopia. S = Situational
H = Hypoxia/ Hypoglycemia
388
“dissection” of the complaint (use
Table 9.1 Guide For A Quick Neurological Exam
modified SOCRATES and SAMPLE),
especially the exact time and rate of
STEP COMMENTS
symptom onset (e.g., sudden onset
suggest an embolic or hemorrhagic
mental status “fogs”
cause, while gradual onset suggests family history, orientation, general info, spelling (back & forth), also
thrombotic stroke or hypoperfusion). It is count backwards from 100 by 3, repeat 7 digit number, recall 3 objects
after few minutes
also essential to identify any risk factors
cranial nerves CN 1: smell tobacco or soap
for thrombotic (hypertension, diabetes, CN 2: visual acuity, gross visual field, ophthalmologic (background)
coronary artery disease) or embolic cause exam
CN 3, 4, 6: pupillary light response, lateral and vertical gaze
(atrial fibrillation, valve replacement, CN 5: double simultaneous stimulation, also corneal reflex
recent MI). CN 8: does he/she hear fingertips moving near ears
CN 9, 10: gag reflex
The focused neurological exam can be CN 11: shoulder elevation
CN 12: stick out tongue
performed within 4 minutes:
motor drift of upper (and lower, if indicated) extremity
hand grasp
• check mental status, toe and foot dorsiflexion
additional: assessment of individual muscles
• cranial nerves,
sensory double simultaneous stimulation with needle pin on hands and feet
proprioception in big toe
• motor and sensory function, additional: check involving dermatomes, light touch, vibration
provided by authors
389
In comatose patients, we can perform modified (neurological)
exam: vital signs, drop hand overhead, pupils, abnormal eye Table 9.2 Cincinnati Prehospital Stroke Scale
movements, grimacing, withdrawal from noxious stimuli, Babinski
response. FACIAL DROP ARM DRIFT SPEECH
How to clinically differentiate between ischemic and hemorrhagic person should person should close eyes person should repeat
stroke? Despite clues and suggestions for one cause of smile or show and straight out arms in a simple sentence
his/her teeth front for 10 seconds
symptoms or another, clinical differentiation alone is unreliable! A
patient with hemorrhagic stroke typically complains about normal: both normal: both arms move normal: repeats the
sides of face equally or not at all sentence using the
headache, sudden onset of symptoms that are gradually move equally correct word and no
worsening, nausea and vomiting. Clinical exam often reveals slurring
decreased level of consciousness, hypertension, bradycardia,
seizures, meningism, fever. Often patients with hemorrhagic Emergency Diagnostic Tests And
stroke present with similar focal deficits as in ischemic stroke, but Interpretation
tend to look sicker. Other clues suggestive of hemorrhagic cause As soon as possibility of stroke has been established, the patient
are uncontrolled hypertension, use of anticoagulants, has to be transferred to a facility where emergency non-contrast
coagulopathies (advanced liver disease), known vascular head CT scan can be performed, mainly to exclude hemorrhage
malformations, brain tumors. as a cause of symptoms so proper treatment can commence.
In prehospital setting Cincinnati Prehospital Stroke Scale (CPSS) Laboratory tests are directed to exclude possible stroke mimics
is highly useful tool to diagnose a potential stroke; if any of tests and should include blood glucose, complete blood count, basic
is abnormal, it suggests possible stroke and this patient should metabolic panel, cardiac enzymes, and coagulation studies, as
be transferred to hospital as soon as possible. CPSS with 1 well as EKG and chest X-ray.
abnormal finding has 72 % probability of ischemic stroke and 85
American Heart Association recommends that workup should be
% probability if all 3 tests are abnormal.
completed within 3 hours between symptoms onset and
beginning of thrombolysis.
390
An NIH Stroke Scale/Score calculator is a
Table 9.3 Recommended Time Frame Table 9.4 Criteria To Become A
In Management Of Ishemic Stroke useful tool for quantifying neurologic Candidate For Thrombolysis
deficit.
QUESTIONS YES NO
ACTION TIME FRAME
A diagnosis of an acute stroke is often all answers must be »yes«
based solely on the patients’ history and is the time of onset of YES
Symptom onset to < 3 hours symptoms clearly defined?
physical exam, since head CT does not
ER doors
show an acute infarction until at least 6 will thrombolysis be possible YES
within 4,5 hours of onset?
hours after the occlusion (but it helps to
Door to lab work 45 minutes has the patient had a good YES
completed rule out intracranial hemorrhage). quality of life until now?
391
Contraindications for • Recent arterial puncture (at the o f stroke increases with age, so
noncompressible site) physicians have to maintain a high level
thrombolysis
Absolute contraindications If a patient fulfills above criteria for of suspicion for stroke when managing
thrombolysis, recombinant t-PA is given undifferentiated geriatric patient who is
• Hemorrhagic (or unknown) CVA anytime at a dose of 0,9 mg/kg IV up to a “just unwell.” Stroke in pregnant patient
• Ischemic CVA within the past six maximum of 90 mg. 10 % of the dose is can occur due to predisposition to
months
given as a bolus, followed by a 60 hypercoagulability, but one must be
• Malignancy of CNS minutes infusion. Also, blood pressure aware that thrombolysis is
must be treated before thrombolysis if it contraindicated in pregnancy until the
• Major (head) trauma or surgery within
the past three weeks exceeds 185/110 (use captopril 12,5 mg first week after Labor has passed.
SL).
• Gastrointestinal bleed in the last month
Disposition Decisions
• Known coagulopathy When hemorrhagic stroke is suspected All patients suffering acute stroke should
(or confirmed), one must do an urgent be admitted to stroke care unit or
• Aortic dissection
consultation with neurosurgeon to decide intensive care unit, depending on local
on further treatment options and plan policy, abilities and patients’ condition.
Relative contraindications (e.g., craniotomy and evacuation of Patient has to be on a monitor and have
hematoma, endovascular aneurysm frequent assessment of neurologic
• TIA in the past six months repair). system.
• Peroral anticoagulation therapy
Pediatric, Geriatric,
• Pregnancy up to less than a week
postpartum Pregnant Patient, And Other
References and Further Reading, click
Considerations here
• Refractory hypertension
Stroke in pediatric population is an
• Advanced liver disease extremely rare occasion, but all the
Introduction
by Fatih Büyükcam Patients with stroke present with sudden onset of paresis, sensory deficits, visual
loss or visual field defects, diplopia, dysarthria, facial droop, ataxia, vertigo,
aphasia and altered mental status. These symptoms and signs may be seen alone
or in combination.
393
Eligibility criteria for • Recent intracranial or intraspinal •Heparin use within 48 hours and an
treatment of acute ischemic surgery abnormally elevated aPTT*
stroke with recombinant • Arterial puncture at a noncompressible • Current use of a direct thrombin
tissue plasminogen activator site in the previous seven days inhibitor or direct factor Xa inhibitor with
(alteplase) evidence of anticoagulant effect by
Clinical
laboratory tests such as aPTT, INR,
394
• Myocardial infarction in the previous warfarin, a direct thrombin inhibitor, or a •Severe aphasia: ≥2 on NIHSS
three months direct factor Xa inhibitor), (3) use of question 9, or
anticoagulants is not known. For patients
• Seizure at the onset of stroke with • Visual or sensory extinction: ≥1 on
without recent use of oral anticoagulants
postictal neurologic impairments NIHSS question 11, or
or heparin, treatment with intravenous
• Pregnancy tPA can be started before availability of • Any weakness limiting sustained effort
coagulation test results but should be against gravity: ≥2 on NIHSS question 5
Additional Relative Exclusion discontinued if the INR, PT, or aPTT or 6, or
Criteria for Treatment from 3 to exceed the limits stated in above.)
4.5 Hours from The Symptom • Any deficits that lead to a total NIHSS
Onset The available data suggest that under >5
• Age >80 years some circumstances – with careful
consideration and weighting of risk-to- Differential Diagnosis
• Oral anticoagulant use regardless of benefit – patients may receive fibrinolytic Syncope, hypoglycemia, drug toxicity,
INR therapy despite one or more relative s e i z u re , i n t r a c r a n i a l h e m o r r h a g i c
contraindications. In particular, there is conditions can be misdiagnosed as acute
• Severe stroke (NIHSS score >25)
now consensus that patients who have a ischemic stroke.
• Combination of both previous ischemic persistent neurologic deficit that is
stroke and diabetes mellitus potentially disabling, despite History and Physical
improvement of any degree, should be Examination Hints
(* Although it is desirable to know the Most important data of the history is the
treated with tPA in the absence of other
results of these tests, thrombolytic time onset of symptoms because this is
contraindications. Any of the following
therapy should not be delayed while the main data that determine the eligibility
should be considered disabling deficits:
results are pending unless (1) there is for thrombolytic therapy. If the symptom
clinical suspicion of a bleeding • Complete hemianopsia: ≥2 on NIHSS onset time is not known, the time the
abnormality or thrombocytopenia, (2) the question 3, or patient was last awake and free of stroke
patient is currently on or has recently symptoms is accepted as symptom onset
received anticoagulants (eg, heparin,
395
time. Also, other important data have to controlled for suspicion of trauma. Emergency Tests and
be asked like co-morbidities, Neurological examination findings give us Imaging Studies
medications, head trauma and prior some clues about the affected or Hypoglycemia may mimic a stroke.
stroke. obstructed vascular region. Therefore, fingertip blood glucose
measurement is one of the initial essential
Stabilization is a priority in every critically Next step is to test motor and sensory
steps. In case of hypoglycemia (blood
ill patient. Once the patient is stable, a function. Muscle strength is assessed
glucose level <60 mg/dL), immediate
focused neurologic examination should against resistance. Pronator drift can be
intravenous glucose administration (slow
be performed. Level of consciousness tested by having the patient sit with eyes
intravenous push of 25 mL of 50%
(LOC), speech, cranial nerve (CN) closed and arms outstretched, with
dextrose) is indicated. Whether the
function, motor and sensory function, and palms toward the ceiling, for 10 seconds.
patient is hypoglycemic or not, stroke
cerebellar function are the main abilities Double simultaneous stimulation may be
probability should be kept in mind until
to assess. The physician may assess performed by simultaneously touching
exclusion.
LOC and speech in a dialogue with the the right and left limbs. The patient with
patient. The physician should also check sensory neglect may feel the right and left The basic workup should include an
pupillary size, reactivity, and eye sides individually but may ignore one side electrocardiogram, complete blood
movements to assess CN III through CN when both are touched simultaneously. count, plasma urea nitrogen, creatinine,
VI. Additionally, eyebrow elevation and electrolytes, cardiac enzymes,
The last step is to assess cerebellar
squinting, smiling, gag reflex, shoulder coagulation parameters like prothrombin
function, reflexes, and gait. Finger-to-
elevation and tongue protrusion are parts time, activated partial thromboplastin
nose and heel-to-shin evaluations,
of CN evaluation. time and an international normalized ratio
asymmetry of the deep tendon reflexes or
(INR). If there is a suspicion for other
As we are still in differential diagnosis unilateral Babinski’s sign and observing
specific diseases liver function tests,
process, we have to do full systemic routine ambulation are al informative
toxicology tests, urinalysis, blood culture,
examination including especially parts of the neurologic examination.
β-HCG, arterial blood gases, lumbar
cardiopulmonary and neurological
puncture, etc. could be evaluated.
examination. Whole body skin should be
396
The physician should send the patient to • Hypoattenuation of a focal parenchymal
Image 9.2 Ischemic stroke
imaging without waiting for the laboratory region
results.
• Obscuration of the silvian fissure and
The evaluation of a suspected stroke insular ribbon
patient starts with non-contrast brain
• The gray-white matter differentiation
computed tomography (CT). A non-
defect of basal ganglia
contrast brain CT is the fundamental
imaging to differentiate hemorrhagic or
ischemic stroke. This information Image 9.1 Hyperdense MCA sign
determines subsequent treatment.
397
may visualize the affected area. DW-MRI
Image 9.4 CT imagining of at 48th Image 9.6 ADC view of the patient
can show ischemic changes within 3 to hour
30 minutes of onset. The apparent
diffusion coefficient (ADC) view of DW-
MRI gives a quantitative measure of the
water diffusion. The decreased water
diffusion in cytotoxic edema of acute
ischemic stroke causes a hyperintense
DW-MRI signal and a hypointense ADC
signal. Please see couple examples
below.
399
is effective for the very early treatment of Prognosis
acute ischemic stroke. Presence of facial paresis, arm weakness
or drift and abnormal speech are the main
Aspirin (acetylsalicylic acid)
predictors of outcome. The NIHSS
• 160 to 325 mg/day PO (National Institutes of Health Stroke
Scale) score on admission gives a clue
• Aspirin may be given rectally for
about stroke outcome. The use of NIHSS
patients with acute stroke who cannot
score is recommended for all patients
take by the oral route.
with stroke.
400
Section 3
Intracranial Hemorrhage
Case Presentation
by Nur-Ain Nadir and Matthew Smetana As you start your 3rd night shift in a row, paramedics bring in
a 70-year-old female with altered mental status. Patient has a
history of hypertension and diabetes mellitus. She is on
Coumadin for atrial fibrillation. She was last seen normal three
hours ago when she went to sleep. Her husband called
emergency medical services (EMS) because she was difficult
to arouse. Her blood pressure in the emergency department
(ED) is 240/120 mmHg, heart rate 45 bpm, respiratory rate 22
bpm, pulse oxygen saturation 96% and temperature 99°F.1
rectally. On physical examination, she is diaphoretic and
unresponsive to any commands. She has dilated fixed pupils.
During your assessment, she begins to vomit. What should be
your next step in management?
401
Critical Bedside Actions and • Pulses?
Image 9.7 GCS
General Approach • Blood pressure?
General Assessment: Is the patient Stable
Glasgow Coma Scale
or Unstable or in Acute distress? • Skin temperature/quality/moisture/
color?
EYE OPENING
Primary Survey
Disability – Check; 4: Spontaneously
Obtain brief chief complaint and history
3: To verbal command
of present illness from EMS providers or
• The patient consciousness – Is the 2: To pain
bystanders. Include time of onset and
patient awake, alert and oriented? 1: No response
preceding symptoms, i.e., a headache,
nausea, vertigo, syncope, chest pain, BEST VERBAL RESPONSE
• The patient’s score on the Glasgow
trauma. Coma Scale (GCS)? 5: Oriented and converses
but is hypoxic, provide supplemental Perform secondary survey which includes 3: Flexion abnormal (decorticate)
intravenous lines and check; Glasgow Coma Score (GCS) (Modified from Teasdale, G., &
Jennett, B. (1974). Assessment of coma and impaired
consciousness: a practical scale. The Lancet, 304(7872),
81-84.) - Please read this article to get more insight regarding
GCS. 402
History and Physical • Age- Directly proportional to ICH risk. Skin – Signs of trauma? Needle
403
ventricles, cortical sulci), midline shift, can be performed. Protect the patient • Mannitol (1 g/kg) and
herniation, and loss of grey-white matter from hypoxia during the procedure. hypertonic saline reduce
junction. cerebral edema by producing
Impending Herniation an osmotic gradient that
Magnetic Resonance Imaging is equally • Clinical signs of elevated ICP may be
prevents water from moving
effective for the detection of acute ICH. subtle due to the brain’s intrinsic
into the cells during membrane
However, scanning typically takes longer autoregulatory mechanisms or more
pump failure and drawing tissue
to perform. It may show the underlying severe including Cushing’s triad
water into the vascular space.
cause of ICH such as a tumor or a (Hypertension, Bradycardia, Irregular
vascular aneurysm. respirations), altered mental status, • Hyperventilation to produce
headache, vomiting or focal vasoconstriction.
Blood tests should include a
neurological deficit.
comprehensive chemistry panel, • Hyperventilation should be
complete blood count, coagulation • When elevated ICP is suspected rapid closely monitored. The goal
profile, urinalysis. A chest X-ray should be treatment must be performed to PCO2 is between 30-35 mmHg.
ordered. decrease the risk of herniation and E x t re m e v a s o c o n s t r i c t i o n
secondary ischemia. secondary to PCO2 less than
Emergency Treatment 20 mmHg may cause brain
Options • Steps to prevent pending herniation:
ischemia. This should be a
404
Neurosurgical Consultation 2. SBP >180 mm Hg or MAP >130 mm Seizures
• ICH dictates immediate neurosurgical Hg and the possibility of elevated • Patients with ICH are at an increased
consultation. If hydrocephalus is ICP, consider monitoring ICP and risk of developing seizures. This risk
present, a ventricular drain will allow reducing BP while maintaining a i n c re a s e s w i t h l o b a r h e m a t o m a
both measurement of ICP and drainage cerebral perfusion pressure ≥60 mm location, hemorrhage size, depressed
of cerebrospinal fluid (CSF). Additional Hg. mental status, history of epilepsy,
hematoma evacuation or history of cirrhosis and penetrating
3. SBP >180 mm Hg or MAP >130 mm
decompressive craniotomy may be trauma.
Hg and no evidence of elevated ICP,
performed.
then consider reduction of BP (e.g., • The current guideline recommends
Hypertension a MAP of 110 mm Hg or target BP against the routine administration of
• Blood pressure should be closely of 160/90 mm Hg). antiepileptic medication. However, in
monitored. An invasive arterial catheter case of seizure, antiepileptics such as
• While the decrease in blood pressure
may be needed. The blood pressure fosphenytoin (20mg/kg loading dose)
may reduce the hematoma formation
targets in ICH is controversial and should be initiated.
and risk of re-bleeding, it may also
depends on the specific type of ICH.
reduce cerebral perfusion. One should Anti-coagulation
Recommended guidelines from the
avoid over-lowering blood pressure as • Coagulopathy should be reversed.
AHA/ASA are illustrated below.
s i g n i fic a n t d ro p s m a y m i n i m i z e Common anti-coagulants and their
• Recommended Guidelines from the perfusion to the ischemic penumbra. reversal agents are illustrated in Table.
AHA/ASA for Treating HTN in ICH Rapidly titratable antihypertensive
drugs are recommended. Hypotension
1. SBP >200 mm Hg or MAP >150 mm may be managed by crystalloid fluid,
Hg, consider aggressive reduction blood or vasopressors to maintain a
of BP with a continuous intravenous systolic blood pressure of >90 mmHg.
infusion
405
Table 9.5 Common anti-coagulants and their reversal agents Pediatric, Geriatric, Pregnant
Patient, and Other Considerations
DRUG
MECHANISM OF REVERSAL • Geriatric patients: The elderly are particularly at risk for
ACTION MEDICATION
spontaneous and traumatic ICH due to higher hypertension and
brain atrophy prevalence, and frequent use of anticoagulation.
Warfarin Inhibits Vitamin K Vitamin K
clotting factors FFP
(2,7,9,10) Prothrombin • Pregnant Patients: During pregnancy, ICH risk increases in case
Complex of preeclampsia, eclampsia and gestational hypertension.
Concentrates
Unfractionated Binds to antithrombin Protamine • Pediatric Patients: The majority of childhood ICH is secondary
Heparin 3
to trauma. The physician must always look for the signs of non-
Low Molecular Inhibits factor Xa Protamine accidental injury in pediatric patients with ICH even if the history
Weight Heparin incompletely reverses
factor Xa inhibition suggests otherwise.
Aspirin Irreversibly blocks Platelet transfusion to
cyclooygenase increase normal Disposition Decisions
platelet count by Patients are typically admitted to an ICU.
50,000
Clopidogrel Inhibits ADP receptor Platelet transfusion
on platelet
membrane References and Further Reading, click here
Dabigatran Direct thrombin No specific reversal
inhibitor
Rivaroxaban, Inhibit factor Xa No specific reversal
apixaban
provided by authors
406
Section 4
Seizure
Case Presentation
by Feriyde Caliskan Tur A 20-year-old female patient presented to the ED with
shoulder pain beginning in the morning at work. She had no
history of trauma. However, her right shoulder had a deformity.
Her X-ray showed a posterior shoulder dislocation, and she
could not explain how it occurred. While the emergency
physician was making preparations to reduce the shoulder, the
nurse shouted that the patient was having a generalized tonic-
clonic convulsion.
407
Introduction L/hour oxygenation was started via an air History and Physical
The seizure is a frequent neurologic mask, and the vascular access was Examination Hints
emergency in the emergency department established. Lorazepam 2mg, IV was History of seizures, head injury, recent
(ED), accounting for 1-2% of all given by slow injection to stop the fever (suggests infection or drug
emergency department visits. The highest seizure. reaction), anticholinergic and
incidence of seizure is among infants and sympathomimetic syndromes (mainly
The seizure stopped in a few minutes.
individuals aged > 75 years. The infantile depending on street drug-abuse) are
The patient’s blood glucose was
seizure occurs due to the high prevalence essential clues of the etiology of seizure.
measured at 122 mg/dL. Her vital signs
of febrile seizures, and in the elderly, it is
were: blood pressure 116/80 mmHg, A full neurological examination should be
mostly secondary to structural brain
heart rate 60 beats per minute, made. Motor movements and the
damage. Most seizures (49%) are related
respiratory rate 12 breaths per minute, accompanying eye movements during the
to alcohol or drugs, head injury, and pre-
oral temperature 98.6 °F, and a pulse seizure may distinguish the seizure from
existing diagnosis of epilepsy. Less
oximetry 100 % on room air. psychogenic seizures (pseudoseizures or
frequent etiologic pathologies are brain
nonepileptic seizures). 12% to 18% of
tumors (3%), metabolic abnormalities Her physical examination was normal
patients with transient loss of
(3%), stroke (3%), and neuro- except for the right shoulder. When the
c o n s c i o u s n e s s a re d e s c r i b e d a s
cysticercosis (1%). The reason for the patient regained consciousness, she
psychogenic seizures. It can exist
rest (41%) is unknown. Managing wanted to know what had happened. It
concomitantly in patients with neurogenic
patients with seizure and no apparent was her first witnessed seizure. There
seizures. Psychogenic seizures are a
etiology may be challenging for the was no drug or substance abuse, and her
manifestation of psychological distress.
emergency physician. menstrual status was normal. She had
frequent headaches for the last month, Neurologic deficits may be secondary to
Critical Bedside Actions and and she had been evaluated by a an old lesion, new intracranial pathology,
General Approach neurologist. or postictal neurologic compromise
The patient was placed immediately in
(called Todd paralysis, the physician may
the left lateral recovery position to avoid
rule out a new structural lesion).
aspiration of vomitus. Simultaneously, 4
408
Seizure is defined as a sudden change in A generalized seizure is related to both Emergency Tests and
behavior, characterized by an alteration in hemispheres accompanied by Interpretation
sensory perception or motor activity, convulsions in the entire body took place. Adult patients with new-onset seizures
resulting from an abnormal, excessive, who are otherwise healthy and have
Focal seizures took place in certain parts
and synchronous electrical firing in returned to baseline require only simple
of the body remain localized in a single
groups of neurons, caused by tests including serum glucose, sodium
hemisphere of the brain so may be easily
disequilibrium of the neuronal cell level, and pregnancy test. In patients with
overlooked. A simple focal seizure may or
membrane, normally kept stable by f e v e r, c o m o r b i d d i s e a s e , o r n e w
may not cause a depressed mental
inhibitory mediators such as gamma- neurological deficit further testing is
status, but a complex focal seizure
aminobutyric acid (GABA). indicated.
causes changes in consciousness.
Convulsions are the motor manifestations
Generalized status epilepticus is seizures Bedside test
of this abnormal electrical activity. The • Capillary glucose level (stick glucose)
that prevent the return to conscious state
clinical manifestations of seizures
with frequent recurrences or last more • Blood gases: It may show an anion gap
include focal or generalized motor
than 20 minutes. According to these metabolic acidosis secondary to lactic
activity, altered mental status, sensory or
definitions, our case had a generalized acidosis. Lactate elevates within 60
psychic experiences, and autonomic
seizure. This definitions of seizure can seconds of a convulsive seizure and
disturbances.
change the patient management. normalizes within 1 hour.
Epilepsy is referred to convulsive seizures
Pregnant patients with seizure: Pregnant • Electrocardiography (ECG) should be
without any recurring or provocative
patients of more than 20 weeks’ gestation obtained in patients with new-onset
reason.
(and up to 6 weeks postpartum) with seizure, or with the suspicion of
The postictal period is a change in eclampsia is the major consideration in decreased CNS perfusion secondary to
consciousness that start before the presentation with new-onset seizures. a cardiac cause. In addition to
seizure and last after for a while. Gestational epilepsy is diagnosed in ischemia, conduction abnormalities and
approximately 25% of patients with new- dysrhythmias are important disorders to
onset seizures during pregnancy. be excluded, see below.
409
• Differential diagnosis by ECG • W o l ff- P a r k i n s o n - W h i t e Imaging modalities
syndrome Brain CT is indicated in all first-time
• Conduction Disorders That Can
s e i z u re s . A d d i t i o n a l l y, n e w f o c a l
Be Cause of Seizure-like Activity Laboratory tests neurological deficit, history of trauma,
• CBC (reveal anemia or infectious
(Adapted from: Seizure: Emergency Medicine, toxic drug and substance use
Second Edition. Editor; Adams, James G., MD, process)
necessitates a brain CT, see below.
2013, 2008 by Saunders, an imprint of Elsevier
Inc. Book chapter 99) • Electrolytes (especially Na, and Ca/Mg),
Indications for CT Scanning of the
• A seizure may also result in
• Serum glucose Brain
dysrhythmia-related
syncope. • Urea-nitrogen, creatinine, Adapted from: Teran F, Harper-Kirksey K,
Jagoda A. Clinical decision making in seizures
and status epilepticus. Emerg Med Pract. 2015
• Brugada syndrome: Right • Pregnancy tests in women of Jan;17(1):1-24.
bundle branch block with ST- childbearing age (rule out eclamptic
• A Persistent change in mental status
segment elevation in leads seizures),
V1-V3 • Advanced age
• Antiepileptic drug levels,
• Long QTc interval • History/clinical evidence of trauma
• Liver function tests, and
• Short QTc interval • H u m a n i m m u n o d e fic i e n c y v i r u s /
• Drugs-of-abuse screening acquired
• Sodium channel blockade
with cyclic antidepressants, • Spinal tap is useful to evaluate • Immunodeficiency syndrome (HIV/AIDS)
lidocaine, anticholinergics suspected CNS infection (patients with
fever, severe headache, or persistent • Infection (neurocysticercosis)
• Torsades de pointes altered mental status) or HIV/AIDS
• New focal neurological deficit
p o p u l a t i o n ( s t ro n g s u s p i c i o n o f
• Widening of QRS complex
immunodeficiency). • Suspicion of parasitic central nervous
system
410
First-onset seizures or seizures with • The absence of a history of alcohol Emergency Treatment
persistent mental status change, focal abuse Options
neurologic deficit, or suspicion of organic Maintenance of adequate cerebral
• The focal onset of the seizure
intracerebral lesion necessitates brain perfusion, oxygen and glucose supply to
computed tomography (CT). It will help to MRI can reveal additional diagnosis like the brain, is the goal of initial treatment.
diagnose epidural or subdural brain abscess and central vascular Airway must be preserved. Continuous
hemorrhage, a brain mass or infections. events. MRI is more sensitive than CT pulse oximetry and capnography should
and can successfully diagnose temporal be monitored. Jaw thrust and
Factors Associated With Abnormal
sclerosis, cortical dysplasia, vascular nasopharyngeal airway ensure an
Computed Tomography Findings
malformations (e.g., AV aneurysms), and improved oxygenation. Preventing
(Adapted from: Teran F, Harper-Kirksey K, some tumors in addition. Its use is limited aspiration in the postictal phase, seizure
Jagoda A. Clinical decision making in seizures
and status epilepticus. Emerg Med Pract. 2015,
in emergency setting. control (administration of
page 9) anticonvulsants), correction of
E l e c t ro e n c e p h a l o g r a p h y ( E E G ) i s
• Altered mental status hypoglycemia, IV line placement, and
important to monitor intubated patients or
administration of oxygen can be
• Closed head injury patients with persistent altered mental
addressed together with coordinated
status. (Suspicion of nonconvulsive
• Focal abnormality on neurological team care. If there is trauma signs
status epilepticus). EEG records brain
examination secondary to the seizure, cervical spine
electrical activity and is used for definitive
precautions (immobilization with a collar)
• History of cysticercosis diagnosis. The need for EEG in the
should be initiated.
emergent setting is limited and must be
• Malignancy saved for when seizure activity is Medications
uncontrollable or difficult to diagnose. Traditionally, pharmacologic therapy of
• Neurocutaneous disorder
(e.g., patients who are under sedation or seizure has been divided into three steps
• Patient aged > 65 y are intubated). (Table). Generally, benzodiazepines are
the initial choice, followed by phenytoin
• Seizure duration > 15 min
or valproic acid. Levetiracetam is the
411
second-step choice in patients with liver • If the patient needs intubation, and aggressive cooling. Phenytoin is
disease. Third step interventions are pretreating with lidocaine (1.5 mg/kg) not effective in substance-related
infusions of benzodiazepines (midazolam and a low dose (defasciculating dose) seizure, and also may be harmful to
or long-acting lorazepam), propofol, or of a nondepolarizing paralytic agent drug intoxications such as tricyclic
barbiturates (e.g., pentobarbital; pay (e.g., vecuronium, 0.01 mg/kg) is antidepressants and antiarrhythmics.
attention to hypotension). In up to 30% of preferable to control intracranial
• The clinician should be aware that
the patients, the first- and second-step pressure from trauma or intracranial
administration of phenytoin and
therapies fail. bleeding. Short-acting paralytic agents
phenobarbital is rate-dependent and
such as succinylcholine is
• The drug choice is same for that patients may continue to seize for
recommended during rapid sequence
nonconvulsive seizures. 30 minutes before effective serum
intubation.
levels are reached.
• Secondary causes for seizure must be
• Remember that phenytoin (effective
considered for the treatable etiologies • Timely administration of antibiotics is
dose 20 mg/kg) must be infused with
(e.g., intracranial infections and lesions, important for the survival of patients
saline solution (not dextrose due to
metabolic abnormalities, drug toxicities, with infectious problems
precipitation). Its main adverse effect is
and eclampsia).
arrhythmia due to QT prolongation. • Prophylactic medication is not indicated
Many considerations on the use of T h e re f o re , t h e p a t i e n t m u s t b e to prevent late posttraumatic seizures.
medications should be remembered; monitored during the infusion.
• New generation drugs such as
• Use of benzodiazepine for active • Alcoholic seizure and seizure secondary lamotrigine (FDA category C) is used for
seizure in the prehospital setting is to isoniazid in tuberculosis treatment partial, generalized, and absence
strongly supported. are treated with 5 gr IV vitamin B6 in seizures for maintenance therapy.
adults and 70 mg/kg IV pyridoxine
• IM midazolam is the best option for the infusion in children.
prehospital treatment of seizure,
especially when no intravenous access • Seizures due to ecstasy or cocaine
is immediately available. abuse are treated with benzodiazepines
412
Table 9.6 Antiepileptic drugs and doses for seizures therapies
MEDICATION LOADING DOSE IV MAINTENANCE DOSE PEDIATRIC DOSE COMMENTS
Diazepam 10 mg over 2 min, or 10-20 mg Repeat q 5-10 min 0.15 mg/kg IV; 0.2-0.5 mg/kg respiratory depression,
hypotension
Lorazepam 2-4 mg IV Repeat once in 10-15 min <13 kg: 0.1 mg/kg IV (max 2 mg); respiratory depression,
13-39 kg: 2 mg IV; hypotension
>39 kg: 4 mg IV
Midazolam 0.1-0.2 mg/kg (also IM, IN 0.001 mg/kg/min 0.2 mg/kg IV, IN (max 5 mg); 0.5 mg/kg respiratory depression,
rectal or buccal) buccal (max 5 mg); <13 kg: 0.2 mg/kg IM hypotension
(max 5 mg); 13-39 kg: 5 mg IM; >39 kg: 10
mg IM
Phenytoin 18-20 mg/kg, max rate of 50 100 mg IV/PO q 6-8 h, 20 mg/ 20-mg/kg IV infusion hypotension, ataxia
mg/min kg IV infusion
413
Pregnant patients with seizure Disposition Decisions
Seizure related hypoxia and acidosis have a greater teratogenicity Admission criteria
potential than anticonvulsant medications. Therefore, actively- Patients with persistent seizures, change of mental or neurologic
seizing pregnant patients may be managed the same as status, or underlying medical conditions that require hospital
nonpregnant. Magnesium sulfate is the therapy of choice in the treatment (e.g., sepsis, overdose, brain trauma) should be
treatment of acute eclamptic seizures and for prevention of admitted. Patients with status epilepticus should be admitted to
recurrent eclamptic seizures. Additionally, a seizing chronic the intensive care unit. Patients with subtherapeutic drug levels
epileptic pregnant can be treated with midazolam. Remember should receive an additional dose before discharge. First-onset
that midazolam (FDA category D) is the safest; valproate and seizures should have follow-up arranged with the neurology
phenytoin are the most harmful (both FDA category D) service/consultant for further investigations. A second attack
antiepileptic drugs in first-trimester pregnancy. occurred in 1 month in 32% of patients with a first-onset seizure.
Risk factors such as alcoholism, comorbidities or known
Emergency Procedures cardiovascular disease, age > 60 years, history of cancer, or
Airway management is the most important procedures during a
history of immune-compromise should be considered for
seizure activity. The majority of the patients, however, will not
admission.
need definitive airway protection. The basic airway maneuvers or
adjunct devices may overcome the temporary airway obstrcution Discharge criteria
risks. Simple seizures are self-limiting in most cases. Maintaining Discharge decision should be based on final underlying
the airway by jaw trust/chin lift maneuvers, inserting an diagnosis. Chronic seizures can be discharged after return to the
oropharyngeal airway, and oxygen mask ventilation are first baseline neurologic levels.
measures to prevent the tongue bite, airway obstruction, and
apnea. A corkscrew is useful to open the jaw. In cases that
oxygen inhalation and intubation fail, a surgical airway is References and Further Reading, click here
indicated.
414
Chapter 10
Selected
Pulmonary
Emergencies
Section 1
Asthma
Case Presentation
by Ayse Ece Akceylan A 50-year-old male with a history of asthma presents to the
emergency department (ED) with shortness of breath,
tachypnea, and audible wheezing. The patient has taken his
prescribed medications at home, but his symptoms did not
relieve. His vitals were as follows: BP 130/90 mmHg, HR 120
bpm, RR 40 bpm, SpO2 92% on room air. Physical exam
revealed accessory respiratory muscle use, expiratory
wheezing and decreased breath sounds with expiratory
rhonchi. Nebulized short-acting beta2-agonists (SABA) and
systemic corticosteroid were ordered. Peak expiratory flow
(PEF) measurements before and after treatment were 125 and
360, respectively. Auscultation after initial treatment revealed
much-improved airflow. The patient was discharged following
clinical improvement, with a prescription of oral
corticosteroids in addition to his current medications.
416
Introduction obstruction and airflow limitation. The spectrum are patients with a “silent
Asthma is a chronic inflammatory repetitive airway inflammation leads to chest,” which reflects very severe airflow
disorder of the airways characterized by persistent structural changes in airways, obstruction and air movement insufficient
recurrent episodes of variable expiratory called airway remodeling. This results in to promote a wheeze.
airflow limitation. Asthmatic patients have increased airway resistance and a
The exacerbation begins with coughing
hyperresponsive airways that constrict decrease in forced expiratory volumes
and a sensation of chest constriction. As
when exposed to various stimuli. and flow rates. As a result, the lungs
the attack advances, expiration is
Symptoms and airflow limitation are often become hyperinflated. Ventilation-
prolonged, wheezing becomes
reversible, either spontaneously or with perfusion mismatch develops despite
prominent, and accessory respiratory
treatment. However, reversibility may be increased work of breathing. The
muscles are used. To decrease the effort
incomplete in some patients. Although interaction of these features determines
of breathing, the patient may sit upright
patients appear to recover completely the clinical manifestations, the severity of
or lean forward. The appearance of
clinically, some asthmatic patients may asthma and the response to therapy.
p a r a d o x i c a l r e s p i r a t i o n s r e fle c t s
have chronic airflow limitation. The Watch this video.
impending ventilatory failure. Alteration in
diagnosis of asthma should be based on
Presenting Signs and mental status heralds respiratory arrest.
the history of characteristic symptom
patterns and evidence of variable airflow Symptoms
The classic symptoms include the triad of
Critical Bedside Actions
limitation documented by bronchodilator 1. Ensure adequate oxygenation
dyspnea, wheezing and coughing.
reversibility testing or other tests.
Physical findings during an asthma 2. G i v e S A B A t o r e v e r s e a i r flo w
Pathophysiology exacerbation can be variable. A patient obstruction
The mediators released in response to with a mild exacerbation may merely be
coughing and complaining of chest 3. Give systemic corticosteroids to relieve
allergens and nonallergic stimuli cause
tightness, whereas a patient with a severe inflammation
inflammation, edema, mucus production,
and airway smooth muscle hypertrophy. exacerbation will be in respiratory 4. Carry out serial assessments to
All of these lead to bronchoconstriction distress, with tachypnea and loud monitor the response to therapy
and hyperreactivity, aggravating airway wheezing. At the other end of the
417
General Approach intravenous magnesium sulfate if the History/Physical
• O b t a i n p a t i e n t h i s t o r y, a s s e s s patient is unresponsive to intensive Examination Hints
exacerbation severity and initiate initial treatment.
treatment simultaneously. Respiratory History
• Do not routinely perform chest x-ray or • P o s s i b l e c a u s e s o f t h e c u r re n t
rate, dyspnea, pulse rate, oxygen
blood gases, or prescribe antibiotics. exacerbation
saturation and lung function reflect
exacerbation severity. • Prescribe ongoing controller treatment • The severity of symptoms compared
before discharge to reduce the risk of with previous exacerbations
• Keep alternative causes of
future exacerbations. Provide follow up
breathlessness in mind. • Other comorbidities
for all patients, preferably within a
• Start treatment with repeated doses of week.
• Current asthma medications and
inhaled SABA by a puffer, spacer, or adherence to therapy
nebulizer. Give early oral corticosteroids Differential Diagnosis
Wheezing, coughing, and dyspnea may • Any use of potential asthma triggering
and controlled flow oxygen in life-
be caused by many other conditions, medication
threatening exacerbations or if Forced
including pneumonia, bronchitis, croup,
Expiratory Volume in 1 Second (FEV1) is
b ro n c h i o l i t i s , c h ro n i c o b s t r u c t i v e • Aspirin
less than 30% of the predicted. Target
pulmonary disease, congestive heart
oxygen saturation is 93-95% in adults • Beta-blockers
failure, valvular heart diseases, pulmonary
and adolescents, and 94-98% in
embolism, allergic reactions, • Angiotensin-converting enzyme
children between 6-11 years.
g a s t ro e s o p h a g e a l re flu x d i s e a s e , inhibitors
• Monitor symptoms and oxygen exposure to odors, dust, and gas, and
• Any risk factors for asthma-related
saturation frequently or continuously. upper airway obstruction from vocal cord
death
Measure lung function after one hour.3 dysfunction, edema, neoplasm or a
foreign body. Any of these alternative • poor adherence to asthma
• Add ipratropium bromide to treatment
diagnoses may also be found together medications
in severe exacerbations. Consider
with asthma.
418
• psychosocial problems • Anaphylaxis Respiratory rate is increased, and the
pulse rate is around 100-120 bpm.
• history of near-fatal asthma requiring • Pneumonia
Oxygen saturation on room air is 90-95%,
intubation and mechanical ventilation
• Pneumothorax and PEF > 50% predicted or best.
• hospital visit for asthma in the past
• Look for signs of alternative conditions Patients with a severe attack can only talk
year
that could explain acute dyspnea in words, sit hunched forwards, use
• currently using or having recently accessory muscles and show agitation.
• cardiac failure Respiratory rate is >30/min. Pulse rate
stopped using oral corticosteroids
exceeds 120 bpm. Tachypnea and
• pulmonary embolism
• not currently using inhaled tachycardia are associated with severe
corticosteroids • PEF in patients older than 5 years obstruction, but a lower rate does not
r u l e o u t s e v e re a s t h m a . O x y g e n
• over-use of SABAs The most common finding on physical
saturation on air is <90% and PEF≤50%
examination is expiratory wheezing. With
• food allergies predicted or best.
severe airway obstruction, it decreases or
Physical Examination vanishes because air movement velocity Patients with the life-threatening attack
• Check vital signs is insufficient to produce sound. Crackles are drowsy or confused and have silent
and inspiratory wheezing are not features chest.
• Look for signs of exacerbation severity
of asthma. They are more likely to be
• use of accessory muscles seen in pneumonia. Inspiratory and Emergency Diagnostic Tests
expiratoy crackles, however, are seen in And Interpretation
• mentation pulmonary edema. • Pulmonary Function Tests: Bedside
spirometry is used both for initial
• sitting position Patients with the mild or moderate attack assessment and for evaluating the
can talk in full sentences or phrases. response to therapy. If possible, and
• level of consciousness
Patients may prefer sitting to lying, but without delaying treatment, record PEF
• Look for complicating factors accessory muscles are not used. or FEV1 before treatment. Patient
419
cooperation is essential for these tests >45 mmHg) indicate respiratory failure. of 93-95% (94-98% for children 6-11
to be reliable. Monitor lung function at Fatigue and somnolence suggest that years).
intervals until a clear response to pCO2 may be increasing and airway
• Inhaled short-acting beta2-agonists
treatment has occurred, or a plateau is intervention may be needed. Do not
(SABAs): Use 4-10 puffs pMDI with a
reached. When possible, management wait for arterial blood gas confirmation
spacer in mild or moderate attacks. For
decisions should be guided by the treat ventilatory or respiratory failure.
severe attacks, administer 1 nebule
patient’s personal best PEF or FEV1
• Other Blood Testing: Laboratory studies every 20 minutes for 1 hour.
value or, if unknown, predicted values.
are rarely helpful in an acute asthma
• Epinephrine (for anaphylaxis): Indicated
• Pulse oximetry: is a noninvasive, attack.
only if acute asthma is associated with
convenient and continuous method for
• Radiology Studies: Radiography is only anaphylaxis and angioedema.
monitoring oxygen saturation before
indicated if there is the possibility of
and during treatment. • Systemic corticosteroids: enhance the
pneumothorax, pneumomediastinum,
resolution of exacerbations and prevent
• Arterial Blood Gas (ABG) analysis: is pneumonia, or other medical
recurrence. They should be utilized
helpful if there is a concern for conditions.
within 1 hour of presentation. Oral and
hypoventilation with carbon dioxide
• Electrocardiogram and Cardiac intravenous administrations are equally
retention and respiratory acidosis. It is
Monitoring: A routine electrocardiogram effective. However, the oral route is
not indicated in the majority of patients
is unnecessary. Older patients and preferred because it is less invasive and
with mild to moderate asthma
patients with coexistent heart disease less expensive. Intravenous
exacerbation. Consider ABG analysis
or with severe exacerbation should corticosteroids can be administered
for patients with a PEF or FEV1 <50%
undergo continuous cardiac monitoring when patients are too dyspneic to
of the predicted, or for those who do
to detect dysrhythmias. swallow if the patient is vomiting, or
not respond to initial treatment or
when patients require non-invasive
continue deteriorating despite
Treatment Options ventilation or intubation. Corticosteroid
treatment. A PaO2 <60 mmHg and
• Oxygen: Administer by nasal cannula or dose is 1 mg/kg (max. 50 mg)
normal or increased paCO2 (especially mask. Target arterial oxygen saturation
420
prednisolone for adults and 1-2 mg/kg NIMV is still controversial in asthma. It comorbidities, concurrent treatments,
(max. 40 mg) for children. improves work of breathing, gas medication side effects (cardiotoxicity
exchange. However, increase the risk of with beta2-agonists; skin bruising,
• Inhaled corticosteroids: are well
barotrauma. osteoporosis, cataracts with
tolerated. However, the cost is a limiting
corticosteroids) and lack of self-
factor. The effectiveness, dose, and This video demonstrates treatment of
management skills should be taken into
duration of treatment in the ED remain asthma. However, in the ER, the actions
account while managing asthma in the
unclear. should be a lot faster.
elderly.
• Ipratropium bromide: Use for moderate- Special Populations Children
severe exacerbations, along with SABA.
Management of asthma exacerbation for
Pregnancy
• Magnesium: Intravenous magnesium The advantages of actively treating adults and children >5 years are mostly
sulfate is not recommended for routine asthma in pregnancy markedly outweigh similar. This section points to the
use in asthma exacerbations. It reduces any potential risks of the usual controller management of asthma exacerbations in
hospital admissions in patients who fail and reliever medications. To avoid fetal children 5 years and younger.
to respond to initial treatment and have hypoxia, acute asthma exacerbations
The presence of any one of these
persistent hypoxemia. during pregnancy should be aggressively
features means a severe exacerbation:
t re a t e d w i t h S A B A , o x y g e n , a n d
• Helium-oxygen therapy: May be
administration of systemic • altered consciousness
considered for patients who do not
corticosteroids.
respond to standard therapy. • oxygen saturation from pulse oximetry
Elderly of <92% on presentation
• Non-Invasive Mechanical Ventilation
The elderly may not describe asthma
(NIMV) and Intubation: If the patient • central cyanosis
symptoms or may associate
begins to exhibit signs of acute
b re a t h l e s s n e s s w i t h t h e i r a g e o r • silent chest
respiratory failure including progressive
comorbidities (cardiovascular disease,
hypercapnia and acidosis, intubation
o b e s i t y, e t c . ) . T h e i m p a c t o f
and mechanical ventilation is indicated.
421
• i m p a i re d m e n t a t i o n ( t h e n o r m a l intravenous methylprednisolone 1 mg/kg decision should be made according
developmental capability of the child 6-hourly. to the patient’s risk factors and the
must be taken into account) availability of follow-up care.
Magnesium sulfate: If the child is not
• pulse rate (>200 beats/min for children responding to standard therapy, consider Risk factors associated with the need for
0-3 years, >180 beats/min for children nebulized isotonic magnesium sulfate admission:
4-5 years). (150mg) 3 doses in the first hour of
• Female sex, older age, and non-white
treatment OR intravenous magnesium
Oxygen: target oxygen saturation is race
sulfate (in a single dose of 40-50- mg/kg
94-98%.
(max 2g) by slow infusion (20-60 min) for • Use of more than 8 beta2-agonist puffs
Bronchodilator therapy: Give 2-6 puffs of children aged ≥2 years with severe in the previous 24 hours
salbutamol by a spacer, or 2.5mg exacerbation.
• Severity of the exacerbation (e.g.need
salbutamol by nebulizer, every 20 min for
the first hour, then reassess severity. If
Disposition Decisions for resuscitation or rapid medical
If pre-treatment FEV1 or PEF is <25% of intervention on arrival, respiratory rate
symptoms persist or recur, give an
the predicted or personal best, or post- >22 breaths/minute, oxygen saturation
additional 2-3 puffs per hour. For children
treatment FEV1 or PEF is <40% of the <95%, final PEF <50% predicted).
with moderate-severe exacerbations and
predicted or personal best,
a poor response to initial SABA, • History of severe exacerbations
hospitalization is recommended.
ipratropium bromide may be added, as 2 requiring admission to hospital
puffs of 80 mcg (or 250mcg by nebulizer) If post-treatment lung function is >60% of
every 20 minutes for 1 hour only. • Previous healthcare facility visits
the predicted or personal best, discharge
requiring the use of oral corticosteroids.
is recommended after considering risk
Systemic corticosteroids: Systemic
factors and availability of follow-up care. An asthma exacerbation does not resolve
corticosteroids: Give initial dose of oral
prednisolone (1-2 mg/kg up to a c o m p l e t e l y o n d i s c h a rg e ; a i r w a y
Patients with post-treatment lung
maximum 20 mg for children <2 years inflammation and peripheral obstruction
function 40-60% of the predicted are the
old; 30 mg for children 2-5 years, OR, may take hours to days to dissipate.
gray zone. Hospitalization or discharge
422
• Prescribe at least a 5-7 day course of oral corticosteroids
(prednisolone or equivalent 1 mg/kg/day to a maximum of 50
mg/day), along with inhaled corticosteroids and reliever
medication.
423
Section 2
Case Presentation
by Ramin Tabatabai, David Hoffman, and Tiffany A 68-year-old male presents to the emergency department
Abramson
(ED) with audible wheezing, and he is in severe respiratory
distress. He is speaking in 2-3 word sentences, and he is
diaphoretic and slightly confused. Per the paramedic report,
the patient is a two pack per day smoker. On physical
examination, the patient demonstrates poor air movement,
and you note that he has a “barrel chest.” As you pick up the
phone to call the respiratory therapist for airway management,
you wonder, “What other interventions should I initiate and are
there other diagnoses I should be considering?”
424
General Approach and treatment in the majority of the patients. limitation. COPD is, therefore, a
Critical Bedside Actions BiPAP therapy for moderate to severe chronic, progressive disease, usually with
Although COPD patients may frequently exacerbations should be kept in mind. an indolent course of gradual decline in
visit ED, some of these presentations Antibiotic therapy should be started for airflow and physical activity level
may require critical interventions such as any acute exacerbation requiring secondary to dyspnea.
intubation. Therefore, the ABC sequence admission or discharged patients with
The etiologies of acute exacerbation can
should be followed in all these cases to increased sputum purulence.
be classified into four different groups
understand an immediate life-threatening
Differential Diagnoses (infectious, pollution, destabilizers,
situation.
During the initial evaluation and ongoing idiopathic). Although approximately 70%
The most patients require Oxygen bedside treatments, emergency physician of exacerbations are due to infection
therapy to keep pulse oximetry 88-92%. lists causes of this attack in his/her mind. (Viral or Bacterial), it is important to
Establishment of intravenous (IV) line and Two major challenges exist in evaluating consider other potential triggers or
fluid replacement may be necessary for the patient with suspected COPD. First, etiologies such as Pneumothorax,
severe attacks. Cardiac monitor and the differential diagnosis for dyspnea is Pulmonary Embolism (PE), Congestive
electrocardiogram (ECG) to assess broad and distinguishing COPD from H e a r t F a i l u re ( C H F ) , P n e u m o n i a ,
cardiac ischemia or arrhythmia is alternative causes can be difficult. Pericardial Effusion, Lobar Atelectasis,
mandatory for every case. While these Second, patients with COPD may harbor Anaphylaxis, Airway Obstruction, and
activities are going on simultaneously, the concomitant cardiopulmonary disease. Trauma.
emergency physicians’ primary role is to
COPD should be considered in anyone Acute exacerbation of COPD is often
rule out other life-threatening causes of
with risk factors and dyspnea, chronic confused with pulmonary edema
dyspnea. Inhaled beta-agonist
cough or sputum production. Major risk secondary to CHF. Cardiac “wheeze” is
bronchodilator (e.g., Albuterol), Inhaled
factors include smoking and easily mistaken for the wheeze classically
anticholinergic bronchodilator (e.g.,
environmental exposures. Pathological heard in acute COPD exacerbation.
Ipratropium), and oral glucocorticoid
changes that occur in the lung causes air Further complicating matters, these
therapy (IV steroids only if unable to
t r a p p i n g a n d p ro g re s s i v e a i r flo w diagnoses are not mutually exclusive and
tolerate PO) are the mainstay of the
425
can often present together in a mixed picture. A thorough speak in full sentences, c o n f u s i o n , a g i t a t i o n , u s e o f
evaluation of clinical evidence of CHF is therefore critical in the accessory respiratory muscles, paradoxical chest wall
evaluation of the wheezing acute COPD exacerbation patient. movements, worsening or new onset central cyanosis,
development of peripheral edema, or hemodynamic instability.
Additional diagnoses should be considered when an acute COPD
exacerbation is more severe than previous or if the patient A thorough examination will involve cardiopulmonary evaluation
deteriorates rapidly. One such disease is PE, which can occur in to assess for the presence of wheeze and auscultation to
COPD patients due to sedentary lifestyles, increased venous estimate the degree of tidal volume that occurs with each
stasis, and increased blood viscosity. Pneumothorax is another ventilation. Markedly decreased air movement indicates severe
critical consideration as COPD patients. As a traditional disease. Other findings in chronic COPD may include a thin,
knowledge, COPD patients have increased risk for ruptured barrel-chested appearance or plethoric, cyanotic appearance.
bullae. Other lethal causes of exacerbation and dyspnea are not
One important sequela of COPD is cor pulmonale. Long-standing
limited to but include pneumonia and lobar atelectasis secondary
increased pulmonary pressures can lead to right-heart strain and
to bronchial plugging.
eventual right heart failure. Patients can therefore present with
History and Physical Examination Hints acute COPD exacerbation along with CHF findings of jugular
In the ED, providers are predominately concerned with acute venous distention and peripheral edema.
COPD exacerbation. An exacerbation is defined as an acute
Finally, a thorough history should be obtained by evaluating risk
event that leads to a worsening of the patient’s respiratory
factors, previous exacerbations, the frequency of exacerbations,
symptoms, beyond normal day-to-day variation and leads to a
and prior intubations. While there are many predictors of a COPD
change in medication.
exacerbation, the best is a history of prior exacerbations.
The physician’s first action in the evaluation of a dyspneic patient
with suspected acute COPD exacerbation is airway, breathing
and circulation, and assessment of vital sign abnormalities. These
are used to determine whether the patient will require immediate
intervention. Any of the following signs on initial visual inspection
indicate severe acute COPD exacerbation: “tripoding,” inability to
426
Emergency Diagnostic Tests diagnosis of COPD in the outpatient
Image 10.1
and Interpretation setting, there is no role for its use in the
Every patient in respiratory distress emergency room.
should be placed on continuous pulse-
Laboratory Tests
oximetry and cardiac monitoring.
Blood tests have little utility because their
pediatric population and is extremely rare Failure to respond to initial medical management
in pregnant patients. Even children with A marked increase in the intensity of symptoms
429
Section 3
Pneumonia
Case Presentation
by Mary J. O. A 74-year-old male with a history of hypertension and
diabetes presented to the emergency department with a
cough productive of rust-colored sputum. His complaints
started approximately three days earlier and progressively
worsened. The patient reported difficulty in breathing, shaking
chills, and fever up to 39ºC. He had no sick contacts. On
examination, the physician noticed an elderly gentleman in
mild respiratory distress. His vital signs were: BP: 110/70
mmHg, HR: 102 bpm, RR 20 bpm, T 38.4ºC and SpO2 91%
on room air. Auscultation revealed rales at the right lung base.
430
Introduction Classification v i r u s ( R S V ) , p a r a i n flu e n z a ,
Pneumonia is an acute respiratory Community-acquired pneumonia (CAP) coronaviruses, adenoviruses, and
infection of the lung parenchyma, occurs in patients with no recent rhinoviruses. Recently, a number of new
particularly the alveoli. The healthy alveoli hospitalization or exposure to the viral pathogens have emerged, including
fill with air when a person breathes; healthcare system. The most common coronaviruses that causes severe acute
however, in pneumonia, the fluid or pus in bacterial cause of CAP is Streptococcus respiratory syndrome (SARS) and the
the alveoli makes breathing painful and pneumoniae. Its incidence is declining Middle East respiratory syndrome
inhibits air exchange. Despite modern due to vaccination. Other common (MERS-CoV).
research and the development of a bacteria are Haemophilus influenzae,
Hospital-acquired pneumonia (HAP)
variety of antimicrobial agents, Moraxella catarrhalis, and
refers to pneumonia newly-contracted at
pneumonia remains a leading cause of Staphylococcus aureus. These so-called
least 48-72 hours after hospitalization. It
death worldwide, especially in the very “typical” pneumonia agents generally
is the second most common type of
young and the elderly. present with primarily respiratory
nosocomial infection (after urinary tract
symptoms and a lobar consolidation on
The most common causes of pneumonia infections), and a common cause of
chest radiograph. Mycoplasma
are bacteria and viruses, but fungi, death in the intensive care unit. Ventilator-
pneumoniae, Chlamydophila
protozoans, and parasites can also cause a s s o c i a t e d p n e u m o n i a ( VA P ) i s
pneumoniae, and Legionella sp. are
infection. These organisms, typically pneumonia that occurs 48 hours or more
among the common atypical causes of
found in the nasopharynx, can infect the after a patient receives mechanical
bacterial pneumonia. They may present
lungs by inhalation. Additionally, airborne ventilation through an endotracheal tube
with a subacute onset, more generalized,
droplets (such as from a cough or sneeze) or tracheostomy. Intubation allows oral
non-respiratory symptoms and respond
or blood-borne infections (such as from and gastric secretions and
to different antibiotics than the typical
mother to baby during delivery) may microorganisms to enter the lower
organisms. The radiographs may not
spread the disease. respiratory tract. Multidrug-resistant
show an infiltration.
(MDR) organisms usually cause VAP.
For an overview of pneumonia, watch this
Common viral causes of pneumonia
video.
include influenza, respiratory syncytial
431
H e a l t h c a re - a s s o c i a t e d p n e u m o n i a presenting with sepsis. Empiric antibiotic tachycardia and tachypnea are
(HCAP) is a particular subset of therapy should be started once the usually present. Patients may be hypoxic
nosocomial pneumonia in which patients diagnosis of pneumonia is established, and hypotensive. Auscultation of the
come from the community but have even before the definite identification of a chest may reveal coarse rales or
frequent interactions with the healthcare microbial cause. bronchial breath sounds. There may also
system. It includes patients who were be dullness to percussion and increased
hospitalized within the last 90 days, Differential Diagnosis tactile fremitus. No single clinical finding
reside in a long-term care facility such as • Asthma is reliable in establishing a diagnosis of
a nursing home, receive hemodialysis or pneumonia.
• Bronchitis
wound care, have contact with a family
For examples of lung sounds, please see
member with MDR pathogens, or are on • Chronic obstructive pulmonary disease
(COPD) the this video.
chemotherapy or intravenous antibiotics.
Like HAP and VAP, patients with HCAP
• Lung cancer Emergency/Diagnostic Tests
are at risk for multidrug-resistant
and Interpretation
pathogens. • Pulmonary edema • Pulse oximetry to screen for hypoxia.
Hypoxia is an indication for admission.
Critical Bedside Actions and • Pulmonary embolism
General Approach • Upper respiratory tract infections • Chest x-ray (CXR): generally the most
Initial evaluation should focus on ensuring important study to determine the
adequate ventilation and oxygenation. Clinical Presentation presence of pneumonia, although it
H y p o x i c p a t i e n t s s h o u l d re c e i v e The classic symptoms of pneumonia are cannot establish the causative agent.
supplemental oxygen. Endotracheal fever/chills, cough (often productive of The absence of findings on CXR should
intubation may be required in patients purulent sputum), pleuritic chest pain, not preclude the use of antibiotics in
with severe respiratory distress. Early and and shortness of breath. Elderly patients patients thought to have pneumonia
a g g r e s s i v e flu i d r e s u s c i t a t i o n i s may present with nonspecific symptoms, based on clinical presentation.
necessary for patients who are such as general malaise, anorexia, and
hemodynamically unstable or who are confusion. On physical examination,
432
peptide (BNP) may help distinguish
Image 10.3
between CHF and pneumonia.
• Computed tomography (CT) of the
chest: more sensitive than CXR, but • The utility of routine blood cultures has
often not necessary. been questioned due to the low yield,
but they should be drawn before the
• Point-of-care ultrasound is becoming
initiation of antibiotics in patients who
more widely used for the rapid
will be admitted, particularly in severely
diagnosis of pneumonia. It can be more
ill patients. Cultures are positive in
sensitive than CXR, though findings of
20-25% of pneumonia caused by S.
consolidation on ultrasound are not
pneumoniae, but the percentage is
specific for pneumonia. The accuracy of
even lower in pneumonia due to other
ultrasound is operator-dependent.
causes. Positive blood cultures may
• This ultrasound video shows help determine local antibiotic
consolidation and pleural effusion resistance patterns.
433
• Urine antigen tests are available for The following recommendations are • I f the patient is allergic to penicillin, use
Legionella pneumophila serotype 1 adapted from: the EMRA Antibiotic aztreonam and levofloxacin instead
(74% sensitivity) and pneumococcus. Guide; Musher et al., NEJM; and World
• If Pseudomonas is likely, use double
Health Organization (WHO) guidelines.
• Rapid diagnostic tests are available for coverage until susceptibilities are back
many viruses, including RSV and Outpatient therapy (adults): – levofloxacin or gentamicin, with the
influenza. addition of an anti-pseudomonal beta-
• Amoxicillin/clavulanate, with the lactam: cefepime, piperacillin/
Treatment Options addition of azithromycin or doxycycline
tazobactam, or aztreonam
Once pneumonia has been diagnosed, if atypical organisms are suspected
antimicrobial therapy should be started HCAP, HAP, or VAP (adults) [choose
• L e v o flo x a c i n o r m o x i flo x a c i n
as soon as possible, as early initiation one from each category below]:
monotherapy may be used instead
leads to better outcomes. Antimicrobial
• Beta-lactams: cefepime, ceftazidime,
therapy should be tailored to the most • If influenza is suspected, treat early with
piperacillin/tazobactam, aztreonam
likely causative organisms in order to oseltamivir
avoid drug toxicity, decrease the rate of • Levofloxacin, or azithromycin plus
resistance to broad-spectrum antibiotics, Inpatient therapy (adults):
gentamicin
and reduce cost. The empiric treatment
• Ceftriaxone or cefotaxime, with the
of CAP has been made more difficult by • MRSA coverage: vancomycin or
addition of azithromycin or doxycycline
t h e e m e rg e n c e o f d r u g - re s i s t a n t linezolid
Streptococcus pneumoniae (DRSP). • Levofloxacin or moxifloxacin may be
Outpatient therapy (pediatrics):
used instead
Risk factors for resistant S. pneumoniae
• Amoxicillin (preferred in low-resource
include age > 65 years; recent treatment • If influenza is suspected, treat early with
settings) or amoxicillin/clavulanate
or repeated therapy with beta-lactams, oseltamivir
macrolides, or fluoroquinolones; and • If atypical pneumonia suspected,
• If MRSA is suspected, vancomycin or
medical comorbidities, including azithromycin
linezolid should be added
immunosuppression.
434
Inpatient therapy (pediatrics): although it more often causes COPD myringitis, though it is actually not
exacerbations than pneumonia. common and is nonspecific.
• Ampicillin
• Klebsiella pneumoniae rarely causes • The Legionella genus is comprised of
• Ceftriaxone or cefotaxime CAP in a healthy host but can cause over 50 species of intracellular
436
antimicrobial therapy should be selected choice for PCP, although alternatives The PSI is the most widely studied clinical
t o a v o i d t e r a t o g e n i c i t y. F e t a l (such as pentamidine, dapsone, and prediction rule for pneumonia. It stratifies
complications are common as fever and atovaquone) are often needed due to patients into five classes for risk of death
hypoxemia are harmful to development. allergic reactions, adverse effects, or (Risk Class I to V) from all causes within
Preterm labor is a known complication of treatment failure. Adjunctive therapy with 30 days of presentation based on medical
pneumonia, and tocolytic therapy may be corticosteroids has been shown to history, physical examination, and
r e q u i r e d . Te s t i n g f o r G r o u p B improve survival, especially in patients laboratory/radiologic findings. All-cause
Streptococcus before delivery and who are hypoxic. mortality ranges from 0.1% for Risk Class
intrapartum administration of antibiotics I to 27.0-29.2% for Class V. As points are
Another pathogen to consider in
can prevent the transmission of the assigned by age, it may underestimate
immunocompromised patients is
bacteria to the neonate. severe pneumonia in otherwise young,
Mycobacterium tuberculosis.
healthy patients and may overestimate
Immunocompromised Patients Cytomegalovirus (CMV) and varicella
severity in older patients (any patient over
Pneumocystis jirovecii (formerly P. carinii) zoster are rare causes of viral pneumonia.
50 years of age is automatically classified
is a fungal agent that does not cause
into Risk Class II).
infection in healthy people but is an Disposition Decisions
A number of clinical prediction rules and Click on the link to access a calculator for
important cause of opportunistic infection
guidelines have been developed to
in immunocompromised hosts. It remains PSI.
determine whether patients with CAP
the most common AIDS-defining illness in
individuals with human immunodeficiency
should be admitted or can be safely CURB-65 severity score
treated as an outpatient. As with all The PSI score uses twenty variables and
virus (HIV). The classic symptoms are
clinical prediction rules, these scores may be cumbersome to use in the
fever, nonproductive cough, fatigue,
should be used as a guideline and should emergency department. The CURB-65
shortness of breath especially with
not override the judgment of the score only requires five variables and is
exertion, bilateral interstitial infiltrates,
physician. easier to compute.
a n d h y p o x i a . Tr i m e t h o p r i m /
sulfamethoxazole (TMP/SMX), also • Confusion
Pneumonia Severity Index (PSI)
known as cotrimoxazole, is the drug of
437
• Urea > 7 mmol/L (in the United States, References and Further Reading,
blood urea nitrogen > 19 mg/dL) click here
SMART-COP
• Respiratory rate ≥ 30 breaths/minute The SMART-COP rule is a clinical rule
that predicts which patients with
• Blood pressure (systolic < 90 mmHg or
community-acquired pneumonia may
diastolic ≤ 60 mmHg)
need intensive care, such as mechanical
• Age ≥ 65 years ventilation or inotropic support. A
SMART-COP score of ≥ 3 points
One point is given for each variable and identified 92% of patients who required
patients can be stratified according to intensive care measures. While this score
increasing risk of mortality, ranging from was superior to CURB-65 for predicting
0.7% mortality for a score of 0 to 57% whether a patient would need intensive
mortality for a score of 5. Consider an respiratory or vasopressor support, like
ICU admission for patients with a score of the PSI, the sensitivity of SMART-COP is
4 or 5. reduced in younger patients and was
noted in one study to stratify 15% of
Compared to the CURB-65 score, the PSI
young adults incorrectly.
identified a greater number of patients as
low-risk (68% vs. 61%). The low-risk To see the SMART-COP tool, follow the
patients according to the PSI had a link.
slightly lower 30-day mortality (1.4%)
compared to the CURB-65 (1.7%). The Ultimately, the decision to admit a patient
clinical relevance of the slightly improved depends on the physician’s judgment, but
accuracy of the PSI is unknown. all the factors listed in the above scoring
systems should be considered.
To calculate a CURB-65 score, click on
the link.
438
Section 4
Spontaneous Pneumothorax
Case Presentation
by Mahmoud Aljufaili A 26-year-old male, with no significant medical history,
presented to the emergency department with acute shortness
of breath and associated right-sided chest pain. The pain
started suddenly while the patient was at rest, it was sharp
and worsening with inspiration. He denied a history of trauma,
fever, cough or any other constitutional symptoms. In the ED,
apart from tachypnea, his vitals were within normal limits. He
was not in distress. The trachea did not deviate. Breath
sounds were markedly diminished on the right side, with
normal breath sounds on the left side. No wheeze or crackles
were appreciated. The chest x-ray is shown below. What is
your diagnosis and plan for this case?
439
Image 10.5 Introduction
Pneumothorax refers to the presence of air in the pleural cavity. It
can impair oxygenation/ventilation. There are two types of
spontaneous pneumothorax 1) primary, and 2) secondary. Primary
refers to no underlying disease. Secondary refers to underlying
pulmonary disease which has a worse prognosis.
• Miscellaneous: Endometriosis
• Family history
• Smoking
440
• Marfans – in the absence of lung symptoms are the driven factor for the • more than 2 cm, then it is a large
disease treatment options. However, knowing the pneumothorax
pneumothorax size is useful to decide the
Critical Bedside Actions and • The American College of Chest
next step in majority of the cases. At
General Approach Physicians
least, today, the algorithms are still
Assess the stability of the patient: Our designed to the size of the • If the distance from apex to cupola is
first responsibility is to evaluate the pneumothorax.
patient vitals and control to airway, • Less than 3 cm, then it is a small
breathing, circulation abnormalities. In How to estimate the size of the pneumothorax
any instability, immediate actions are pneumothorax?
• More than 3 cm, then it is a large
needed to stabilze the problem. Although
• On the bedside, this can be done with pneumothorax
there is a low chance to have a tension
Chest x-ray. It is ideal to get upright,
pneumothorax in spontaneous
postero-anterior, and inspirium- Image 10.6
pneumothorax, this can be the worst
expirium x-rays. However, good quality,
case scenario for those patients. Oxygen,
s i t t i n g a n t e ro - p o s t e r i o r b e d s i d e
IV lines and cardiac monitorization may
portable x-rays may guide us well.
b e n e c e s s a r y. N e e d l e o r t u b e
thoracostomy can be necessary • British Thoracic Society guidelines:
immediately on the bedside. These
• If the interpleural distance at the level
critical bedside actions are rarely needed
of the hilum is
for asymptomatic or mildly symptomatic
patients. Therefore, we may have time to • less than 1 cm, then it is a small
use proper diagnostic techniques for pneumothorax
differential diagnoses.
• 1 to 2 cm, then it is a moderate MacDuff A, Arnold A, Harvey J Management
Size of pneumothorax: When we pneumothorax of spontaneous pneumothorax: British
Thoracic Society pleural disease guideline
diagnosed pneumothorax, the patient
2010 Thorax 2010;65:ii18-ii31.
441
• Primary or secondary • Esophageal rupture t h e difference in small pneumothorax,
especially in a busy and noisy ED
Differential Diagnoses • Toxin ingestion
environment.
The patients present mostly with
• Epiglottitis
shortness of breath (SOB). Therefore, Hypotension (think tension
pulmonary, cardiac and other causes of • Anemia pneumothorax!). This is very important
SOB should be considered first. “red flag” for a pneumothorax patient.
If the pneumothorax is made clinically or The patients are generally agitated
Pulmonary radiologically, then the types should be because of hypoxemia and low blood
• Airway obstruction confirmed as spontaneous, traumatic, supply to the brain. This finding should
primary, secondary or tension etc. warn physicians to immediate action to
• PE
treat the pneumothorax.
• Pulmonary edema
History and Physical
Examination Hints Emergency Diagnostic Tests
• Anaphylaxis Sudden pleuritic chest pain. Most often
and Interpretation
occur at rest.
• Asthma Chest X-ray
Increased work of breathing and • Displaced visceral pleural line without
• Cor pulmonale
tachypnea can be seen in moderate and lung markings between pleural line and
• Aspiration severe pneumothorax. chest wall
Hypoxemia can be seen in severe cases. • Deep sulcus sign on supine x-ray
Cardiac
• MI Normal oxygen saturation does not rule
out pneumothorax. The Chest x-ray shows left side large
• Tamponade pneumothorax with fully collapsed lung
Reduced breath sound on the affected tissue. If the patient is vitally unstable
• Pericarditis side is more obvious with the increased (hypotensive, tachycardic, hypoxemic)
size of pneumothorax (moderate or and agitated, then this x-ray means
Others
severe). Auscultation may not appreciate “tension pneumothorax.” If the patient
442
vitally stable, there is no tension. There is Ultrasound Image 10.8
very important teaching point for all • No sliding lung sign
physicians. tension pneumothorax is a
• Barcode (instead of the wave on the
clinical diagnosis, not imaging diagnosis.
beach) appearance on M-mode (video)
Therefore, if the patient is clinically
unstable and there is no breath sounds This video shows normal (left) and
on the left side, this is tension abnormal (right) lung findings. Left side
pneumothorax until proven otherwise, shows normal pleura and lung tissue
and this x-ray should not be ordered. relation and called seashore sign. Right
Nowadays, yes, you can use ultrasound one shows no clear differentiation
in seconds to diagnose if you are in between these structure and look like a
doubt. barcode. This finding is a warning for
pneumothorax presence.
443
Procedures This video demonstrates chest tube Small pneumothorax with no
Needle or catheter aspiration as effective insertion symptoms and normal findings can be
as chest tube for small pneumothorax. discharged.
The image shows left side chest tube
Therefore, they are both appropriate
location. Please see the below algorithm below to
treatment options. Although large
understand possible treatments and
pneumothoraxes may require tube
Image 10.9
thoracostomy, choosing the narrow tube
Image 10.10 Management of
size is effective as wide tubes. Most of Spontaneous Pneumothorax
the spontaneous pneumothorax are easily
and safely treated with pig-tale catheters.
N e e d l e d e c o m p re s s i o n ( v i d e o ) i s
necessary for tension pneumothorax. The
classical teaching was 2nd intercostal
space, mid-clavicular line, over the rib
insertion. However, this location is
recently controversial, especially in obese
patients. Therefore, for adults, the new MacDuff A, Arnold A, Harvey J Management
of spontaneous pneumothorax: British
location is mid-anterior axillary line Thoracic Society pleural disease guideline
2010 Thorax 2010;65:ii18-ii31.
crossing with 4-5 th intercostal line. This
location is also entry side of the chest Disposition Decisions disposition decisions.
tube. The below video demonstrates old Recurrent pneumothorax, the patient with
version of needle decompression. abnormal vitals, bilateral pneumothorax, If patients were discharged no flying for a
However, this location is still acceptable and all secondary pneumothorax should week after resolution and no diving are
in skinny adults and children. be admitted. standard recommendations.
444
Chapter 11
Selected
Psychiatric
Emergencies
Section 1
Case Presentation
by Elizabeth Bassett, Nidal Moukaddam, and A 25-year-old female is brought in by police after being found
Veronica Tucci
in a gas station, behaving bizarrely, talking to herself. The
patient has no identification, cannot provide her name, and no
medical history is available. She is responding to internal
stimuli, responds to questions with inappropriate laughter and
illogical statements such as “look, a bird, I am queen, meow,
what, Jesus, leave me alone,” and not making eye contact
with staff. She is noted to be paranoid, repeatedly looking at
the air vent above her bed. Initially calm, she became violent
after attempts to establish IV access. Verbal de-escalation and
redirection were not fruitful. The patient was placed in
physical restraints and eventually required emergency
pharmacologic intervention. Initial vital signs are Temperature
100.1 Fahrenheit (38.4 degree Celsius), HR 120 bpm, BP
Audio is available here 110/75 mmHg, RR 24 per minute, O2 saturation 98%. A liter
446
of IV fluids is given, and an hour later the patient Introduction
Acute psychosis may be encountered on a daily basis in the
is sleeping, physical restraints are removed, and
emergency department (ED). Psychosis is characterized by
all vital signs are within normal limits. disorganized thinking, delusions (false, unshakable beliefs), and
hallucinations, often auditory, visual. Acute psychosis can also be
The patient wakes up again, slightly calmer, but is
accompanied by behavioral changes and agitation that are not
perseverating on being pursued by a dark necessarily commensurate with the severity of psychotic
organization which can read her mind, and wants symptoms. The role of the emergency physician, in addition to
medically stabilizing and treating acute agitation/psychosis, is to
to cast her in a pornographic video. She insists
determine whether the patient is experiencing symptoms related
that the technician assigned to the ED is an agent to primary psychiatric diagnosis or secondary to a medical illness.
of evil, and refuses further vital signs. She also This can be challenging given both the limited time and history
available to the emergency physician, and the often-noted lack of
refuses oral medications, and when asked if
cooperation of acutely psychotic patients, known to be amongst
pregnant, lowers her voice and says “that’s why the hardest amongst patients in the emergency room. The
they’re after me, help me please.” She refuses to distinction, however, is critical, as incorrectly diagnosing a
provide further history, and from that point on, patient’s behavior as primarily psychiatric in nature, and missing
causes of altered mental state (AMS), can lead to dire
becomes mute.
consequences for the patient. This chapter will cover
management aspects of psychosis in the ED.
the patient to look for evidence of cancer of AIDS) poor historian and collateral information
trauma. ( f ro m p o l i c e , E m e rg e n c y M e d i c a l
7. Intracranial bleed (especially if Services, or patient’s family) is often
5. Perform a head to toe complete evidence of trauma or anticoagulated helpful. Make every effort to meet with
physical exam with attention to patient) them at the time of arrival, as such
neurologic exam. information may not be available later on.
8. Hyperthermia/heat stroke (unlikely with
For our patient, no history is available;
Differential Diagnosis a temperature of 100.1, however,
however, in general, the key information
1. P r i m a r y p s y c h i a t r i c e t i o l o g y : checking a rectal temperature may
sought includes:
schizophrenia versus schizoaffective reveal significantly higher core body
disorder, depression with psychotic temperature) 1. Pick up location: Street, home, nursing
f e a t u re s , b i p o l a r d i s o rd e r w i t h home? Get contact information of the
9. Hypoxia/hypercarbia (unlikely given
psychotic features family or nursing home if available,
this patient’s pulse oximetry reading)
including prescribed medications. If
2. Hypoglycemia
10.Vitamin deficiencies (Wernicke’s) the patient was from home or nursing
3. Drug or alcohol intoxication or home, was any medical history
11.Hypotension/hypoperfusion (unlikely
withdrawal provided such as a history of mental
with systolic of 110 unless the patient
illness or past similar episodes. The
448
absence of previous psychiatric history and waning course? Is the patient’s o r medical reasons for the symptoms at
strongly suggests a medical cause of mental status improving or declining? hand.
the behavior.
6. H a s t h e p a t i e n t b e e n s t a r v i n g 1. HEENT: Look for evidence or recent
2. Timing: When was the patient last seen themselves because of psychotic trauma – lacerations, abrasions,
at baseline? Has the onset of abnormal beliefs? hematoma, basilar skull fracture
behavior been gradual or rapid? Rapid (raccoon eyes, battles sign, CSF or
7. How paranoid is the story the patient is
onset suggests underlying medical blood in the ears). Look for evidence of
telling you? While individuals may
condition or drug use. past traumatic brain injury as
indeed be the target of mysterious
evidenced by old neurosurgical scars.
3. What did the scene look like: Empty organizations, most paranoid,
pill bottles, alcohol, illicit drugs, a persecutory delusions are extremely 2. Eyes: Pay special attention to the
potential for other toxic exposures? unlikely. ocular exam. Assess for pupil size and
We r e t h e r e a n y p r e s c r i p t i o n responsiveness to light, presence or
8. Do they have pre-existing medical
medications at the scene? Obviously, absence of extra-ocular eye
conditions they have been neglecting
the presence of prescription anti- movements, and presence of
because of their psychosis? Many
psychotics can help with the diagnosis nystagmus. Ocular findings can be a
patients with mental illness have
but the entire medication list can help clue towards various toxidromes or
medical comorbidities, often poorly
with determining the patient’s past space-occupying lesions.
treated.
medical history and may be the key in
3. Neck: Assess for meningismus and
diagnosis if the etiology is medical in
Physical Examination Hints thyromegaly
nature. It is imperative that a head to toe exam
be performed. This may be the only full 4. Pulmonary: The presence of rales,
4. Vitals and blood sugar of the patient en
physical exam that the patient receives wheezing can be a clue that the patient
route to the hospital if available.
while in the hospital and therefore the is experiencing hypoxia secondary to
5. The mental status of the patient at the only opportunity to assess for traumatic CHF, COPD, or asthma. Hypoxia can
scene vs. on arrival. Is there a waxing be a cause of the patient’s altered
449
mental status although unlikely if the 8. Neurologic: A complete neurologic a n abnormal neurologic exam should
patient’s oxygen saturation is high. exam is often difficult to perform as it prompt a CT head to assess for a bleed
Rales or diminished breath sounds requires cooperation on the part of the or lesion. However, note that inpatient
may be a clue, especially in elderly patient. Assess for cranial nerves, psychiatric facilities may require testing
patients, that the AMS is secondary to strength, sensation, coordination, independent of clinical status.
a pulmonary infection. reflexes, and gait; focal deficits
suggest a medical cause of psychosis. Emergency Treatment
5. Cardiac: This exam is unlikely to aid in Options
the diagnosis; however the presence Emergency Diagnostic Tests These are divided into medical and
of an irregularly irregular heartbeat may and Interpretation psychiatric.
indicate that the patient is The lab and radiologic studies are
anticoagulated and therefore at dependent on the clinical presentation. Initial Stabilization
increased risk of spontaneous or As always, ensure airway, breathing, and
Indicated studies may include
traumatic intracranial bleed. circulation. Ensure a safe and if possible,
electrolytes, acetaminophen levels,
Tachycardia or bradycardia may also a low-stimulus environment to minimize
salicylate levels, LFTs, ammonia, PT/INR,
indicate various toxidromes. agitation. This may be done by
thyroid studies, HIV, pregnancy test, ECG,
attempting to redirect the patient verbally
CXR, UA, urine culture, blood culture, CT
6. A b d o m e n : A s s e s s f o r r i g i d i t y and tur ning down the lights and
head, LP. Increasing age, preexisting
suggesting trauma or infection. Look decreasing the number of people in the
medical comorbidities, the absence of
for evidence of encephalopathy: room. Temporary physical restraints and
past psychiatric history warrant, whereas
hepatomegaly, ascites, caput medusae emergency pharmacologic intervention
young patients with a known psychiatric
may be needed if the patient escalates.
7. Skin: Assess for rashes, petechiae, history, normal vitals/physical exam, a
Psychotic patients will benefit from an
track marks. This can be a clue to classic toxidrome or admitted drug use
antipsychotic agent.
infection, trauma, intoxication, or may not require lab or imaging studies
withdrawal. unless the patient’s mental status fails to
Medications
improve on serial assessments. Evidence Antipsychotics and benzodiazepines are
or trauma, the use of anticoagulants, or the mainstays of treatment for acutely
450
psychotic patients who are agitated or When possible, get a baseline ECG o f time, have returned to their baseline
violent. These may be given alone but are prior to administration. mental status.
often given in conjunction and will be
3. Atypical Antipsychotics: Olanzapine, Admit to the psychiatric facility: This is
beneficial not only to the patient with
Ziprasidone, Quetiapine, Risperidone. appropriate for patients with higher
psychosis secondary to primary
These drugs also cause QT symptom burden who have been
psychiatric condition but also in various
prolongation but generally have fewer medically cleared; dangerousness to self
sympathomimetic toxidromes as well.
extrapyramidal side effects. or others, or inability are unable to care
1. Benzodiazepines: For the acutely for themselves due to psychosis warrant
agitated patient, the benzodiazepines Disposition Decisions admission.
of choice are typically midazolam and Admission to the hospital: This is
its long half-life. In the elderly or or patients with abnormal vitals. Inpatient
2. First-generation antipsychotics:
haloperidol and Droperidol. Potential Discharge to home: This may be
side effects include extrapyramidal appropriate for patients with substance-
side effects, e.g., dystonic reaction, as induced psychosis who, either with the
well as potential arrhythmias, help of medications or simply the tincture
especially long QT leading to torsades.
451
Section 2
Case 2
As you are pondering your next step, you see the paramedics
wheeled an older gentleman past you and into the next room.
You step into the next room to get a report. The family is at
the bedside and states the patient is an 82-year-old male with
Audio is available here
a history of hypertension and BPH who has been increasingly
452
confused and aggressive over the past two days. General Approach and Critical Bedside
You note that he is mildly tachycardic when you Actions
hear the PA system announce, “Security is General Approach and Key Concepts
The first steps in evaluating any patient who presents to the
needed in the critical care hallway.”
emergency department are to assess and ensure that the
Case 3 patient’s airway, breathing, and circulation is intact. However,
A nurse pops her head into the room and when presented with an acutely agitated or psychotic patient,
even before assessing the ABC’s, you should ask yourself if the
requests your immediate assistance. You follow patient poses an immediate threat to the safety of both your
him down the hall and see your charge nurse patient or your medical staff.
along with three security officers trying to hold If you determine that the patient poses an imminent threat to self
down a male patient. The patient, who appears or staff, a number of factors should be considered prior to
to be in his late twenties, is actively kicking and administration of medications in order to achieve rapid
stabilization without over-sedation or use of undue force. These
trying to bite and spit at the medical staff. He
factors include age, known psychiatric history, known or
appears flushed and diaphoretic. suspected substance abuse, and severity of agitation. Case 3,
above, is a common scenario in the ED where a patient clearly
poses an immediate threat. Clearly call out the medication(s) and
dosage(s) you would like, and while it is being prepared, attempt
de-escalation techniques. Appropriate pharmacologic and non-
pharmacologic agents will be further discussed under Emergency
Treatment Options.
454
Although it is often said that history is Emergency Diagnostic Tests Emergency Treatment
80% of the diagnosis, in cases of acute and Interpretation Options
agitation, a thorough physical Blood work, diagnostic tests, and The goals for the treatment of acute
examination is all the more important due imaging should be guided based on agitation is early recognition, intervention
a limited HPI and review of systems. The history and physical exam. Depending before escalation into more violent
physical exam of every acutely agitated on your institution, laboratory tests behavior, and stabilization of life-
patient should include a full neurologic required for medical clearance should threatening conditions. Therapy should
exam and head-to-toe visualization for also be taken into account. A basic be aimed at decreasing agitation and
obvious signs of trauma or injury. A full metabolic panel and CBC, although not psychosis to the greatest extent possible
neurologic exam may not always be standard, is typically ordered for most without oversedation in order to allow for
possible during the initial assessment but patients with acute undifferentiated further assessment of the patient to
should be completed as soon as feasible agitation or psychosis. determine the underlying cause.
and prior to disposition. Interventions can be divided into
A urine pregnancy should be ordered on
nonpharmacologic and pharmacologic
When dealing with acute undifferentiated all women of childbearing age. When
strategies.
agitation due to a limited history and urine is unobtainable, consider a
physical, a number of key signs and qualitative hCG or substituting blood for Non-pharmacologic strategies include
symptoms may help to at least narrow urine on a point-of-care pregnancy test. environmental interventions, de-
the differential to organic vs. inorganic escalation techniques, mechanical
causes. Organic causes of agitation tend In cases of suspected ingestion or
restraints, and seclusion. Environmental
to be associated with abnormal vital substance abuse, consider checking
conditions are often difficult to control in
s i g n s , d i s o r i e n t a t i o n , flu c t u a t i n g acetaminophen and salicylate levels, as
the ED, but the concept is simple: create
symptoms, or signs of trauma, whereas, well as an EKG and measurable levels of
a safe space that minimizes stimulation.
inorganic causes lack these features. prescription drugs to which the patient
This means screening patients for
has access.
weapons, removing objects that could be
used as weapons (pens, chairs, or other
loose objects), finding space away from
455
the noise and activity of the ED when Although environmental and de- Whereas, in patients with
possible, and dimming room lights. De- escalation strategies can be very undifferentiated agitation or psychosis,
escalation techniques involve both verbal effective, many times, acutely agitated or monotherapy with a benzodiazepine may
and non-verbal methods. Once again, psychotic patients will require some form be a better option due to its added
the concepts are simple and should be of pharmacologic intervention. The two anxiolytic effects and usefulness in cases
applied as first-line techniques in the major classes of drugs used for this of substance-related psychosis such as
management of acutely agitated or purpose are antipsychotics and phencyclidine (PCP) use or alcohol
psychotic patients. Successful use of de- benzodiazepines. They may be used in withdrawal.
escalation techniques will vary from combination or as monotherapy and are
When the above interventions fail to
situation to situation, but many times available in many formulations. In the
stabilize an acute agitated or psychotic
hinges on the ability to establish rapport case of acute agitation or psychosis,
patient, physical restraints and/or
with the patient quickly. Often times this these medications are most often given
seclusion may be necessary. It is
can be accomplished by addressing a parenterally, either intramuscularly or
important to understand, however, that
patient’s basic needs of safety, hunger, intravenously for rapid tranquilization.
these are methods of last resort and
and comfort. Provide reassurance that Refer to Table 2 for common agents and
should never be used out of convenience
the patient is in a safe place, offer food, doses.
or as a form of punishment. Seclusion
water or warm blankets, and make sure
Choice of medication(s) varies greatly differs from placing the patient in a safe
to address pain management. It is
depending on personal preference; and less stimulating environment in that
equally important to be mindful of
however, the two most commonly used seclusion involves involuntary
personal space and avoid the threatening
agents are haloperidol and lorazepam. In confinement. Both seclusion and
or confrontational behavior. Verbal de-
patients with a known history or high physical restraints are associated with
escalation techniques involve maintaining
suspicion for underlying psychosis, increased morbidity and mortality.
a calm and respectful demeanor while
monotherapy with an antipsychotic such
acknowledging the patient’s anger,
as haloperidol may be considered.
frustration or agitation.
456
Pediatric, Geriatric, substance-induced psychosis may be
457
Section 3
Case Presentation
by Veronica Tucci A 35-year-old female presents to the ED after the family called
the paramedics for “bizarre behavior.” She notes that her
family persuaded her to seek evaluation; however, they are not
with her currently. She seems somewhat paranoid and
tangential and is difficult to obtain a history from. On review of
systems does endorse some mild abdominal pain and
diarrhea. Her vital signs on arrival as recorded in triage are as
follows: heart rate 135, blood pressure 110/90, respiratory rate
24, oxygen saturation of 96% on room air, temperature 100.7.
When you speak with the family, they state that she has been
agitated and paranoid. They are also concerned that she
made suicidal threats while with friends.
458
abdominal is soft and non- Introduction that this did not hold true in the two
Many medical conditions can present as areas that are mandatorily evaluated in
tender. She has no meningeal
psychiatric complaints. The case below the ED – suicidal ideation and acute
signs. She is tachypneic and will demonstrate the importance of the psychosis. This suggested that the
has crackles in the lung bases. medical evaluation of these patients, as increase in visits was related to non-
well as the need to keep a broad emergent psychiatric complaints that
Her neurologic examination is
differential diagnosis. There are also might be better managed by outpatient
non-focal. She reports suicidal mental health professionals.
medical problems which may exacerbate
ideation without a plan. psychiatric symptoms or need to be
ED physicians are often tasked with
addressed in order for a patient to be
evaluating these patients for medical
able to be transferred and safely
problems prior to clearing them for
managed at a psychiatric center. In
possible psychiatric evaluation and
addition to these scenarios, the patient’s
admission. They must control the acute
underlying psychiatric disorder may lead
symptoms, attempt to determine the
to an emergent medical condition, such
etiology of complaints (particularly
as an overdose or a self-inflicted trauma.
functional vs. organic), provide
Psychiatric complaints are common appropriate initial treatment, and
presentations for our ED (emergency determine disposition. Of the utmost
department) patients and are ever importance is identifying and treating
increasing. Mental health-related visits immediate life-threatening problems.
increase from 1992 – 2001, most Historical data, mental status
significantly in the areas of substance- examination, physical examination, and
related disorders, mood disorders, and appropriate ancillary testing are indicated.
anxiety. Pediatric mental health visits are
This process has previously been termed
also increasing. Interestingly, one study
“medical clearance.” While the
which showed this increasing trend found
459
importance of this process cannot be and treatment or using the term medically family member with them at all times.
stressed enough, is fraught with both stable. There has also been shown to be Importantly, she should not be allowed to
intrinsic and extrinsic difficulties. wide variation in the comprehensiveness leave the ED until the evaluation is
Nevertheless, a thorough medical of medical clearance examinations. complete.
assessment is imperative to taking
excellent care of this high-risk patient General Approach and History Taking and Physical
population. Critical Bedside Actions Examination Hints
The most important first step in the For this patient, you will want to obtain
One challenge is with the term “medical assessment of this patient is to assess for further history including prior episodes,
clearance” itself, which can be abnormalities in the airway, breathing or p a s t m e d i c a l h i s t o r y, a s s o c i a t e d
misleading. It means different things to circulation which may require immediate c o m p l a i n t s ( c o u g h , f e v e r, h e a t
different providers, and its overuse can stabilization. A rapid blood glucose level intolerance, headache, neck pain/
result in poor patient care. No standard should be obtained early on. The patient stiffness, changes in hair or skin, etc.),
criteria exist for what medical clearance should be placed on a cardiac monitor prior medications, drug and alcohol use,
consists of, or even what the status of a and continuous pulse oximetry, and IV prior hospitalizations. It is important to
medically cleared patient truly is. access should be established with tubes obtain collateral for this patient who may
Complicating this further, different collected for blood work. Place the be unable or unwilling to provide a full
specialties have their own approaches to patient on oxygen by nasal cannula, and and accurate history for you.
this evaluation. In addition, receiving consider IV fluid.
psychiatric facilities often have their own A thorough history and physical are the
requirements, irrespective of what the With regards to the family’s concern starting point of any patient evaluation.
treating ED physician and psychiatrists about suicidal ideation, some precautions Several studies looking at missed medical
believe to be medically indicated. Some should be taken. This may include diagnoses in patients with psychiatric
have suggested modifying the term or removing items and clothing from the complaints have shown that these should
replacing it instead with a thorough room that could be used for self-harm. have been identified if a proper history
discharge summary. Another suggestion The patient should not be left alone and and physical were performed.
is to provide a summary of the evaluation should have a staff member or a reliable Unfortunately, studies looking at the
460
thoroughness medical evaluations of History should be obtained from the The mental status examination (MSE)
these patients have often found them to patient in addition to those close to them plays a crucial role in the evaluation of
be incomplete. An incomplete medical like family and caregivers, and an effort these patients. The MSE needs to be
evaluation can lead to missed medical s h o u l d b e m a d e t o c o n fir m t h e focused and brief, and evaluate seven
diagnosis, which can be dangerous for information obtained from outside major areas (affect, attention, language,
patients. One study found that “medically sources whenever possible. Sudden orientation, memory, visual-spatial ability,
clear” had been documented in 80% of onset in changes in behavior, mood, or and conceptualization). Again, this should
patients where a medical diagnosis thought in a previously normal patient, or be structured and evaluate changes in
should have been identified. One a deterioration in a patient with a chronic alertness, cognition, behavior. Remember
retrospective chart review found that disorder should be suspicious for an delirium, dementia, and psychiatric illness
complete vital signs were only underlying medical etiology. h a v e s i g n i fic a n t d i ffe r e n c e s i n
documented 52% of the time. management and outcomes, and thus
Assessing for substance abuse, use, and
need to be identified. Delirium in the ED is
All patients require a complete history, changes are important. Also, inquire
associated with decreased survival. There
physical and mental status examination. about adherence to their current
are also alternatives to the traditional
This should be approached in an medication regimen. Family and social
mental status examination. The quick
organized fashion in order to determine stressor should be assessed. It is
confusion scale is a scoring system that
the etiology of their complaints as important to find out about medical
was published and is quickly obtained,
functional or organic. The medical comorbidities, or physical symptoms and
easily calculated, readily interpreted
evaluation of these patients should be no complaints as these might also indicate a
score.
different than of those presenting with medical etiology (trauma, fever, etc.). Be
medical complaints. The history and aware that many medications can lead to Differential Diagnosis
physical should guide laboratory and changes in behavior, especially in at-risk In the above patient, the following is a list
other diagnostic testing and imaging. The groups. Physical complaints, abnormal of possible etiologies for her symptom:
information gathered from this will form exam findings, and abnormal vitals must sepsis, diabetic ketoacidosis, pneumonia,
the clinical picture. be evaluated and addressed. pulmonary embolism, meningitis,
encephalitis, hyperthyroidism/thyroid
461
storm, schizophrenia, bipolar disorder, of abnormal vital signs in comparison to organic etiology of their symptoms. A
psychosis, salicylate ingestion, acute patients admitted to medical units. study looking at 658 psychiatric
intoxication, alcohol withdrawal/delirium outpatients receiving medical and
Some special groups are at increased risk
tremens. There are several abnormalities biochemical evaluation found the
of having a medical etiology of their
in history and physical examination which incidence of medical disorders producing
complaints, and care should be taken
suggest that the patient’s symptoms are psychiatric symptoms at 9.1%. The
when evaluating these patients. Several
not primarily psychiatric in origin. etiologies included infectious, pulmonary,
prior studies have identified these as the
thyroid, diabetic, hematopoietic, hepatic
Alterations in mental status may elderly, those with substance abuse,
and CNS. Another study of 100
incorrectly be attributed to psychiatric those without a prior psychiatric history,
psychiatric patients who had been
diagnoses. A review looked at 64 cases and those with pre-existing or new
previously medically screened found that
of patients admitted to the psychiatric medical complaints. Intoxicated patients
46% had a medical illness that caused or
ward, whom were later found to actually represent a particular challenge. In
exacerbated their symptoms and 80% of
have a medical diagnoses that explained addition to often providing a limited
these required treatment. They concluded
their symptoms. The etiologies identified history, they may express certain
that a battery of laboratory and ancillary
included intoxication, withdrawal complaints (like thoughts of self-harm),
testing would have identified the majority
syndromes, overdose. In this, they noted only while intoxicated. A study looked at
of these.
that none had an appropriate medical 100 consecutive alert patients with new
screening examination performed. In psychiatric complaints. They excluded Emergency Diagnostic Tests
another study looking at factors which those obviously intoxicated, prior and Interpretation
may have contributed to a patients diagnosis of abnormal behavior, those The following diagnostic testing should
symptoms being attributed to a with medical complaints and overdose or be considered in the above case.
psychiatric problems instead of a medical suicide patients. For all patients, they
one, found that these patients had a then performed a history, physical, panel
lower rate of complete history, physical of laboratory tests, CT scan of the head
examination, cognitive assessment, and lumbar puncture if febrile. They
indicated ancillary testing and treatment concluded that 63/100 patients had an
462
While everyone can agree that these b e the basis of beginning the psychiatric
Table 11.1 Medical Clearance -
Suicidal Thought/Ideation Diagnostic patients deserve a complete history and assessment and recommend considering
Tests physical, the role of laboratory and a period of observation to determine if
TEST COMMENT ancillary testing is less well delineated symptoms resolve as intoxication
and is often viewed differently among ED resolves. A study looked at patients with
Complete blood Anemia, hematologic
count abnormality and psychiatric physicians. What studies isolated psychiatric complaints and past
Complete Metabolic abnormality, are required for medical clearance of the medical history of psychiatric disorder.
metabolic panel uremia, liver failure, renal psychiatric patient, and whether this None of these had positive screening
failure
process should be standardized, or be laboratory or radiograph results. The
Electrocardiogram Arrhythmia, evaluation of
tachycardia and irregular performed on a case by case basis, is the remaining patients had a presenting
pulse source of much controversy. medical complaint as well, and these
Chest X-ray Pneumonia, heart failure, complaints directly correlated with the
other etiology of The American College of Emergency
tachypnea need for labs and radiography. They
Physicians published a clinical guideline
Urinalysis/Urine Source of sepsis concluded that patients with a psychiatric
on the subject. They suggest that
culture complaint with a documented past
diagnostic evaluation should be directed
Blood cultures Sepsis evaluation psychiatric history, negative physical
by the history and physical and routine
Troponin and BNP Heart failure findings and normal vital signs, who deny
laboratory testing of all patients is of very
current medical problems did not require
Thyroid function Hyperthyroidism / thyroid low yield. Routine urine toxicology
studies storm further labs or testing in the ED.
screens in awake, alert, cooperative
CT scan of the Abscess, meningitis,
brain patients do not affect ED management, Another systematic review of the
mass
and using this screening in the ED literature indicated that history, physical
Lumbar puncture Meningitis/encephalitis
because of the requirement of receiving examination, review of systems, and tests
Alcohol level/urine Intoxication, may be
drug screen psychiatric facilities or service should not for orientation had relatively high yield for
required at psychiatric
facility delay evaluation or transfer. They also say detecting active medical problems.
Acetaminophen Commonly ingested in that patients’ cognitive abilities rather Routine laboratory testing was relatively
and salicylate suicide attempts than a specific blood alcohol level should low yield. However, four groups were at
levels
464
evaluation is ultimately needed. A study mental health crisis, the discovery of
Diagram 11.1
looking at several risk assessment scales mental health issues in ED patients, and
found that in general, they overestimated approaches to advocating for improved
suicide risk. They did note that they might recognition and treatment in mental
help highlight important concepts and illness in children. The ED evaluation of
risk factors. This may be particularly pediatric mental health is crucial to the
useful for non-psychiatric medical child’s long-term care and treatment.
personnel or junior residents. They may
It is important to note the overall
help identify high-risk patients in the ED
significance of medical problems in the
early in assessment, and those that may
population of patients with psychiatric
need psychiatric referral.
disorders, and the challenges that they
Conclusion face interfacing with and accessing the
The role of the ED provider in psychiatric medical community. A study of this
care is increasing, and external resources population out of Nova Scotia showed
Original by author
are often inadequate. A study of increased mortality from cancer, which
There are several clinical rating scales in California EDs showed that there are may be attributed to delays in detection
suicide risk assessment. An example of limited mental health resources for or initial presentation and difficulties in
one is the SAD PERSONS scale. It stands suicidal patients. It suggested the need communication and access to healthcare
for: Sex, Age, Depression, Previous for more regional solutions including contribute to this finding. Another study
attempt, ethanol abuse, rational thinking improved access to mental health looked at compulsory community
loss, social support lacking, organized personnel and follow of suicidal patients treatment in this patient population. They
plan, no spouse, sickness. One point is and community mental health resources saw a reduction in all-cause mortality in
given for each. for patient referrals. The same is true in their intervention, group which they
the pediatric patient. The ED physician stated that might be partially explained by
Assessing the risk of suicide is
plays an important role in the pediatric ED increased contact with health services in
complicated, and complete psychiatric
in the stabilization and management of a the community. Looking at 200 patients
465
re c e i v i n g p s y c h i a t r i c c a re i n t h e challenging. The ED physician is tasked
outpatient setting for schizophrenia and with the initial assessment both of
affective disorder diagnosis, both groups psychiatric risk and medical clearance.
had greater odds of having comorbid Care should be taken to stabilize any life-
medical conditions than those in the threatening condition and then to try to
general population. differentiate a functional versus organic
cause of the patient’s symptoms. They
In addition to the challenges of
must also assess for any underlying
assessment, these patients present
medical problems that may exacerbate
logistical difficulties in the ED setting.
the patient’s symptoms or need to be
Patents with psychiatric related
managed at a psychiatric facility. The
complaints have long lengths of stays in
psychiatric disorder itself may also lead
the ED. Older individuals, the need for
to a life-threatening medical condition
hospitalization, restraint use and
that needs to be threatened or treated.
diagnostic testing prolonged the length of
This is a very important part of the care of
stay. Drug and alcohol screening also led
this challenging patient population.
to delays. They also tend to have high
rates of readmission. Predictors of 12-
month readmission and ED revisits for
References and Further Reading, click
patients with substance abuse, and
here
mental health-related complaints were
highest in those with dementia, psychotic
disorders, autism, impulse control
disorders and personality disorders.
466
Chapter 12
Selected
Orthopaedic
Problems
Section 1
Back Pain
Case Presentation
by Funda Karbek Akarca A 45-year-old age male presented to the emergency
department with severe back pain after lifting a heavy object.
He described the pain radiated to the right leg. He had
difficulty with walking. His medical history revealed no
additional diseases except for occasional back pain. The vital
signs were normal. The physical examination showed palpable
peripheral pulses, no motor or sensory deficit, no drop foot or
murmur in the abdomen. Straight leg raising test is positive at
45 degrees. Palpation of the vertebrae revealed no tenderness
on spinous processes but paravertebral muscles spasm. The
patient’s pain decreased after resting in the supine position,
muscle relaxants, and analgesics. The patient was discharged
with a recommendation of neurosurgery visit in ten days.
468
Critical Bedside Actions and corticosteroid or anticoagulant •Abdominal aortic aneurysm
General Approach use, cancer
• Aortic dissection
Back pain is a common problem and
Make an orderly and thorough
affects up to 90% of the general • Upper Urinary Tract Infection, renal
physical examination
population at some point in their lives. It infarction, renal colic
is the fifth leading cause and accounts for Order necessary imaging and labs
• Abdominal infection (cholecystitis,
2% to 3% of emergency department
Assess the risks and consider the cholangitis, pancreatitis, retroperitoneal
visits. Although most back pain is due to
potentially life-threatening or abscess)
a benign and self-limiting reason, a
debilitating diagnoses.
minority of patients may face a risk of • Abdominal neoplasm
permanent neurological damage or death.
Differential Diagnoses
History and Physical
Acute, non-traumatic low back pain can
Spinal origin Examination Hints
be divided into three groups: • Musculoligamentous In many patients, a thorough history and
musculoskeletal causes with no
physical examination are essential and
neurologic deficits, musculoskeletal • Discopathy
s u ffic i e n t f o r d i a g n o s i s . T h e t i p s
causes with neurologic deficits and other
• Fracture indicating severe pathologies should be
causes that can present with back pain.
investigated (red flags are shown in Table
• Spondylolisthesis 1). Additional questions are whether the
Check vital signs; especially fever
• Vertebral osteomyelitis patient has a similar pain before, has any
Learn the history of current illness; prior diagnosis related to this complaint
pain duration, how the pain • Spinal epidural abscess or receive any treatment.
started and spread.
• Spinal epidural hematoma
Ta k e m e d i c a l h i s t o r y ; d i s c
• Neoplasm/metastatic disease
herniation history, recent spinal
a n e s t h e s i a o r s u rg e r y,
Nonspinal causes
469
Table 12.1 Red Flags In Back Pain Illustration 12.1
HISTORY PHYSICAL EXAMINATION
Pain duration more than 6 Fever
weeks
Age;child or elderly Major motor weakness esp. bilaterally
Recent instrumentation or
spinal anesthesia
provided by author
The patients under 18 and over 50 years old are under risk for
non-musculoskeletal pathologies.
470
The systemic symptoms are another tip for non-musculoskeletal
Illustration 12.2
pain. Fever, tremor, night sweating, anorexia, unexplained weight
l o s s a r e s i g n i fic a n t f o r i n f e c t i o n a n d m a l i g n a n c y.
Immunocompromised patients (diabetic, the corticosteroid use, IV
drug use) may not develop a healthy inflammatory response and
accordingly the systemic symptoms; therefore, they may require
further investigations. Consider spine infections in IV drug users.
Evaluate ankle and the first toe’s dorsiflexion and plantar flexion Lumbosacral anterior-posterior and lateral X-rays are indicated in
for L5-S1 nerve roots. Examine patella and ankle deep tendon case of suspected fractures, especially in patients over 50 years
reflexes. Evaluate bilateral dermatomes and check for saddle old.
anesthesia. Test the sensation of light touch along dermatomes
from L1 to S1. Standard dermatomal charts can be helpful, but
there is variability between individuals, and this test is highly Image 12.1 Normal lumbosacral X-ray. Lateral (left), AP (right)
subjective. In the upper lumbar roots, there is often a significant
overlap. The L4, L5 and S1 nerve roots are the most discrete
levels for testing. Additionally, these are the most often affected
lumbar discs.
472
Image 12.2 Lumbar flattening Image 12.3 Normal spinal CT lateral Image 12.4 L2 compression fracture
view
Emergency Treatment
Options
Initial Stabilization
Structured management is essential in
the emergency department. Stabilization
is a priority. A critical abnormality in the
vital signs and clinical may lead to the
474
early intervention in the life-threatening diseases and permanent For children: Ibuprofen; Infants and Children <50 kg: Limited
neurological damage is at stake. After stabilization, pain control data available in infants <6 months: 4 to 10 mg/kg/dose every 6
should be provided. to 8 hours; maximum single dose: 400 mg; maximum daily dose:
40 mg/kg/day. Children ≥12 years: Refer to adult dosing.
Medications
• Pain is the main symptom. Non-steroidal anti-inflammatory Elderly considerations
drugs (NSAIDs) are considered as first-line therapy for acute Consider fractures in elderly patients with relatively minimal
back pain. Ibuprofen has less adverse effects and toxicity. trauma. Additionally, consider non-musculoskeletal causes of
back pain, such as abdominal pathologies, aortic aneurysm or
• Acetaminophen may be another choice.
dissection.
• Opioids analgesics should not be administered more 1-2
Pregnant considerations
weeks.
Back pain is frequent in later pregnancy. The neurological deficit
• The muscle relaxants are another treatment choice. is infrequent. Pain control via analgesics and back strengthening
exercises are recommended. Paracetamol is considered safe in
• The use of steroids is not recommended due to lack of pregnancy and should remain the first-line treatment for pain and
evidence. fever. General Dosing Guidelines: 325 to 650 mg every 4 to 6
hours or 1000 mg every 6 to 8 hours.
• The patients should return to their daily activities after a few
days of bed rest.
Disposition Decisions
Pediatric, Geriatric, Pregnant Patient, and Admission Criteria
Other Considerations • Patients with uncontrolled pains
475
Discharge Criteria
Patients with musculoskeletal pain without neurological deficits
may be discharged after pain control
Referral
Patients should be referred to neurosurgical or orthopedic surgery
departments.
476
Section 2
477
• Make an orderly and thorough • Visual inspection and palpation: look for • In anterior dislocations, the limb is
examination t e n d e r n e s s , p a l l o r, e c c h y m o s i s , abducted, externally rotated, and
deformity, abrasions, lacerations, and shortened.
• Order necessary imaging and labs
open wounds.An open fracture is a
• Check neurovascular status: Femoral
• Noncritical orthopedic injuries should fracture associated with overlying soft
nerve and artery may be injured with
be treated only after more threatening tissue injury, creating communication
anterior hip dislocations. The sciatic
injuries have been addressed. between the fracture site and the skin.
nerve may be injured with a posterior
Even a puncture wound extending to
hip dislocation or a hip fracture. Check
Differential Diagnosis the depth of an underlying fracture is
The patient might have one or more of pinprick sensation, light touch and
considered an open fracture. Open
the following: motor function. Also, check femoral,
fractures are usually classified by their
popliteal, dorsalis pedis, and posterior
severity, based on the size of the
• Hip fracture tibial pulses.
overlying laceration, the extent of tissue
• Hip dislocation damage, lack of bone coverage, the • Dislocations and fracture-dislocations
kinetic energy of the injuring force, and of the hip are two true orthopedic
• Acetabular fracture evidence or likelihood of significant emergencies. The hip joint possesses
• Neurovascular injury contamination. impressive inherent strength and
stability; therefore, considerable force is
• In a femoral fracture, the limb is
History and Physical required to produce these injuries. It is
shortened and externally rotated.
Examination Hints highly recommended that in the
• Note syst emic illnesses, known • Most hip dislocations are posterior. In presence of this type of injury, patients
metabolic disorders and medications. posterior dislocations, the limb is be managed as major trauma victims.
These may provide clues that lead to adducted, internally rotated, and
uncovering the reason behind what may shortened. Emergency Diagnostic Tests
seem like a simple trauma. (I.e., a fall and Interpretation
may be the result of a cardiovascular • Anteroposterior (AP) and lateral
event.) radiographs of the hip are usually
478
sufficient to diagnose hip dislocations • Significant pain with weight bearing in angiography or CT Angiography are
and fractures. (See Image 12.8 and the face of normal radiographs should necessary.
12.9) raise suspicion for occult fracture,
especially at the femoral neck or E m e r g e n c y Tr e a t m e n t
acetabulum. Options
Image 12.8 Right hip dislocation • Most femoral and hip fractures need
• If there is a suspicion of fracture but operative repair. Consult an orthopedic
plain radiographs appear negative, surgeon. Meanwhile, immobilize the
computed tomography (CT, See Image extremity to prevent it from further
12.10) or magnetic resonance imaging damage.
(MRI) may be used for diagnosis.
• If a fracture is suggested clinically but
radiographic films appear negative, the
Image 12.10 Left acetabular fracture patient should initially be treated with
immobilization as though a fracture
were present.
Image 12.9 Fracture of the femoral • Patients with a traumatic fracture of the
neck and peritrochanteric fracture
hip or femur may lose about 2 to 3 units
of blood at the fracture site and require
blood transfusions. Therefore, order
blood type and crossmatch for at least 2
units of blood.
479
• The sooner a joint is relocated, the • In case of open dislocation/fracture, injuries, in which contamination with
b e t t e r, t o a v o i d n e u r o v a s c u l a r remove gross contaminants from the Clostridium perfringens can be
compromise. Also, delays cause wound and irrigate the injury thoroughly. present. Early surgical intervention for
swelling and muscle spasm, which Apply saline-soaked sterile gauze, and debridement and irrigation is crucial, so
hinder reduction. Use adequate splint the injured leg. If a significant emergency orthopedic consultation is
analgesia or conscious sedation before deformity is present, immediate indicated. Administer analgesics as
attempting relocation. The emergency reduction before splinting is indicated. necessary (Morphine sulfate: 2–10 mg
physician sometimes may be unable to Administer tetanus immunoprophylaxis (pediatric dose: 0.05–0.1 mg/kg per
reduce a dislocation. Orthopedic as appropriate (Tetanus booster: 0.5 ml dose IV or equivalent analgesic)).
consultation is necessary in such cases. (Tdap) IM, Tetanus immunoglobulin: 250
• In case of neurovascular injury, surgical
IU IM if not previously immunized
• For hip dislocations, after reduction, the consultation is necessary.
against tetanus). Start the patient on
legs are immobilized in slight abduction
intravenous antibiotics. For injuries with
with a pillow between the knees, and Special Populations
mild to moderate contamination, a first-
the patient should be sent for • Treatment options are mostly the same
generation cephalosporin such as for children, elderly and pregnant
radiographs. Check neurovascular
cefazolin 1–2 g (pediatric dose: 20 mg/ patients.
status before and after all reductions
kg IM/IV)is usually sufficient.2Heavily
and after administration of
contaminated wounds require the • In a fall, elderly patients may have
immobilization. sustained additional injuries; most
addition of gram-negative bacterial
coverage, typically an aminoglycoside commonly, these injuries involve a
• Withholding Oral Intake: Any patient
who might go under general anesthesia such as gentamicin 1.5–2 mg/kg fracture of a vertebral body or wrist.
or procedural sedation should not be IV(pediatric dose: 2–2.5 mg/kg IV). Cervical spine and intracranial injuries
allowed to eat or drink from the moment Adding either penicillin G 4–5 million U also are considered.
of arrival until the need for, and timing IV (pediatric dose: 50,000 U/kg IV)or, if
• The dislocation reduction methods for
of, such a procedure has been penicillin allergic, clindamycin or
patients with hip arthroplasty are the
ascertained. metronidazole as a third antibiotic is
same as with a native hip.
necessary for farm-or soil-related crush
480
• Fractures involving the physis, the be reduced in the operation room under normal. The x-ray revealed a
cartilaginous epiphyseal plate near the general anesthesia.
comminuted patellar fracture
ends of the long bones of growing
• Hip fractures and hip dislocations (even (Image 12.11). The patient was
children, are called Salter fractures.
if reduced in the ED) need to be
Damage to the epiphyseal plate during admitted to the orthopedics
admitted to the orthopedics ward.
a child’s growth may result in an
ward for surgical repair.
aborted or deformed growth of the limb.
General Approach mentioned above in the topic “hip.” dorsiflexion of the ankle. The posterior
These steps are the same as those tibial nerve may also be injured. This
• See Image 12.12 for open knee
mentioned above in the topic “hip.” manifests with diminished plantar
dislocation.
sensation and plantar flexion of the
Differential Diagnosis foot.
The patient might have one or more of
Image 12.12
the following. • Check vascular status: knee trauma
may cause vascular injury. Check the
• Distal femoral, proximal tibial, proximal popliteal, dorsal pedal and posterior
fibular fracture tibial arteries.
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A grossly unstable knee after a traumatic the joint above and the joint below the I n acute knee trauma, the goal of
injury should be assumed to be a injury, not to miss associated injuries. radiography is to rule out frac¬ture.
re d u c e d d i s l o c a t i o n u n t i l p ro v e n Because radiographs are not 100%
The joints above and below a fracture
otherwise. sensitive, knee immobi¬lization and
should generally be imaged for coexisting
orthopedic referral for reevaluation are
(For more information, videos 5 and 6 will fractures.
options. When suspicion for a fracture is
be helpful)
Pre-and-post-reduction radiographs are extremely high, CT or MRI can be used.
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for 4 to 6 weeks. Displaced fractures are ice, non–weight-bearing status, and application and analgesic use and an
treated surgically. referral for an orthopedic follow-up. orthopedics outpatient follow-up.
Patellar Dislocation: After reduction, In case of neurovascular injury, urgent • Give the patient instructions about
immobilize the knee in full extension for 3 surgical consultation is necessary. splint care, crutch use, range-of-motion
to 6 weeks. Ice, elevation, non–weight exercises, weight-bearing status,
Controlling Pain and Swelling: The early
bearing, and analgesia are beneficial in war ning signs for neurovascular
application of cold and elevation are
the acute setting. The patient can be impairment and compartment
effective in minimizing swelling or at least
discharged with a referral for a follow-up syndrome and follow-up.
deterring its progression. Administer
within 2 weeks. Watch this video.
analgesics as necessary. • The patient can begin exercises when
Knee Dislocation: To avoid tissue the pain subsides and can return to full
Withholding Oral Intake: same as
damage, the reduction should be activity when full pain-free motion and
mentioned above in the topic “hip.”
attempted as soon as possible.. After equal strength are attained in both
reduction, immobilize the knee and call limbs.
Special Populations
for an orthopedic consultation. Watch this Treatment options are mostly the same
Ankle
video. for children, elderly and pregnant
485
• See Images 12.15 and 12.16 for ankle Emergency Diagnostic
Image 12.16
open fracture plus dislocation. Tests and Interpretation
• The blunt ankle trauma evaluated within
48 hours of injury, the Ottawa Ankle
Image 12.15
Rules (OAR) can be used to determine
necessity of x-rays. The OAR does not
apply to the hindfoot or forefoot. Finally,
the OAR is not applicable to intoxicated
patients, patients with head injuries,
multiple injuries, or diminished
sensation related to neurologic deficits.
486
Emergency Treatment Special Populations
Options Treatment options are mostly the same
Ankle Dislocations: See video for for children, elderly and pregnant
reduction maneuvers. Reassessment of patients.
the neuro¬vascular status, splint
immobilization, ankle elevation, and post- Disposition Decisions
reduction radiography should follow. • Ankle dislocations and most ankle
fractures should be admitted to the
Watch this video.
orthopedic ward. Consult an orthopedic
Ankle fractures: Displaced intraarticular surgeon.
fractures require surgery.
• Soft tissue injuries can be discharged
Achilles Tendon Rupture: Splint the leg in with the recommendation of ice
plantar flexion; arrange orthopedic follow application, elevation, immobilization,
up as an outpatient. and analgesic use.
487
Section 3
Pelvic Injuries
488
Illustration 12.5 Posterior view of Illustration 12.6 Pelvic ligaments Illustration 12.8 Acetabulum
pelvic bones anathomy
The pelvis has a complex vasculature. pubis form the anterior part of the
Iliac arteries and main veins are close to acetabulum. (See Illustration 12.8)
both sides of the sacroiliac joints. (See
Illustration 12.7) The thin-walled venous Cauda equina courses through the sacral
structures have limited contraction spinal cord and leaves at the sacral spinal
capabilities. Therefore, patients with Three bones form the acetabulum. The foramina to form the lumbar and sacral
pelvic fractures may have life-threatening ilium forms the upper boundary; ischium plexus. Lumbosacral plexus is the
bleedings. forms the posterior part and ilium and thickest peripheral nerve of the body and
489
is frequently injured in posterior hip Acetabular fractures are often associated
Image 12.19 Iliac and anterior column
dislocation with acetabular fracture. with the femur fracture, hip fracture and fracture of acetabulum
Watch this video for detailed information. dislocations, and knee injuries. Posterior
wall fracture is the most common
Pelvic fractures are divided into three
acetabular injury and is usually
groups:
associated with posterior dislocation of
a) pelvic fractures which cause separation the hip. Posterior hip dislocation is
of pelvic ring, generally associated with sciatic nerve
injury. Watch this video for detailed
b) no separation of pelvic ring with one information. (See image 1, 2, 3 )
bone fracture (see Illustration 12.9) and
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Several classifications are used to identify A P compression or open book injury is
Illustration 12.10 Lateral
pelvic fractures (see video) compression fractures of pelvis the second most common mechanism
and corresponds to 25% of injuries. An
Young-Burgess Classification classifies
example is a frontal impact of the motor
fractures according to the direction of the
vehicle. (See Illustration 12.11) (See
force that caused the injury and the
image 12.21 and 12.22)
mechanisms of injury . There are four
different fracture models according to this Left to right. Type 1, Type 2, and Type 3. Type
1 includes sacral compression fracture on Illustration 12.11 Anteroposterior
classification system: ipsilateral side. Type 2 is a sacral injury with
disruption of posterior sacroiliac ligaments.
compression fractures of pelvis
• lateral compression (LC), Iliac wing fracture on impaction side can be
seen. Type 3 includes Type 1 and 2 injuries on
impaction side with open book fracture/injury
• anteroposterior compression (AP), on contralateral side.
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The least common is Coexistence of other injuries constitutes 20-25% of injuries.
Image 12.21
Antero-posterior VS as it generates 5%
Tile classification is about the mechanical stability of the pelvis.
compression type 2 of the injuries. Falls
injury with right from heights are Type A – Stable pelvic ring injuries, posterior stability is intact: Avulsion fractures,
femur bone fracture
examples. (See isolated iliac wing fractures, isolated pubic rami fractures, transverse fractures of
Illustration 12.12, sacrum or coccyx.
image 12.23)
Type B – Partially stable pelvic ring injury (incomplete disruption of the posterior
Illustration 12.12 pelvis) rotationally unstable, vertically stable: Open-book fractures, lateral
Vertical compression compression fractures, double rami fractures and posterior injury
injury. Pubis and
sacroiliac joints are
Type C – Unstable pelvic ring injury: Vertical shearing fractures, rotationally and
disrupted.
vertically unstable.
Tile classification system predicts the need for surgical intervention. Young and
Image 12.22 Type 3 Burgess determines the pattern of the fracture and predicts the chance of
injury
associated injuries and mortality risk.
492
Case Presentation Critical Bedside Actions and General
A 38-year-old male presents to the emergency Approach
In multi-trauma patient, start with general trauma care including
department following a motor vehicle accident.
ABC.
The patient has left femoral and hip pain. His
Mechanical stabilization and immobilization of the patient are
vitals are as follows: Blood pressure 100/60
important because they reduce the risk of bleeding and
mmHg, heart rate 108 beats per minute, pulse secondary organ injuries.
oxygen saturation at room air 99%. His physical
Consider other organ injuries, especially with unstable pelvic
examination reveals suprapubic tenderness, fractures (e.g., intraabdominal injuries, gastrointestinal tract
limitation of motion in the left hip joint, pelvic injuries, genitourinary injuries, major vascular injuries, and
neurological injuries)
tenderness and hemorrhage at urethral meatus.
Point-of-care ultrasonography shows no • Check vital signs
493
Differential Diagnoses forces (such as falls from heights) may
Image 12.24 Cullen’s Sign.
• Abdominal pain in elderly lead to damage to the ligaments and
pelvic floor that lead to significant
• Blunt abdominal trauma instability in the posterior pelvis.
495
• CT should be used when the clinical Resuscitation
Image 12.29 Outlet view
suspicion is high, but the plain pelvic All critically ill patients should be
radiograph is negative. given oxygen and intravenous
fluids.
• CT identifies secondary injuries in
patients with pelvic fractures on x-ray. Lower extremity veins should not
be preferred as an intravenous
• It is preferred in suspected acetabular
line in patients with severe pelvic
fractures.
fracture because of the risk of
• Contrast-enhanced CT gives useful leak into the retroperitoneal
data for evaluation of soft tissue space.
injuries, vascular injuries, and pelvic
Opioids may be given for pain
hematoma.
control.
Avulsion fractures of the L5 transverse • The presence of arterial bleeding is
process, avulsion fractures of adhesion Antibiotics should be given for
80-90% recognizable with CT.
places of sacrospinous and patients with bowel rupture,
urogenital injury, and an open
sacrotuberous ligaments, avulsion of Emergency Treatment
fracture.
lower lateral lip of the sacrum and vertical Options
sacral fractures that extend to medial part There is no standardized protocol for the Tetanus prophylaxis is applied to
of sacral foraminae may show an treatment of pelvic injuries. Treatment appropriate patients.
unstable pelvic fracture exclusively. options should be based on the
hemodynamic status, the severity of Crystalloid fluids and blood
Computed Tomography trauma, the mechanism of injury, the type products may be required in
• CT is the gold standard for evaluation of patients with a pelvic injury.
of fracture, and concomitant injuries.
pelvic injuries.
Open book injuries, fractures that
cause separation of more than 0.5
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cm in the pelvic ring, and fracture • Open book injuries get the most benefit Angiographic embolization is
findings that include displacement from bed linen wrapping method. reported to be effective at controlling
at symphysis pubis or obturator arterial bleeding, while external fixation is
• This maneuver may aggravate the
ring may need the blood reported to be effective at controlling
degree of the displacement in lateral
transfusion. venous hemorrhage. However, it is
compression injuries because of the
difficult to determine the origin of the
Hemodynamically unstable internal rotational strain.
hemorrhage whether venous or arterial
patients, due to hemorrhagic
• External fixation and extraperitoneal until angiography is applied.
shock caused by trauma, should
packing may be preferred by the
be treated considering the ATLS Complications
o r t h o p e d i c s u rg e o n a s i n v a s i v e
guidelines. Timely intervention is crucial for
treatment options.
prevention of complications.
Control of Hemorrhage
Treatment choice should be selected Angiographic Embolisation Life-threatening hemorrhage, deformity,
P o s t e r i o r p e l v i c r i n g i n j u r i e s a re
according to the capacity of the health neurological and genitourinary injuries are
associated with the most severe
center with an emergency physician, an complications that should be diagnosed
hemorrhages. The majority of pelvic
orthopedic surgeon and an interventional and treated in pelvic traumas.
bleeding has the venous origin. Arterial
radiologist to take control of pelvic
hemorrhages account for 10-15%. Early Complications
hemorrhage.
Shock and death are associated more • Hemorrhagic shock
Mechanical stabilization
with arterial bleeding.
• The bed linen is wrapped tightly around • Urethral injury
the pelvis as a simple non-invasive Angiography is indicated in patients with
technique. Please see videos 1 and 2. a major pelvic fracture who have resistant • Bladder injury
497
• Perineal injury Discharge Criteria
• Hemodynamically stable Type A pelvic fractures with no
• Limbo-Sacral nerve root injury
evidence of other system injuries.
Late complications
• Chronic pain
References and Further Reading, click here
• Sexual dysfunction
• Shortening of extremity
• Malunion or nonunion
Disposition Decisions
Admission criteria
• Tile type B or C pelvic fractures
• Acetabular fractures
498
Section 4
Spine Injuries
• Check immobilization
499
• Order monitorization and IV line palpate the posterior structure of •Examine the motor and sensory
vertebrae behind the neck (Adam) after function. Motor function is assessed
• Learn mechanism of injury
unfastening the patient’s cervical collar from 0 to 5.
• Examine the vertebra and preventing the reflexive movement
0 – is total paralyzed,
of the head with the other hand. Check
• Examine motor and sensory function the posterior neck for midline sensitivity, 1 – is palpable contraction,
swelling, ecchymosis, step-off sign.
• Check exclusion rules
Examine motor and sensory function. 2 – motion with gravidity,
• Examine other injuries
• If the patient is fully conscious and has 3 – motion against gravidity,
• Order imaging and labs. no posterior midline tenderness, the
4 – motion is present but less power,
emergency physician may remove the
Differential Diagnosis cervical collar. Then rotate the head left 5 – normal power.
• Spinal cord injuries and right, caudal and cephalad slowly
• To assess sensory function, examine
• Cervical spine injuries and check if the patient is feeling any
deltoid muscle for C5, the thumb for
pain.
C6, the middle finger for C7, and the
• Cervical Ligamentous injuries
• Evaluate the exclusion criteria if the little finger for C8.
• Vertebral artery injuries patient is conscious and has no
• Check deep tendon reflexes (biceps,
posterior midline tender ness on
• Torticollis triceps).
examination. Nexus and Canadian C-
• Cervical hematomas, masses spine rules are the main rule-out criteria • Spinal cord injuries may lead to
of a cervical spine injury. neurogenic or spinal shock (See the
History and Physical shock and spinal cord injuries).
Examination Hints For nexus criteria, watch this video.
Hypotension and bradycardia are the
• The examination must start with general main symptoms of shock.
For Canadian C-spine rules, watch this
trauma care. On physical examination,
video
the emergency physician should
500
• Motorcycle accidents, falls from height • Simple wedge fracture generally occurs • Type 2: base of dens fracture
and sports injuries are common causes anteriorly when longitudinal ligament
• Type 3: dens and vertebra fracture
of cervical spine injuries. pulls vertebrae body and ruptures due
to flexion forces. Extension
• Victims may be under effects from drug,
alcohol, and unconsciousness • Flexion teardrop is an unstable fracture • C1 posterior arch fracture an unstable
associated with head trauma. c a u s e d b y fle x i o n f o rc e s . I t i s fracture of the atlas
associated with severe ligamentous
• Inspect for any other injuries such as • Hangman’s fracture is the fracture of
injury, anterior cervical cord syndrome
maxillofacial and head injuries. bilateral C2 pedicles
and quadriplegia.
Unconscious and vitally unstable
patients with a head, abdominal and • Clay Shoveler’s fracture is the stable Vertical compression fracture
thoracic injuries should be considered fracture of the C7 spinous process.
• Jefferson Jefferson fracture is C1 burst
to have a cervical injury.
• Spinal subluxation is characterized by a fracture. It is characterized by widened
• Learn the mechanism of injury. Cervical bone fracture with enlargement of predental space on open mouth
spine injuries are categorized according interspinous and intervertebral space. odontoid X-ray.
to mechanism into flexion, extension,
• Bilateral facet dislocation is associated • A burst fracture is mostly seen in lower
and vertical compression.
with soft tissue, annulus fibrosis and vertebrae. Lateral views show the
Flexion anterior ligament injury. fracture best.
• C1-2 atlantooccipital or atlantoaxial • Simultaneous flexion and rotation Emergency Diagnostic Test
dislocation is caused by displacement forces may produce unilateral facet and Interpretation
of the head anteriorly and posteriorly. It dislocation. C2 dens fracture. • Decide the need for imaging using
is diagnosable by plain radiography. exclusion criteria.
• C2 dens fracture has three types:
Atlantooccipital dislocation is a life-
threatening injury and more frequent in • Type 1: avulsion fracture
children.Flexion
501
• Choose the best test for the patient • Magnetic Resonance Imaging (MRI): injury is excluded by clinical or
according to your examination, findings Spinal Cord Injury without Radiographic radiologic means.
and mechanism of injury. Abnormality (SCIWORA) defines the
• Consider full monitoring. Monitorize the
presence of neurological deficit with no
• Imaging is indicated if pain and midline patient for spinal and neurogenic shock
radiographic or computed tomographic
tenderness, neurologic deficit or or phrenic nerve paralysis.
features of spinal fracture or instability.
intoxication/altered mental status is
Therefore, the presence of neurologic • Apply sedation to prevent self-injury or
present.
deficit necessitates MRI for the other complications in agitated patients
• Computed Tomography (CT): Cervical diagnosis of traumatic myelopathy. secondary to additional injuries or
CT is indicated if the patient is substance effects. (See sedation
unconscious, the physical examination
Emergency Management chapter)
• Trauma surveys should be applied any
is unclear, the neurologic deficit is
c-spine injury patients. See this chapter. • Provide cervical immobilization with in-
present or CT is planned for another
F o l l o w i n g re c o m m e n d a t i o n s a re line stabilization during intubation. (See
injury (especially head maxillofacial
specific to c-spine, not general trauma intubation indications in a trauma
t r a u m a ) . H o w e v e r, c u r r e n t A J R
management. patient).
guideline recommends CT scan in the
presence of any violation of NEXUS or • Immobilize the patient at the first • In-line stabilization (video 1 and 2):
Canadian-C-spine rules. contact. Watch this video Have the assistant stand at the head of
the patient and stabilize the patient’s
• Because you may not have CT scan • Immobilization is the first step of
neck using both hands and prevent
availability in some institutions, knowing management. If not done at the
hyperextension.
how to interpret c-spine x-rays is prehospital setting, immobilize the
important. Please see this chapter. You patient’s neck, place the collar • Intubation with video laryngoscope is
will also see many c-spine injury posteriorly with an assistant and fasten. recommended, if available.
samples in that chapter. Unfasten the collar as soon as possible
to prevent complications after the spinal
502
• Continue immobilization until the The patients with neurologic or spinal The patient reported chest
imaging if the patient needs an shock should be admitted to the ICU. The
pain. Blood Pressure: 130/80
emergent operation. patients with unstable fractures should be
admitted and/or operated immediately by mmHg. Heart Rate:120 bpm.
Medications neurosurgery. His Glasgow Coma Scale was
Corticosteroid treatment for spinal cord
injuries secondary to spine injuries has Discharge 15. There was no midline
been shown that having many flaws, Patients with stable fractures and no tenderness on cervical
therefore is not recommended anymore. neurologic deficits may be discharged.
examination. The respiratory
Recommend Philadelphia or Miami collar
Analgesics should be applied to awake
to the patients with suspected ligament
sound was normal. His E-FAST
patient.
injury. examination showed pleural
Pediatric, Geriatric, Refer the patients to neurosurgery clinic.
fluid. The chest x-ray revealed
Pregnant Patıents and Other hemothorax. Thorax CT
Thoracic
Considerations showed thoracic vertebrae
Some diseases may predispose a person
to cervical injury. Rheumatoid arthritis spinous process fracture.
may cause C2 transverse ligament
rupture. Atlantooccipital dislocation is
Spine Critical Bedside Actions and
General Approach
Injuries
seen with Down syndrome
Please refer to cervical spinal injuries
Patients with long-term corticosteroid use section.
or osteoporosis are predisposed to
Case Presentation
fractures. Differential Diagnosis
A 40-year-old male presented • Spinal cord injuries
Disposition Decision to the emergency department
• Thoracic Ligamentous injuries
Admission
after a motorcycle accident.
503
• Vertebral artery injuries • A scapular injury is an indicator of high •Flexion-rotation injuries: occur with a
energy trauma. In case of scapular posterior ligament injury.
• Rib fracture
injury, consider a thoracic spine injury.
• Shear injuries: Posterior anterior, lateral
• Pneumothorax
• Remember that spinal cord damage listezis occur with ligament injury.
• Scapula fracture may lead to spinal and neurological
shock. Emergency Diagnostic Test
History and Physical and Interpretation
• Learn the mechanism: Thoracic Patients who have vertebrae pain, midline
Examination Hints
vertebra injuries are classified as sensitivity, bone deformity, neurologic
• Thoracic injuries mostly occur with
flexion, extension, rotation, shear, deficit, more than 60 years old and high-
high-energy mechanisms, namely,
distraction and axial compression energy mechanism requires imaging.
motorcycle accidents, fall from height
injuries according to their mechanisms.
and gunshot injuries.
Anteroposterior (AP) and Lateral X-rays:
• Flexion injuries: occur with anterior AP images show lateral pedicles. Lateral
• First, immobilize the patient if he is not
compression. Instability is associated images show subluxations, compression
on a backboard. A vacuum splint or
with the posterior ligament injury. fractures (Image 1) and chance fractures.
scoop stretchers is useful. Logroll
Wedge fracture is an example. It is the
(video) the patient for examination. For
most common fracture in the thoracic Computed Tomography (CT): Patients
logrolling, a leader and three assistants
spine. with a neurologic deficit or altered mental
should be available.
status require CT.
• Extension injuries: are anterior ligament,
• Examine the patient’s vertebrae for
facet, laminar, spinous process injuries. Magnetic Resonance Imaging (MRI):
m i d l i n e s e n s i t i v i t y, s w e l l i n g ,
Patients with the suspected ligament,
ecchymosis, step-off sign. Additionally, • Axial compression injuries: are burst disk or epidural space injuries require
check the motor and sensory function fractures and occur with high-energy MRI.
and deep tendon reflexes. mechanisms.
504
Emergency Management Disposition Decision a history of corticosteroid
• Check immobilization
Admission usage. Vital signs are normal.
• Remove backboard if there are no signs Patients with spinal and neurogenic On her examination, she had
of injury. Prefer a sliding board instead shock symptoms should be admitted to
pain on her back at the level of
of backboard when prolonged the intensive care unit.
immobilization needed (i.e. the risk of
lumbar 2-3. The lateral X-ray
injury continues). Discharge showed an L2 compression
Patients with stable fractures and no
• Provide full monitoring, especially in neurologic deficits may be discharged
fracture.
patients with spinal or neurogenic after the consultation with neurosurgery
shock or phrenic nerve paralysis. or orthopedic department. Referral to
Critical Bedside Actions and
these clinics should also be planned.
General Approach
• Flexion restriction braces (Jewett or Please refer to spinal injuries section.
Knight-Taylor) is recommended if there
is no stable angle fracture.
Lumbar Differential Diagnosis
• Spinal cord injuries
Spinal
Medications
• Lumbar spine injuries
Please refer to cervical spinal injuries
section. • Spinal epidural hematoma
Disposition Decision
Admission
Admit patients with shock and
intraabdominal organ injuries to intensive
care unit.
Discharge
Patients with a simple transverse sacral
fracture, isolated spinous fracture or
isolated transverse process fracture may
507
Section 5
508
anterior glenohumeral Differential Diagnosis Image 12.34 Clavicle fracture
Fractures: Proximal end of the humerus
dislocation. The dislocation
(the most frequently injured bone of the
was reduced in the emergency shoulder) [Image 12.33] , clavicle (80 %
room. being middle-third fractures) [Image
12.34], scapula [Image 12.35].
Critical Bedside and General
Approach Image 12.33 Proximal humerus
Preserving function, preventing infection fracture Image 12.35 Scapular fracture
and assuring perfusion of the limb should
be the goals. Proper diagnosis and
treatment are essential for establishing
these goals.
509
s u p e r i o r ) [ F i g u re 4 ] , f o l l o w e d b y Shoulder instability may be subtle or usually misreferred to as cardiac,
acromioclavicular, sternoclavicular. obvious subluxation or dislocation. biliary or abdominal pathology.
514
fracture leads to the loss of regular Emergency Diagnostic Tests epiphyses and ossification centers.
olecranon prominence. and Interpretation To identify fractures, physeal injuries and
Plain radiographs should be obtained in dislocations ultrasound is a useful tool.
Gradual onset of dull ache at the elbow
three views of plain x-rays – AP, lateral, Children with lateral condyle fractures
happens with epicondylitis. This pain
and lateral oblique are necessary. AP may benefit from an MRI.
increases with grasping and twisting of
view shows the epicondyles (medial and
the elbow. Emergency Treatment
lateral) and the articular surfaces.
With the elbow in a 90° flexion, the radial (radiocapitellar and ulnotrochlear) The Options
head, tip of the olecranon and the lateral lateral view provides the relation of the Initial Stabilization
epicondyle normally form an equilateral bones of the distal humerus and proximal Before taking radiographs, to prevent
triangle. Fracture of the radial head, forearm. The radiocapitellar joint, medial further injury, immobilization should be
olecranon or the lateral epicondyle alters epicondyle, radioulnar joint, and coronoid performed. Please refer to “Critical
this relationship. process view with the lateral oblique. Bedside And General Approach” part in
the topic “shoulder.”
A complete neurovascular examination Fat pad sign: With a history of known or
should be made for the elbow and distal suspected trauma of the elbow, if there is
Medications
extremity. This examination should an abnormal fat pad sign this should be Please refer to the topic “shoulder.’’
include: sensation and strength tests of considered as an indication of an occult
t h e m e d i a n , r a d i a l , u l n a r, a n d fracture. Wide anterior fat pad, also, Procedures
musculocutaneous nerves, deep tendon known as ‘’sail sign’’ indicates an occult Supracondylar fractures:
reflexes of the biceps (C5), brachioradialis fracture. Posterior fat pad sign in an adult
• Nondisplaced fractures of children do
(C6), and triceps (C7), palpation of the indicates radial head fracture; in children
not require immediate orthopedic
brachial, radial, and ulnar pulses, the indicates supracondylar fracture. Watch
evaluation. These patients may be
range of motion and strength of the this video.
referred for follow up within a week
elbow should be examined.
X-rays of the uninjured elbow help after splinting. The family should be
distinguish fractures from the normal informed to return if an unmanageable
515
p a i n o r c o m p a r t m e n t s y n d ro m e supination/flexion and hyperpronation. olecranon, external (lateral)
happens. The latter is more successful for the epicondyle (mnemonic: CRITOE).
reduction and may be less painful.
• Displaced supracondylar fractures Disposition Decisions
generally require open or closed Epicondylitis: Once a clinical diagnosis of
reduction and percutaneous pinning for epicondylitis is made, the initial treatment Admission Criteria
monitoring of pulses, never function consists of activity modification, counter • Open fractures accompanying vascular
coldness in the region of the • Smith’s Fracture (Reverse Colles’ • Distal radioulnar joint disruption
wrist. On physical examination, Fracture): Transverse fracture of the
• Pediatric fractures of the distal radius:
distal radial metaphysis with associated
she had swelling and ‘’dinner- Torus [Image 12.41], Greenstick,
volar displacement and angulation.
fork’’ deformity. The complete fractures [Image 12.42]
• Barton’s Fracture: Oblique intra-
neurovascular examination was
articular fracture of the rim of the distal
normal. On the PA and lateral radius with associated displacement of
views of the wrist, a distal the distal radial fragment.
517
Image 12.41 Torus fracture Image 12.42 Complete shaft fracture Image 12.43 Scaphoid fracture
of radius and ulna
Carpal injuries:
519
Distal radioulnar joint disruption: A long Pediatric, Geriatric, •F r a c t u r e s w i t h c o m p a r t m e n t
arm cast is applied after closed reduction Pregnant Patient, and Other syndrome or neurovascular
compromise
Pediatric fractures of the distal radius: A Considerations
short arm splint is required for • Fractures needing immediate operative
Pediatric
immobilization. The most common fractures in children management or general anesthesia for
and adolescents are the distal radial reduction
Carpal injuries: A short arm splint with a
fractures (44). Commonly growth plate
thumb spica is required for • Fractures associated with soft tissue
injuries occur with the distal radius
immobilization. complications
fractures leading to physeal injuries (45).
Carpal tunnel syndrome: The wrist is The most important aspect of these • Fractures associated with circulatory
splinted in a neutral position and physeal fractures is premature closure deterioration in the hand
cortisone injections are given additionally and growth arrest of the injury site.
into the carpal tunnel. Discharge Criteria
Geriatric • Appropriate reduction and
De Quervain’s Disease: for mild and Distal radius fractures in older patients immobilization
moderate forms conservative should be screened for osteoporosis.
• Orthopedic follow-up should be
measurements such as rest of the arm in Also, distal radius fractures in an senior
arranged
elevated position, splinting, NSAIDs and man is an early and sensitive marker of
corticosteroid injections into dorsal skeletal fragility (47). Subsequent • Pain control measures should be taken
extensor compartment of the wrist may fractures are prevalent and treatment of adequately
be sufficient. underlying osteoporosis in this population
group is required. • Cast or splint care instructions should
be given at discharge and should be
Disposition Decisions assured the patient understands them.
Admission Criteria
• Open fractures
520
• After ED treatment, the documentation of intact neurovascular
function is performed.
Referral
For a close follow-up, all fractures discharged from ED should be
referred to an orthopedic surgeon.
521
Chapter 13
Selected
Infectious
Problems
Section 1
Epiglottitis
Case Presentation
by Kuan Win Sen A 62-year-old man presents to the ambulatory area of the
emergency department complaining of sore throat, fever, and
chills. He has history of type 2 diabetes mellitus, hypertension,
and obesity. He was seen by the general practitioner (GP) 2
days prior and was prescribed thymol gargle and paracetamol.
Further history reveals progressive difficulty and pain in
swallowing, decrease in appetite, and worsening sore throat
since the GP visit two days ago. On physical examination, he
is alert, has a temperature of 39.1C, heart rate of 112 per
minute, blood pressure of 136/74mmHg, respiratory rate of 18
per minute and oxygen saturation of 98% on room air. He
speaks with a muffled voice and has drooling of saliva. There
are no obvious findings in the oropharynx and no cervical
lymphadenopathy. The rest of the physical examination is
unremarkable.
523
Critical Bedside Actions and • Laryngotracheitis (croup) Patients with croup have a “barking”
525
Section 2
Meningitis
Case Presentation
by Alja Parežnik A 55-year-old previously healthy woman presented with fever,
headache, vomiting, and photophobia for three days. One
week earlier, she started to complain about a sore throat and
pain in the right ear. Neurological examination revealed
diminished consciousness and neck rigidity. Lumbar puncture
was performed and in CSF found >10.000 leukocytes/mm3.
Direct examination of CSF showed Gram-positive cocci in
chains and culture yielded S. pyogenes. The patient had
treated with Ceftriaxone (4 gr/day).
526
Introduction • through stool (enteroviruses), common pathogen since routine
Meningitis is an inflammation of the immunization of infants with H. influenzae
• through coughing and sneezing,
membranes of the brain and spinal cord. type B began in 1992. Table 13.1
It can be related to infectious and • through kissing, sexual contact or presents the most common bacteria and
noninfectious causes. The infection agent contact with infected blood, their specification. M. tuberculosis,
is usually bacteria or virus, and S.aureus, Borrelia burgdorferi and gram
• from eating a specific food (Listeria negative bacilli are among the rare
occasionally fungus. Additionally;
monocytogenes), causes.
physical injury, autoimmune disorders,
cancer or certain drugs can cause • from rodents and insects (leptospirosis Viral meningitis is much more common
meningitis . by mice, hamsters, rats and West Nile than bacterial. It tends to be less severe
virus through mosquito bites). and usually recovers completely without
Pathogenesis
Bacteria can breach the blood-brain specific therapy. Most common viral
Etiology
barrier (BBB) to infect the meninges by pathogens causing meningitis are;
The severity of illness and the treatment
direct spread, or contiguous infection differ depending on the cause. • Enteroviruses (Coxsackie, echoviruses)
(from a source such as the sinuses or
middle ear), trauma, neurosurgery, or Bacterial meningitis is a life-threatening • Arboviruses (KME, West Nile),
indwelling medical devices. neurological and infectious emergency. It
can lead to death within hours. Bacterial • Herpes viruses (HSV-1,2, VZV, EBV,
Nasopharyngeal colonization from
meningitis can lead to long-term CMV)
infected droplets of respiratory secretions
or distant localized infection (lungs, urine) problems, like hearing loss, vision loss,
• Others (mumps, HIV, parvovirus,
with subsequent bloodstream invasion, problems with memory and rotavirus, etc)
are other sources of infection. concentration, epilepsy, coordination,
movement and balance problems, Fungal meningitis is rare form and
Pathogens causing meningitis can be learning difficulties and behavioral generally occurs only in
spread in different ways: problems. In community-acquired immunocompromised people.
meningitis, S. pneumoniae is the most
• during birth from mother to her baby,
527
•malaria,
Table 13.1 Main common bacterial pathogens in meningitis and their specifications
NEISSERIA STREPTOCOCCUS HAEMOPHILUS LISTERIA • cancer of meninges,
MENINGITIDIS PNEUMONIAE INFLUENZE MONOCYTOGENES
Age Children, adults Children, adults Adults, not older, newborns, • vasculitis of CNS.
(living in crowded vaccinated pregnant women,
spaces) children immunocompromised
History and Physical
Vaccine yes yes yes
Examination Hints
Associated Sore throat Ear infection, Sinusitis The classic triad with fever, neck
diseases sinusitis,
pneumonia stiffness and altered mental status is
Characteristics Petechial rash, Rash, Rash present in only 44% of cases. However,
muscle pain and Neurological the absence of all of the triad almost
weakness changes (seizures,
focal) eliminates the possibility of meningitis.
It is essential to perform LP as soon as WBC (white blood cells) <5 >1000 <1000 <1000
possible. In some cases, LP is delayed Differential (neutrophils) <15% >80% <15% <15%
due to imaging, limited resources, signs CSF glucose (mg/dL) 45-65 reduced normal reduces
of severe sepsis or rapidly evolving rash, CSF protein (mg/dL) 20-45 >250 50-250 >250
severe respiratory or cardiac compromise
Opening pressure <20 Normal to high, Normal to high
and significant bleeding risk. It is prudent Normal to high
(cmH20) typically 15-30
to give empiric antibiotic therapy first. In Gram stain +
pneumococcal meningitis, an PCR +
approximate window to perform an LP
Quattromani EN, Aldeen AZ. Focus on: emergent evaluation and management of bacterial meningitis.
after antibiotic administration is 4-10 American college of emergency physicians news. 2008 May[updated 2014]. https://www.acep.org/
Clinical---Practice-Management/Focus-On--Emergent-Evaluation-and-Management-of-Bacterial-
Meningitis/. Accessed April 18, 2016.
530
Emergency Treatment • Penicillin/Cephalosporin anaphylaxis: Dexamethasone, 0,15 mg/kg (max.
531
Prevention and prophylaxis Pediatric, Geriatric and and has a fever, has bacterial meningitis
Patients hospitalized with suspected N. Pregnant Patients until proven otherwise.
meningitidis infection or meningitis of An atypical presentation is common in
Laboratory findings in blood and CSF can
uncertain etiology require droplet elderly (>65 years) as lethargy, the
be normal in extreme ages.
precautions for the first 24 hours of absence of fever and minimal signs of
treatment or until N. meningitidis can be meningismus. Older adults and people Disposition Decisions
ruled out. with additional medical conditions may Admission criteria: If there is clinical
only present with a slight headache and suspicion of meningitis, patients should
Those who came in close contacts with
fever or general weakness. be admitted for further workup and
an infected person, especially with N.
treatment.
meningitidis or H. influenzae, give Neonates, infants and young children
Rifampin (600mg/12h oral for 2 days; usually show poor feeding, irritability, and ICU Referral: Patients with signs of shock
children >1year 10 mg/kg/12h, <1year 5 fever. In babies, a fever, irritability, or septicemia must be admitted to
mg/kg/12h) or Ciprofloxacin (500mg oral, decreased appetite, rash, vomiting, and a Intensive unit care (ICU). These signs
1 dose 250mg for child 5-12 years). In shrill cry may point to meningitis. Other include capillary refill time more than 4
pregnancy give a single dose of signs include stiff body and bulging soft seconds, unusual skin colour or rapidly
Ceftriaxone 250mg IM or ciprofloxacin spots on the head that aren’t caused by progressive rash, systolic hypotension
500 mg oral. crying. Babies with meningitis may cry <90mmHg, pulse rate <40 or >140/min,
when handled. respiratory rate <8 or >30/min, acidosis
Procedures pH < 7,3 or base excess more negative
If there is suspicion of bacterial Young children with meningitis may have
than -5, white blood count < 4×109/L,
meningitis, the emergency physician flu-like symptoms, cough or respiratory
lactate > 4mmol/L, GCS < 12 or a drop of
should perform tasks in the following distress. In children, history of respiratory
2 points, moribund state, altered mental
order: blood cultures, steroids, tract infection is common, and they are
state/decreased conscious level, poor
antibiotics, CT and LP also more likely than adults to experience
urine output, poor response to initial fluid
a seizure. When a child is looking sick
resuscitation.
532
References and Further Reading, click here
533
Section 3
Sinusitis
Case Presentation
by Katja Žalman and Gregor Prosen The 32-year-old married woman presented with nasal
stuffiness with yellow nasal drainage, pain over the cheek,
obstructed nose, facial pain and pressure, subjective fever
and chills, mildly productive cough and overall malaise for ten
days. She has used over-the-counter medication without
significant benefit. She smoke three packs of cigarettes per
week. She takes no medications and denies chronic medical
diseases.
534
edema or erythema. The tympanic membranes Introduction
Sinusitis is one of the most common infections treated by
are neither bulging or retracted; the ear
emergency physicians and affects about 1 in 8 adults in the north
landmarks are easily identifiable. The neck is America. It is the fifth most common diagnosis for which
supple without lymphadenopathy. The chest is antibiotics are prescribed.
A healthy sinus is sterile and lined with a thin layer of mucus that
traps dust, germs and other particles in the air. Tiny, hair-like
projections in the sinuses seep the mucus towards ostial opening
that leads to the back of the throat, and then they slide down to
the stomach.
535
documentation of sinonasal from tumors, abnormal anatomy, weaker with acute rhinosinusitis is to
inflammation may be achieved using immune system, nasal polyps and also eradicate infection, decrease severity and
anterior rhinoscopy, nasal endoscopy or nasogastric and nasotracheal intubation. duration of symptoms and prevent
computed tomography. The primary pathogens responsible for complications.
acute bacterial and recurrent ARS are
The different subgroups of acute Differential Diagnosis
Streptococcus pneumonia, non-typable
rhinosinusitis are based on the duration The diagnosis of rhinosinusitis consists of
H. influenza, and M. catarrhalis.
of symptoms and signs, into acute the combination of clinical history,
bacterial rhinosinusitis (ABRS) or viral In chronic sinusitis, however, anaerobic physical examination, imaging studies,
rhinosinusitis (VRS). Four or more bacteria, streptococcal species, S. aureus and laboratory tests.
episodes of rhinosinusitis per year, and also fungi (Rhizopus, Aspergillus,
without persistent symptoms in between, Candida, Histoplasma, Blastomyces, Conditions that predispose to
the state is termed as recurrent ARS. Coccidioides, and Cryptococcus species) rhinosinusitis are
play role. • Allergic and nonallergic rhinitis
The acute rhinosinusitis is most
frequently (90%) associated with viral • Anatomic abnormality of the
Critical Bedside Actions and
upper respiratory tract infection. It is the ostiomeatal complex
General Approach
most important risk factor for the First, check conditions and vital signs of • Aspirin sensitivity
development of acute bacterial sinusitis the patient, and stabilize them if
and it is most often caused by rhinovirus, necessary. The most of the patients are • Associated conditions: asthma, otitis
c o r o n a v i r u s , i n flu e n z a A a n d B , rarely need any intervention during the media
parainfluenza, respiratory syncytial virus, primary evaluation (ABC) stage. When the
• Churg Strauss sydrome
adenovirus, and enterovirus. patient is stable, we can continue with
taking the history and physical exam, list • Cilliary dyskinesia,
The most common occlusions that leads
of differential diagnoses, general
to bacterial overgrowth and excess • Cocaine abuse
diagnostic and appropriate treatments.
mucus production are allergies, trauma
The acute care of a patient diagnosed • Cystic fibrosis
and fractures, mechanical obstruction
536
• GERD • Concha bullosa and other middle •signs and symptoms (major and
turbinate abnormalities minor)
• Immune diseases and
immunocompromised status • Infectious rhinitis (viral upper tract • questions on allergic symptoms
infections) (sneezing, watery rhinorrhea, nasal
• Instumentation (nasogastric and
itching and itchy watery), asthma and
nasotracheal intubation) • Nonallergic rhinitis (vasomotor rhinitis,
immunocompromising disorders
aspirin tolerance, eosinophilic
• Kartagener syndrome,
nonallergic rhinitis • history of previous episodes of
• Nasal anatomic variants rhinosinusitis
• Rhinitis medicamentosa
• Nasal polyps (decongestants, β – blockers, birth • history or possibility of trauma,
control pills, antihypertensives) fractures, nasal anatomic variants and
• Rhinitis medicamentosa anatomic abnormality of the
• Rhinitis secondary to: pregnancy,
ostiomeatal complex
• Trauma hypothyroidsm, horner sindrom, weger
granulomatosis – midline granuloma • active or passive smoking
• Tumors
• Tumors • current medications
• Young syndrome
• Vascular headache (migraine) Symptoms associated with rhinosinusitis
Differential diagnosis of
are divided into major and minor groups.
rhinosinusitis History and Physical Combinations of these symptoms provide
• Allergic rhinitis (seasonal, perennial)
Examination Hints a diagnosis based on the patient’s
• Anatomic abnormalities (foreign body, Before we start the focused physical history, viewed by anterior rhinoscopy, or
nasal polyps, nasal septal deviation, exam, which is based on an examination as a postnasal discharge on pharyngeal
enlarged tonsils and adenoids) of the respiratory system, we have to take examination.
a look at a patient’s history and have to
• Cerebral spinal fluid rhinorrhea be especially focused on: Major Symptoms
537
• Facial pain/pressure/fullness should distinguish between viral •When symptoms or signs (PODS) –
rhinosinusitis (VRS) and bacterial ABRS. It the presence of ≥ 2 PODS symptoms,
• Fever (for acute sinusitis only)
can be difficult to distinguish between one of which must be O or D of ARS
• Hyposmia/anosmia acute viral from acute bacterial sinusitis. lasting for more than 10 days but less
than 30 days without any evidence of
• Nasal obstruction/blockage P – Facial pain, pressure or fullness (may
clinical improvement.
involve the anterior face, periorbital
• Nasal or postnasal discharge/purulence region or manifest with headache) • Onset with severe symptoms or signs of
high fever (≥39°C [102°F]) and purulent
Minor Symptoms O – Nasal obstruction (congestion, (infected, colored or oozing) nasal
• Cough blockage, stuffiness) discharge or facial pain lasting for at
• Dental pain D – Nasal purulence or discolored least 3–4 consecutive days at the
beginning of the illness.
• Ear pain/pressure/fullness postnasal discharge (infected, colored,
oozing) • Onset with worsening symptoms or
• Fatigue
signs characterized by the new fever
S – Hyposmia or anosmia (smell)
• Fever (for subacute or chronic sinusitis) (fever is present in some patients with
Acute rhinosinusitis typically progresses VRS in the first few days of illness but
• Halitosis over a period of 7 to 10 days; it is mostly does not predict bacterial infection as
self-limited and resolves spontaneously. an isolated diagnostic criterion – it has
• Headaches
a sensitivity and specificity of only
During a viral upper respiratory tract
Acute rhinosinusitis is diagnosed when a about 50% for ABRS), headache, dental
i n f e c t i o n , t h re e c o m m o n c l i n i c a l
patient presents with up to 4 weeks of pain, or increase in nasal discharge,
presentations should guide the clinician
purulent nasal drainage, nasal following a typical viral upper
to think that it is an episode of acute
obstruction, facial pain-pressure-fullness, respiratory infection (URI) that lasted 5–
bacterial sinusitis: persistent symptoms,
or all of these symptoms. When a patient 6 days and were initially improving
s e v e r e s y m p t o m s , o r w o r s e n i n g
meets the criteria for ARS, the clinician (“double-worsening”).
symptoms.
538
Chronic rhinosinusitis is diagnosed when deemed unreliable. Endoscopy provides Ultrasound is safe, rapid and
a patient presented greater than 12 ideal direct visualization of the nasal noninvasive for evaluating only the
weeks of anterior or posterior cavity, and anatomical structures such as maxillary and frontal sinuses. The A-
mucopurulent drainage, nasal Eustachian tube orifice, tonsils, posterior mode may be useful for screening the
obstruction, facial-pain-pressure-fullness tongue, epiglottis, glottis, and vocal fluid in the maxillary sinus, and the B-
and decreased the sense of smell. cords. The nasal polyps can be identified, mode detecting fluid in the cavity,
as well as the presence of purulent ostial mucosal thickening, or soft tissue mass in
Invasive fungal sinusitis usually occurs in
s e c re t i o n s . E n d o s c o p y i s u s u a l l y the maxillary sinus.
immunocompromised patients and
performed by otolaryngologists.
patients with diabetes. It is generally X-rays is not recommended for patients
Therefore, emergency physicians should
associated with fever, nasal pain, cloudy who have already met the clinical
chose the patients who needs proper
rhinorrhea, and affected turbinates by diagnostic criteria for ABRS. Radiography
referral.
dark, thick and greasy material. cannot be used to distinguish between
Emergency Diagnostic Tests bacterial and viral etiologies.
The anterior rhinoscopic examination is
best performed after the application of a and Interpretation
X-rays includes 3 different
topical decongestant. The status of the Imaging projections:
nasal mucosa, the presence and color of In the majority of patients with • Waters view (occipitofrontal) – for
nasal discharge should be evaluated. rhinosinusitis, radiographic imaging is maxillary and frontal sinuses
Predisposing anatomical variations can unnecessary in case of meeting
• Caldwell view (angled posteroanterior) –
also be noted during anterior rhinoscopy. diagnostic criteria for acute rhinosinusitis.
only that visualizes the ethmoid air cells
Imaging procedures are useful when
The endoscopic examination should be
symptoms are vague, in poor response to • Lateral view – visualize the sphenoid
used in selected patients with chronic or
initial management, comorbidities that sinus and primary for adenoids in
recurrent sinusitis, in the patient with
predispose complications, atypical children
rhinosinusitis who do not respond to
presentation and a history of trauma.
therapy as expected, and in younger
children in whom a medical history is
539
Radiographic findings of acute CT is not used for routine evaluation and 50% of patients with a recent upper
sinusitis are; is limited to chronic and recurrent respiratory infection have abnormal
sinusitis, causes of questionable findings on CT scan. On the CT with
Image 13.2 diagnose, patients with unresponsive
disease, immunocompromised patients Image 13.4
with fever, dentomaxillary pain or
investigation of complications (severe
headache, facial swelling, cranial nerve
Image 13.3
• Diffuse opacification,
acute rhinosinusitis, we can find
• Mucosal thickening (>4 mm), or an air- opacification, air-fluid level, and severe
fluid level. mucosal thickening.
Case courtesy of A.Prof Frank Gaillard,
• Mild-to-moderate mucosal thickening, Radiopaedia.org. From the case rID: 4890 MRI is not used for routine evaluation.
however, is a nonspecific finding. MRI is a sensitive technique for
palsies, or forward displacement or
evaluating suspected fungal sinusitis and
bulging of the eye – proptosis). More than
540
for differentiating between inflammatory Emergency Treatment The clinician must also consider the
disease and malignancy. Options p a t i e n t ’s a g e , g e n e r a l h e a l t h ,
cardiopulmonary status, and comorbid
Laboratory Tests Viral rhinosinusitis (VRS) conditions when assessing suitability for
Complete blood cell count (CVC) is treatment watchful waiting.
g e n e r a l l y n o t s p e c i fic , a n d i t i s Viral rhinosinusitis is a self-limited disease
unnecessary for the majority of patients that occurs from 2 to 5 times per year in When we decide to treat ABRS with an
with uncomplicated rhinosinusitis. In the average adult. Decongestant therapy antibiotic, the commonly used drug for
most cases, the results show that the such as topical steroids, topical and/or children and adults is amoxicillin (with or
CBC may be within normal ranges. oral decongestants, which can not be without clavulanate as first-line therapy).
used more than 3 to 5 day, mucolytics, A period from 5 to 10 days regimen of
Higher level of erythrocyte sedimentation
and intranasal saline spray. They may be amoxicillin 500 mg, 2 times a day is
and C-reactive protein level can be seen
used alone or in varying combinations. recommended by many as the first-line
in patients. Both of them are not specific.
Analgesics or antipyretic drugs therapy. The acute sinusitis generally
Nasal cytology can be useful with variety (acetaminophen, ibuprofen, or other responds to treatment from 10 to 14
of syndromes, including allergic rhinitis, nonsteroidal anti-inflammatory agents) days. Some physicians continue
bacterial sinusitis, eosinophilia, nasal may be given for pain and fever. treatment for 7 days after the patient is
polyposos, and aspirin sensitivity. well to ensure complete eradication of the
Bacterial rhinosinusitis (BRS) organism and prevent relapse.
The culture of secretions from the nasal treatment
cavity or nasopharynx do not differentiate Delaying antibiotic treatment of ABRS for For patients who do not respond to
ABRS from VRS and are not routinely up to 7 days after diagnosis is the current amoxicillin, allergic to or intolerant of
obtained unless in immunocompromised, approach. This allows the infection get amoxicillin, live in communities with a
intensive care patients and patients with better on its own. If not, prescribe initial high incidence of resistant organisms,
complications of rhinosinusitis. antibiotic therapy for adults with failure to respond within 48-72 hours,
uncomplicated ABRS. persistence of symptoms beyond 10-14
day the second-line therapy is the most
541
commonly used, which include cephalosporins, macrolides or
quinolones.
References and Further Reading, click here
Adjunct therapy such as intranasal saline irrigations, intranasal
corticosteroids and local topic decongestants (oxymetazoline
hydrochloride) is recommended. Topical agents should be used
for up to 5 days; as extended use results in rebound vasodilation
and nasal obstruction, the condition is termed as “rhinitis
medicamentosa.” Antihistamines are not recommended as
adjunct therapy unless there are patients with a history of allergic
rhinosinusitis.
Disposition Decisions
Patients with uncomplicated rhinosinusitis can be discharged
home with prescription for decongestant therapy, nonsteroidal
anti-inflammatory drugs and in the case of ABRH with
appropriate antibiotics. All other patients with complications
require additional work-up or admission.
542
Section 4
Sepsis
Case Presentation
by Emilie J. Calvello Hynes 74 y/o female with history of diabetes, hypertension and
coronary stent placement presents with confusion and cough.
She has had a cough for 2 days and saw her primary care
doctor who prescribed an antibiotic. Her husband describes
her as behaving normally until today 3 hours prior to
presentation. She is taking Insulin, Lisinopril, Aspirin,
Metoprolol, and Azithromycin. There are no allergies to
medications.
543
sounds are regular but Introduction and Definitions t oprompt the right treatment
In the last 20 years, the collective interventions.
tachycardic. Her abdomen is
understanding of sepsis care has gone
flat and non-tender, and her P r i o r d e fin i t i o n s o f s e p s i s w e r e
through a major transformation. The term
predicated on the inflammatory response
neurological exam reveals no sepsis describes a physiologic syndrome
from the host, termed the systemic
focal deficits. with characteristic biochemical
inflammatory response syndrome (SIRS).
abnormalities initiated by infection. While
the mortality from sepsis in many high- Systemic Inflammatory
income countries is decreasing, the Response Syndrome
reported incidence has found to be
increasing due to aging populations as
well as greater attention paid to early Two or more of the following
Identification of these patients should * Because of higher vascular tone, neonates and children may be in a shock state long before
manifestation of hypotension.
prompt further diagnostic evaluation for
end-organ damage. The definition of septic shock has been simplified as a subset of sepsis in which underlying
545
circulatory and cellular/metabolic • Check glucose •Congestive heart failure
abnormalities are profound enough to
• Start 2 L IV Fluid bolus (LR or NS) for • Pulmonary embolism
increase mortality substantially. These
adults or 20 mL/kg for pediatrics
patients are identified by persistent • Acute respiratory distress syndrome
(unless malnourished)
hypotension and having lactate greater
than 2 mmol/L after fluid resuscitation. Of • Be prepared to assist with airway Environmental
note, the term severe sepsis should no • Heat stroke
patency or protection (i.e., intubation) if
longer be used as all sepsis is considered necessary • Burns
to have a high probability of being severe.
• Prepare broad-spectrum antibiotics for
Endocrine
Critical Bedside Actions and administration within the first hour
• DKA
General Approach
For the critically ill patient, you must Differential Diagnosis • Adrenal crisis
make a rapid determination of syndromic
Differential Diagnosis of Sepsis • Thyrotoxicosis
category of their acute illness. If they
– non infectious etiologies
meet the above definition of sepsis and • Pancreatitis
there is a concern for ongoing shock, Shock states
• Cardiogenic shock • Hypoglycemia
proceed to the critical bedside actions.
546
Neurologic Table 13.4 Findings Associated with an Physical Exam Signs
• Status epilepticus Infectious Source • Vital Signs: Tachycardia, fever, low BP,
FINDING SOURCE tachypnea
• Cerebral hemorrhage
Pulmonary findings Pneumonia,
empyema, • Poor perfusion: hot or cool skin, altered
History and Physical Exam parapneumonic mental status, poor urine output (<0.5
effusion
Hints mL/kg/hr), weak pulses,
Urine appearance URI, pyelonephritis,
infected renal calcluli
History • Pediatric-specific: skin mottling,
• History of immunocompromise (HIV, Skin findings Cellulitis, abscess,
(wounds, rash, meningococcus, viral delayed capillary refill skin, poor urine
chemotherapy, etc.), alcoholism, crepitus, bullae) or tick borne disease, output (<1 mL/kg/hr)
malignancy, liver disease, diabetes, gangrene, necrotizing
fasciitis
ongoing steroid use, intravenous drug • Associated finding less likely to be non-
Focal neurologic Cerebral abscess,
use deficit epidural abscess infectious source: chest pain, evidence
of DVT, evidence of ingestion (pill
Bony findings (pain or Myositis, discitis,
• Travel history, vaccination status asymmetry in osteomyelitis, septic fragments)
extremities) joint
• Recent illness, sick contacts Peritoneal signs Intra-abdominal Emergency Diagnostic Tests
abscess/
• History associated with source: cough, inflammation, and Interpretation
perforation,
dysuria, shortness of breath, chest pain, spontaneous bacterial
peritonitis
Labs
abdominal pain, vomiting, diarrhea,
• Specific derangements in sepsis:
back pain, decreased urine output, Heart findings (rub, Pericarditis,
murmur) endocarditis creatinine, LFTs, bilirubin, platelets,
focal neurological deficits, rash or skin
Stridor Epiglotitis, tracheitis, coagulation studies
changes, change in mental status croup
• Serial serum lactates
• Pediatric-specific: increased work of Vaginal discharge Pelvic inflammatory
disease, endometritis,
breathing, decreased PO intake, septic abortion,
chorioamnionitis
change in behavior
original by the author
547
• Source testing (guided by H&P): UA, • spine MRI, Hydroxyethyl starch should be
CSF, pleural, intraperitoneal, synovial avoided.
• extremity X-ray
fluid
Albumin may be used if indication AFTER
• Cultures: Blood, urine Emergency Treatment adequate crystalloid resuscitation.
Options
• CSF, body fluid if indicated Mortality for sepsis and septic shock can Monitor for signs of fluid overload
be as high as 40-50%. Decreases in (increasing hypoxia, rales, hepatomegaly
• Cultures are positive in sepsis only
mortality are accomplished via two goals: in children).
30-40% of the time
1. Restore tissue perfusion Oxygenation
• Special tests (if indicated): malaria,
dengue, viral hemorrhagic fever, etc. 2. Locate and treat infectious source Target saturation of > 90%
548
Norepinephrine (0.01-3 mcg/kg/min) the • Remove catheters and lines Pediatric, Geriatric,
preferred choice, with the recommended associated with infection. Pregnant Patient and Other
second agent of epinephrine (0.1 – 1
Timing Considerations
mcg/kg/min) or vasopressin (0.03 units/
min) Critically ill patients should have
Pediatric
Neonates and immunocompromised
antibiotics given within 1 hour.
Steroids (sickle cell, oncology, diabetic and HIV)
Do not delay antibiotics for testing! patients are at particular risk for
Consider for those with MAP < 65 mmHg
overwhelming infection.
despite fluid and vasopressor therapy. Antibiotics
Controversy exists regarding fluid
Hydrocortisone (adults – 200 mg, Choice of antibiotics driven by local
management in developing countries with
pediatric 1-2 mg/kg) or equivalent resistance patterns, region-specific
high malaria prevalence rates with fluid
epidemiology (HIV, malaria, influenza, etc.
Locate and treat infectious boluses found to increase mortality.
prevalence), and availability of drugs
source
For respiratory distress and hypoxemia,
Those with septic shock should always
make early use of high flow nasal cannula
include broad-spectrum coverage (gram
Location and CPAP while starting resuscitation.
positive, gram negative, anaerobes).
• Guided by history and physical Extracorporeal Membrane Oxygenation
Consider antimalarials where appropriate.
(ECMO) may be considered for refractory
• Source control: pediatric shock and respiratory failure.
Consider specific anti-viral therapy when
• Debride or drain any localized source appropriate (i.e., acyclovir for
Geriatric
of infection; surgical consult for meningoencephalitis, oseltamivir for
Increased risk factors due to
deeper infections such as influenza in the immunocompromised
comorbidities, endocrine deficiencies,
intrabdominal abscess or empyema. host).
pre-existing malnutrition, and age-related
immunosenescence.
549
Diagnosis may be more difficult as the References and Further Reading, click
initial inflammatory response to infection here
may be blunted or absent.
Pregnant
The etiology of sepsis in pregnant women
is expanded and includes septic abortion,
chorioamnionitis/endometritis, group A
Streptococcus infection, particular
susceptibility to influenza and necrotizing
vulvitis.
Disposition Decisions
All patients with suspected sepsis should
be admitted.
550
Chapter 14
Selected
Toxicologic
Problems
Section 1
Opioid Overdose
Case Presentation
by Aldo Emigdio Bartolini Salinas and Jesús A 22-year-old male was brought to the emergency room by
Daniel López Tapia
EMS at 7 pm. His parents arrived at the hospital and
mentioned that this was not the first time their son had a
similar event. The patient was lethargic upon his arrival so
clinical history was difficult to obtain from the patient and the
parents had no additional information to provide.
552
were needle marks on both of his forearms. The and medicinal settings. Unfortunately, opioid derivatives such
as prescription drugs and “recreational” drugs like heroin have
rest of the systematic evaluation was normal.
been motive of abuse and intoxication, being the number one
Electrocardiogram and laboratory studies were illicit drug on the market with more deadly outcomes due to
made to rule out other possible diagnoses. abuse.
553
identified: mu (µ), delta (δ) and kappa (Κ). • Nalmefene Three main effects caused by opioid
An opioid-receptor like-1 is still under consumption are analgesia, euphoria, and
• Naloxone
investigation. These subtypes have a anxiolysis. Analgesia occurs by inhibiting
specific and different effect on the body. • Naltrexone transmission from the peripheral nerve to
They are capable of producing cAMP the spinal cord. Anxiolysis happens when
(adenylate cyclase), closing/opening Opioid Agonist-Antagonist opioids act upon noradrenaline releasing
calcium and potassium channels, leading neurons located in the locus coeruleus.
• Buprenorphine
to the ability to hyperpolarize the cell and Euphoria is related to the mesolimbic
modulating neurotransmitter release. • Nalbuphine s y s t e m d o p a m i n e i n c r e a s e .
Most opioids are metabolized by the liver
There are three action category; • Pentazocine
to active metabolites and excreted by the
Opioid Agonists Opioids can be consumed orally, by kidneys. They have a large distribution
snorting and by subcutaneous or volume of 1-10L/kg and are protein-
• Codeine bonded in most cases, which makes
intravenous injection. Its effects vary
depending on their site of administration, hemodialysis a problematic way for
• Diphenoxylate-atropine
dose and the type of opioid consumed. If opioid clearance.
• Fentanyl it is taken orally, it may take about six
hours to have its maximum effect History and Physical
• Heroin
(methadone) and its clinical effect may Examination Hints
Opioids affect the body in various ways.
• Hydrocodone persist for 24 to 48 hours. When snorted,
The more consistent clinical effects of
its peak effect is usually 30 minutes after.
• Loperamide opioids are a depressed respiratory rate,
When injected subcutaneously, it may
changes in mental status, decreased
• Meperidine take just about 15 minutes. It may show
bowel sounds and pupillary constriction
a n i m m e d i a t e e ffe c t w h e n d o n e
• Methadone (miosis). Additional findings include
intravenously.
hypothermia, bradycardia, hyporeflexia,
Opioid Antagonists dermal marks.
554
Pupillary constriction (miosis) is frequent intoxication). It is usually resolved once a Drug-induced toxicity
in opioid intoxication. However, normal normal respiratory rate and ventilation are
• Ethanol toxicity produces none or little
pupils or mydriasis (pupil dilation) are obtained. Cardiovascular changes,
miosis and no gastrointestinal changes.
possible when the patient takes a mostly bradycardia and hypotension is
Withdrawal produces hyperthermia and
stimulant simultaneously or when the in due to an increase in parasympathetic
seizures.
case of extended respiratory depression. activity and release of histamine. Lethal
Therefore, normal pupil examination does ventricular tachyarrythmias might occur. • Sedative-Hypnotics toxicity causes less
not exclude the possibility of intoxication. respiratory depression and ataxia in
G a s t ro i n t e s t i n a l c h a n g e s i n c l u d e
A thorough and careful examination is a children. Withdrawal produces
decreased bowel sounds, peristalsis, and
must. hyperthermia and seizures.
constipation. Additionally, renal changes,
Check respiratory rate to evaluate a particularly renal failure due to • Clonidine toxicity causes miosis,
suspected opioid-intoxication. A rhabdomyolysis may be present (from hypotension, bradycardia and no
respiratory rate below 12 bpm is a great heroin and methadone abuse). Skin gastrointestinal changes.
predictor of toxicity. The pulse oximeter marks due to “skin popping” may be
shows oxygen saturation, but a normal present secondary to subcutaneous • Hypoglycemic agents
reading does not exclude hypercapnia. injection. Changes in the reproductive
Organophosphate toxicity causes miosis,
Monitoring respiratory ventilation via end- system include changes in menstrual
vomiting, diarrhea, bradycardia,
tidal CO2 monitoring and capnography cycles, infertility, abnormal prolactin
hypotension or tachycardia and
helps to assess diagnosis and possible secretion, and decreased libido.
hypertension.
complications.
Differential Diagnoses Any medical condition that causes coma.
Noncardiogenic pulmonary edema is Generally, clinical manifestation is enough
frequent in opioid intoxication. The for diagnosis. When in doubt, laboratory Emergency Diagnostic Tests
symptoms include cyanosis, pink and imaging findings may be helpful. The and Interpretation
bronchial secretions, and rales (with all most common differential diagnoses are History and physical examination are
the additional symptomatology of the following. generally sufficient to make a diagnosis.
555
In some complicated cases, laboratory Routine urine toxicologic screens are not •L o p e r a m i d e : Q T o r Q R S
studies, urine screening tests and cardiac recommended. They confirm recent prolongation, ventricular tachycardia.
screening are recommended. abuse, but not acute toxicity.
• Oxycodone: QT prolongation.
Laboratory tests They can report many false positive
• S e r u m o r fin g e r- s t i c k g l u c o s e results. Imaging tests
Plain chest X-rays are reserved for
measurement (to rule out hypoglycemia)
Cardiac screening patients who present with symptoms of
• Serum acetaminophen concentration (in aspiration pneumonia, respiratory distress
Electrocardiographic (ECG) evaluation is
case of suspected concurrent use with syndrome, uncorrected hypoxia or
strongly recommended in patients who
opioids, to rule out suicidal attempt with abnormal sounds during lung
present palpitations, syncope, chest pain
acetaminophen) auscultation.
and dysrhythmias.
• Serum creatine phosphokinase, blood Emergency Treatment
If the initial ECG is normal, a control ECG
urea nitrogen, creatinine, urinalysis and Options
should be repeated 4-6 hours after.
s e r u m e l e c t ro l y t e s ( t o r u l e o u t
rhabdomyolysis). If the initial ECG shows abnormalities
Initial Stabilization
In an emergency setting, evaluating
such as QT or QRS prolongation, cardiac
• Serum ethanol level (to rule out circulation, airway, breathing and vital
monitoring should be done until a normal
intoxication) signs are a priority. Ventilatory support
rhythm.
should be given with a bag mask and
• Blood gas measurement.
Some specific cardiac disturbances are 100% oxygen to patients with respiratory
• Basic metabolic panel presented in the following abused distress or when the proper respiratory
substances: function has been jeopardized. If the
Urine toxicologic screenings
patient has oxygen saturation above 90%
• Methadone: torsade de pointes, QT
Opioids can be detected in urine samples and more than 12 breaths per minute at
prolongation.
in a maximum period of two days. room air, observation is adequate.
However, if oxygen saturation drops
556
below 90%, supplemental oxygen, bag mask and 0.05 mg Procedures
intravenous naloxone must be administered to restore normal Naloxone might be administered intravenously, nebulized and
ventilation. If the blood glucose is 60mg/dl or less, administer intranasally. A summary of dosage and administration route is
glucose intravenously. discussed in Table 14.1.
Medications
The first line treatment is Naloxone, a lipophilic, short-acting Table 14.1 Naloxone Administration
opioid antagonist, that can effectively reverse opiate-related INTRAVENOUS NEBULIZED INTRANASAL
NALOXONE NALOXONE NALOXONE
symptoms. Full patient history is essential to determine whether
Recommended 0.4 mg in 10 mL 2 mg in 3ml 1 mg/ml per
the patient is a long-term or short-term opioid user, the type of Dosage of normal saline normal saline naris
opioid consumed, time of administration and dosage. (0.04mg/ml). solution with a (total dose: 2mg)
Administration in standard face
separate boluses mask.
The recommended naloxone dose is 0.4 mg for most patients, of 1ml.
including those with methadone abuse. It should be diluted in 10 Pros. A gentle method Easy titration, Can be used in a
mL of normal saline to reach 0.04mg/ml dilution. Administer 1 ml of opioid lower risk of patient with
intoxication withdrawal complicated
separate boluses to improve the patients’ respiratory rate above reversal, no symptoms. intravenous
eight breaths per minute. Its clinical effects last up to acute withdrawal access.
symptoms
approximately 70 minutes.
Cons. Close monitoring No clinical data It might be
is is available. difficult to titrate
In patients that have abused fentanyl or other synthetic opioids, recommended. because of
an increased dosage is recommended. No established dosing is unknown
absorption rates
available, but some recommend increasing naloxone dose every and
bioavailability in
2-3 minutes, starting with 0.5mg -2mg-4mg-10mg and
humans.
administering a maximum dose of 15mg. Another suggested
Adopted and developed from
method of use is by administering naloxone every 2-3 minutes
Li, K., et al (2018). Annals of Emergency Medicine, 72(1), 9–11., Stolbach,
starting with 0.04mg-0.08mg-0.16mg. If respiratory rate is not A., & Hoffman, R. (2018, April 18). Acute Opioid Intoxication in Adults.
improved after maximum dose, a different diagnosis must be Retrieved from UpToDate: www.uptodate.com, and Yin, S. (2018, January
10). Opioid Intoxication in Children and Adolescents. Retrieved from
considered. UpToDate: www.uptodate.com
557
Pediatric, Geriatric, for pregnant women are codeine, o f toxicity or abuse, care must be done
Pregnant patient, and other morphine, pethidine, and propoxyphene. by a geriatrician or addictionologist.
In lactation, morphine can be
Considerations
administered, but it must be interrupted Respiratory or Hepatic
Pediatric population every 4 to 6 hours. Buprenorphine and pathology
Morphine and fentanyl might be used for Opioid use should be avoided. If used,
fentanyl are not recommended due to
moderate pain in children under 12 years close monitoring is of importance.
their high concentration in breast milk.
of age and infants, although respiratory
depression is frequent. Codeine and Opioid intoxication during pregnancy can Disposition Decisions
tramadol may be used in children older result in severe respiratory distress in
Admission criteria
than 12 years old. both the mother and the neonate. Opioid
• Opioid overdoses with short-acting
abuse causes neonatal abstinence agents may be treated in the
The treatment of opioid intoxication is syndrome characterized by low birth emergency department.
dependent on children’s weight. 0.1 mg/ weight, CNS hyperirritability, myoclonus,
kg IV naloxone (max.2mg per dose) hyperreflexia, sweating, vomiting, • Opioid overdoses with a long-acting
should be administered below 20 kg. 2 diarrhea, death, and others. Opioid (ex. methadone) agents or
mg IV naloxone is recommended over 20 intoxication during pregnancy requires a combinations must be admitted to the
kg. neonatologist in the team. ICU.
559
Chapter 15
Selected Eye
Problems
Section 1
Eye Trauma
561
Please visit this link to see detailed Eye Globe Injuries •Eyelid lacerations
Anatomy videos. 1. Open-globe injuries ( Rupture of globe)
• Retrobulbar hematoma
2. Closed-globe injuries
Illustration 15.1 Anatomy of the eye • Traumatic optic neuropathy
• Conjunctival laserations
• Ophthalmic arter injuries
• Partial thickness corneal and scleral
• Extraocular muscle entrapment
lacerations
562
concentration. Ultrasonography (USG) Image 15.1 ectopic pupil after Image 15.2 corneal foreign body
can be useful in making a diagnosis, penetrated eye trauma
especially with posterior ruptures.
Computed tomography (CT) sensitivity
ranges 56–75%. In cases of anterior
globe injuries, USG use, and if there is a
risk of a foreign metal body, magnetic
resonance imaging, are contraindicated.
Prompt ophthalmology consultation is
required. While in the emergency
d e p a r t m e n t , t e t a n u s p ro p h y l a x i s ,
analgesics, bed rest, head elevation, and Image 15.3 corneal foreign body
systemic antibiotic therapy are required. Foreign Bodies
Orbital foreign bodies are classified as
The most commonly preferred antibiotics
superficial or intraorbital. Superficial
are cefazolin and vancomycin. Age over
foreign bodies constitute the second
60 years; injury sustained by assault, on
most common general eye injury, after
the street/highway, during a fall, or by
corneal abrasions, and are the most
gunshot; and posterior injuries are
common work-related injuries. They
indications of a poor prognosis.
usually consist of earth, stone, wood and
metal pieces. Organic foreign bodies
have a higher risk of infection. Intraocular
foreign bodies (IOFB) are most commonly
observed in young males in the form of
hammering injuries. Blast injuries and
combat injuries are also frequently
observed.
563
Image 15.4 superglued eye lamp. Any buried foreign bodies should might be caused as a result of the
be removed by an ophthalmologist. If defect, relieving pain, and speeding up
there is a risk of IOFB, the patient should recovery must be targeted.
be referred to an ophthalmologist. If there Fluoroquinolones are preferred as
is an IOFB, the patient should be treated antibiotics, and oral analgesics are
as a case of globe rupture. preferred for relieving pain. Topical non-
steroids and anesthetics should not be
Corneal Abrasions
These are epithelium defects following a
Image 15.5 Fluorescein staining
non-penetrating eye trauma; they
confirms the presence of a corneal
constitute the most common eye abrasion
Diagnosis usually depends on patient pathology caused by trauma. The most
history. The patient should be asked the common cause is chronic contact lens
location and intensity of the trauma, as use. Other causes include blunt trauma,
well as time elapsed since the injury. In foreign bodies, burns, and radiation.
addition, the patient’s tetanus risk should Symptoms include stinging, burns, pain,
be determined. There may be multiple and a feeling that there is a foreign object
foreign bodies. During the diagnosis, a present. During diagnosis, a slit lamp
microscopic examination with fluorescein examination must be conducted with
must be conducted, and it must be fluorescein, and the dimensions and
determined if there is an intraocular shape of the defect must be ascertained.
foreign object. After applying local Linear defects indicate the possibility of a Courtesy of Simon Arunga. Retrieved
foreign body located in the inner part of from https://flic.kr/p/NZrhfH.
anesthesia, superficial foreign bodies can
be removed with saline irrigation or a wet the eyelid. Therefore, the inner parts of
used.
cotton swab. If unsuccessful, an attempt the eyelid must be examined for foreign
can be made to remove the object with a bodies as well. In the treatment,
25G needle under direct vision using a slit preventing bacterial superinfections that
564
Hyphema Image 15.7 Hyphaema from blunt
It is defined as bleeding in the anterior trauma.
chamber; the source of the bleeding is
the iris root or ciliary body. Although
hyphema can be caused by many
medical conditions, the most common
one is trauma. Among the causes of
566
to the retinal veins following blunt trauma. Examination findings can vary from a enophthalmos greater than 2 mm,
It is usually accompanied by retinal simple ecchymosis and edema to loss of significant hypoglobus or diplopia, and an
detachment, and the patient complains of vision. Sensitivity in the orbital wall, increase inorbital volume greater than 1
a sudden loss of vision. Fundoscopy, subcutaneous emphysema, and cm3.
USG, and CT can be used for diagnosis. irregularity in orbital rhythms can be
Treatment is surgical; although there are observed. Pupil diameters and light Orbital Compartment Syndrome
This condition is an ophthalmologic
differing views on its timing, due to high reflexivity must be evaluated. Upper and
surgical emergency that develops
TRD frequency, it is suggested that the lower eyesight restriction and diplopia
following an acute increase in intraorbital
surgery is performed at an early stage. can develop if the inferior rectus and
volume and pressure. A sudden increase
inferior oblique muscles are caught in the
Periorbital Injuries fracture line. In cases of medial wall
in pressure can cause blindness via
compression of the optic nerves and/or
fractures, patients can suffer epistaxis.
Orbital Fractures vascular structures when not diagnosed
It can occur as isolated incidents, as well When orbital pressure increases to very
at an early stage and treated. The most
as together with other facial bone high levels, optic nerve damage and loss
common causes are trauma, intraocular
fractures. The most commonly observed of vision can occur.
injections, and surgery. Orbital cellulite or
isolated orbital fracture is a blow-out The gold standard in diagnosis is CT, and abscess, orbital emphysema, foreign
fracture. There are three theories it should be used to evaluate the axial bodies, and tumors can also lead to this
regarding its formation: indirect impact and coronal planes. Fractures can condition. Orbital volume is about 30 ml,
related to increasing intraorbital pressure manifest in two ways in CT: the first one and it is surrounded by the bony orbit,
caused by trauma (hydraulic mechanism); is direct visualization of irregularity and which prevents expansion. The only
direct conveying of energy during orbital dislocations in bone cortexes, and the possibility is to expand toward the
wall trauma (the buckling mechanism); second one is visualization of air-liquid anterior, but that movement is limited by
and a combination of the two level in the sinuses around the orbit and the canthal ligaments attached to the
mechanisms. The most common air in the orbital cavity. Immediate surgery eyelids. Diagnosis is clinical. In patients
fractures are in the inferior and medial is rarely necessary for treatment. Surgical with the predisposing causes mentioned
walls. treatment indications include above, it should be considered as a
567
possibility if there are findings such as Eyelid Lacerations and toxoid should be administered
reduced eyesight, diplopia, pain, and Eyelids anatomically consist of five layers. together. Superficial lacerations can be
proptosis. Reduced eyesight, afferent The outermost layer is the thin skin layer; sutured with 6.0 nylon or polypropylene.
pupil defect, elevated IOP, painful eye beneath it is the subcutaneous tissue, Eyelids have a risk of edema, and a cold
movement, and proptosis can be and beneath that are the orbicularis oculi compress after repair can decrease
detected during a physical examination. muscle, which allows the eyelids to be swelling and wound tension. Sutures can
Widened blind spot, reduced color sight shut, the meibomian glands and the be removed on the fifth day. Ptosis in the
(especially red), and afferent pupil defect tarsal plate containing the eyelashes, and eye, lacerations closer than 1 cm to the
detected during a visual field test are the the innermost layer is the conjunctiva. medial canthus, and cuts reaching the
most reliable findings that suggest optic Eyelid lacerations (ELLs) are injuries tarsal plate should be evaluated by an
nerve damage. The possibility of optic caused by blunt or penetrating ophthalmologist or plastic surgeon.
disc edema and retinal vein occlusion or mechanisms. Because the eyelid is
congestion should be investigated with anatomically thin, it provides little Retrobulbar hematoma
Retrobulbar hematomas are hemorrhages
fundoscopy. If the patient history and protection against penetrating injuries,
formed behind the globe due to trauma,
physical examination support the and the risk of globe injury is high in
surgery, and posterior injections. They are
findings, no time should be lost with penetrating traumas. ELLs are injuries
usually arterial in origin; the inferior orbital
visualization methods. Normal IOP level is that require special attention, and certain
arteries and anterior ethmoidal arteries
3–6 mmHg. Although there is not a points must be considered. Before
are most commonly injured. The clinical
specific pressure limit defined for orbital repairing the laceration, a complete
importance is that this condition leads to
compartment syndrome, values ≥30 physical examination must be
compartment syndrome by causing
mmHg are considered to be high. The undertaken. During the examination, lid
increased pressure inside the orbital
most important factor in making a and globe movements, visual field,
cavity. Patients can suffer decreased
treatment decision is the presence of corneal injuries, foreign bodies, and globe
visual acuity, sluggish light reflex,
clinical findings. Treatment is surgical, perforation should be evaluated. All
restricted eye movement, painful
and lateral canthotomy and cantholysis patients must be asked about tetanus
proptosis, and afferent pupil defect. CT is
are the surgeries preferred most often. immunization. If there has been no
the most commonly preferred
immunization, immunoglobulin (250 U)
568
visualization method for diagnosis. Grade 1: Only epithelial damage; no While the prognosis is good for
Although there is not a globally accepted limbal ischemia. grades 1 and 2, it is poor for grades 3
algorithm for treatment, there are and 4. The first thing to do when a
Grade 2: Obscurity on the cornea;
medical and surgical treatment options. chemical substance contacts the eye is
however, iris details can be spotted and
Corticosteroids are used in medical to irrigate it with normal saline or Ringer’s
there is ischemia in less than 1/3 of the
treatments, and lateral canthotomy and lactate solution in order to neutralize the
limbus.
cantholysis are the surgical treatments. eye’s pH. Applying a local anesthetic will
Grade 3: Total loss of corneal epithelia. relieve the patient’s pain. If care is being
Chemical Injuries administered at the scene, tap water can
Stromal obscurity prevents spotting iris
Eye traumas caused by chemical
be used for irrigation. Grade 1 and 2
substances constitute a wide spectrum
Image 15.9 corneal chemical burn injuries can be treated with antibiotics,
ranging from corneal abrasions, which
steroids, and cycloplegic drugs. As
are simple burn symptoms, to serious
antibiotics, preparations containing
burns that can result in permanent
tobramycin or quinolone (ciprofloxacin,
blindness. The most commonly
ofloxacin) can be used 4–5 times per
encountered chemicals are cleaning
day. Steroids decrease inflammation and
materials, personal care items, and
prevent neutrophil activation. Grade 3
automobile chemicals. Alkaline chemical
and 4 injuries may require surgical
injuries are more common than acidic
treatment.
ones. Because acidic materials lead to
coagulation necrosis and scar formation,
deep penetration is restricted. Alkaline
details. 1/3–1/2 limbal ischemia. References and Further Reading, click
materials cause deeper wounds due to
here
liquefaction necrosis. Burns are grouped Grade 4: The cornea is completely
into four grades, based upon intensity. opaque and there is >50% limbal
ischemia.
569
Section 2
Case Presentation
by David Brian Wood A 27-year-old female with no past medical problems presents
to the emergency room complaining of 2 days of a red, itchy
and burning left eye. She notes that she has had a lot of
watery discharge during this time and that her vision is blurry
on occasion but improves after blinking a few times. She
works in a day care where many of the children have been sick
lately. She does not use corrective lenses and does not recall
any trauma to the eye. She also denies systemic symptoms
such as fever, photophobia, or joint pain. Vitals: T 98.5oF, HR
78, BP 124/68, RR14, SpO2 100% on room air. Visual acuity:
20/20 in both eyes. Peripheral fields: intact. Forehead/maxilla:
no erythema or swelling. Lids/lashes: left eyelid mildly swollen.
Otherwise, lids and lashes are normal, and eversion of eyelid
demonstrates no foreign bodies. Conjunctiva: conjunctiva on
the left is diffusely injected, and there is watery discharge.
570
Pupils: round, reactive to light, Figure 15.1 Approach to red eye.
and equal bilaterally. Slit lamp:
lids, lashes, and conjunctiva as
above. No abrasions or
lacerations visualized with
fluorescein. Anterior chamber
without cell and flare.
Intraocular pressure: 18 mmHg
bilaterally.
572
• Soft contact use-more susceptible to 3. Extra-ocular eye movements: Look for including vitreous hemorrhage, retinal
bacterial infection disconjugate gaze and ask if the detachment, or optic neuritis.
patient develops any diplopia when
• Immunocompromise 8. Slit lamp exam: Re-examine the lids,
looking in a certain direction. Either of
lashes, conjunctiva, and cornea. Use
The ocular examination has numerous these findings suggests an entrapped
fluorescein to evaluate for foreign
components, requires particular technical extraocular muscle or nerve deficit.
bodies, abrasions, lacerations, or
skill and therefore should be approached
4. Surrounding structures (forehead and Siedels sign (streaming of aqueous
systematically so that no part of the exam
maxilla): Assess for surrounding humor from punctured globe site).
is overlooked.
erythema, induration, or rash. Always have the patient move the eyes
One approach to examining the eye is for in all directions to visualize the entire
5. Eyelids and lashes: Remember to evert
the examiner to begin peripherally and conjunctiva. Visualize the anterior
the eyelids as well. Look for localized
progress inward, ending with the chamber to look for cell and flare,
swelling or redness.
fundoscopic examination as shown white blood cells (hypopyon), or red
below: Order of Exam 6. Conjunctiva blood cells (hyphema).
574
To prevent secondary infection, topical Antibiotics Image 15.11 Corneal ulcer with
antibiotic ointments can be used (below circumcorneal congestion.
recommendations are adopted from • Gentamicin ointment/solution 0.3%
575
Image 15.12 Herpes simplex virus do not improve after 1-2 weeks of Image 15.14 Posterior blepharitis
treatment.
Top left: Child with measles and severe herpes Courtesy ofJohn KG Dart Retrieved from https://
simplex keratitis affecting the right eye. Top www.flickr.com/photos/communityeyehealth/
right: Dendritic ulcer stained with fluorescein dye 32271350840/in/photolist-aBgGJh-aBgGZo-
Bottom left: Geographic ulcer stained with aBe1Hi-aBgGR1-aBe1cn-aBgFWu-aBgH3S-
fluorescein dye Bottom right: Inflamed aBe1gM-aBgFV9-
© International Centre for Eye Health
conjunctiva and geographic ulcer Photo aBe1We-9J2LcJ-9J2L9d-9A9VAo-9HYUGv-
www.iceh.org.uk, London School of Hygiene &
(clockwise from top-left): John Sandford-Smith, RaH7r9-RaH7hG
Tropical Medicine. Retrieved from https://
Allen Foster, David Yorston). Retrieved from
www.flickr.com/photos/communityeyehealth/
https://www.flickr.com/photos/
8423448539/in/photolist-dQmNx6- Herpes zoster ophthalmicus
communityeyehealth/5616320250/in/
dQmnMn-9Ezoru
photolist-9yi7kL-cAjBe7-dQmoJB-9yi7rQ- Patients with herpes zoster ocular
cAjAUY-cAjAQj-cAjBbA-dQmoR2-
cAjB8s-9EwFS5-9AaetU-9wqCZN-cAjAAC Acute Blepharitis infections should be treated with artificial
Blepharitis is caused by inflammation of tears and erythromycin ointment to
Eyelid an eyelash follicle due to an overgrowth prevent secondary infection. Oral antiviral
of bacterial skin flora. The mainstay of medication can be used if there is skin
Internal/External hordeolum and
treatment consists of daily cleaning of the involvement and, after consultation with
acute chalazion
edge of the eyelashes. an ophthalmologist, topical antivirals may
Initial treatment for these conditions
be prescribed as well. The significant pain
consists of warm compresses and
from herpes zoster infections may require
erythromycin ointment twice daily for
opiate treatments or the use of an
7-10 days. Referral to ophthalmology as
an outpatient can be made if symptoms
576
antidepressant such as amitriptyline Image 15.16 Acute glaucoma, red eye. parasympathetic agonist, causes
25mg P.O. TID. myosis. Rarely causes sweating,
bradycardia, hypotension.
Image 15.15 Herpes zoster
ophthalmicus • Apraclonidine – 1% – 1gtt q5min x3
doses. Decreases production of
aqueous humor (alfa-2 agonist). Used
most often in chronic glaucoma but
may be useful in AACG.
577
Conjunctivitis Ciliary/scleral Image 15.18 Recurrent scleritis
Most cases of conjunctivitis will be due to
allergic or viral causes and can be treated Episcleritis
Artificial tears can be used up to four
with artificial tears 5-6 times per day. If
times per day to help lubricate the eye. A
there is a concern for a bacterial cause of
trial of oral NSAIDs can be given in the
conjunctivitis the patient can be treated
emergency room and if pain resolves can
four times daily for 5-7 days with topical
be continued as an outpatient. If the
antibiotic drops such as trimethoprim or
patient continues to have significant pain
polymyxin B. If the patient wears soft
after NSAID a topical steroid can be used
contact lenses, then Pseudomonal
to relieve the discomfort. The steroid
coverage is necessary with a
drops can be continued as an outpatient
fluoroquinolone or aminoglycoside.
until seen by ophthalmology in 2-3 By Imrankabirhossain – Own work, CC BY-SA
4.0, Retrieved from https://
weeks. commons.wikimedia.org/w/index.php?
curid=60068874
580
ophthalmic burr if available. After the bony orbit and lower eyelid to allow the having the child fixate on an object of
foreign body is removed, the resulting orbit to move forward to compensate for interest. If the vision is normal, the child
the increased pressure placed on it. To will continue to fixate on the object. By
Image 15.24 Corneal foreign body perform a lateral canthotomy the canthus around 3 years old visual acuity can be
is first anesthetized, then crushed with tested more effectively using an Allen
curved forceps, and then cut with chart or Tumbling E chart.
scissors. The inferior canthus tendon can
Neonatal conjunctivitis is usually caused
then be identified by strumming it with
by exposure to an infectious agent while
the scissors and can then be incised.
exiting the birth canal. Most commonly
Following severing the tendon, the inferior
neonatal conjunctivitis is caused by
eyelid should be released completely
Chlamydia trachomatis or Neisseria
from the orbit. Depending on the amount
gonorrhoea but can also be due to
This is a ‘rust ring’ which shows signs of having of time the retina was ischemic, there
been present for some days. The iron particle or herpes simplex virus. Treatment is based
may be rapid improvement in vision as
‘rust’ will lift off the cornea easily but will leave a on the incubation period as shown below
stained area beneath. Removal with a needle or the pressure is reduced.
drill (burr) will be necessary. Retrieved from (adopted from Harwood-Nuss). In
https://www.flickr.com/photos/
communityeyehealth/8408519738 Pediatric Patients addition, neonates with HSV will require
Pediatric patients suffer from many of the ophthalmology consultation. HSV and
defect can be treated as a corneal same etiologies of red eyes as adults but gonococcal conjunctivitis will require
abrasion with topical antibiotic ointment. may be more difficult to obtain an inpatient therapy with ophthalmology
adequate exam on. Visual acuity in serving as a consult.
Procedures children begins around 20/100 and
While rare, the main ophthalmologic N. gonorrhoeae has 2-7 days incubation
improves to 20/20 by approximately 8
procedure performed in the emergency period. Ceftriaxone 25-50mg/kg IV or IM,
years of age. Before 5 years of age, most
department is a lateral canthotomy. The once is effective for treatment. For
children will be unable to read a Snellen
overall goal of the lateral canthotomy is prophylaxis, 1% silver nitrate, 0.5%
chart. Visual acuity can be grossly tested
too severe the connection between the
by covering each eye separately and
581
erythromycin ointment, 1% tetracycline can be used.
Disposition Decisions
The vast majority of patients presenting for red-eye will be
discharged home. Even many of the ocular emergencies will be
able to be discharged following evaluation by ophthalmology.
There are a few conditions requiring admission such as
endophthalmitis, retrobulbar hematoma, and globe rupture.
Disposition and urgency of consultation are covered in the above
clinical management of ocular problems.
582
Chapter 16
Selected
Procedures
Section 1
584
• a face shield to provide a barrier 4. As soon as the AED arrives, CPR providers should continue CPR
between the patient and first aid with minimal interruption of chest
• switch on the AED and attach the
provider during rescue breathing, compressions while attaching an AED.
electrode pads on the patient’s bare
Standard AEDs are suitable for use in
• rubber gloves, chest.
children older than 8 years. AEDs are safe
• trauma shears for cutting through a • CPR should be continued while to use. Currently, There are no published
patient’s clothing to expose the chest, electrode pads are being attached to reports of AEDs’ harmful effects on
the chest, if there is two rescuer. bystanders. Also, there are no reports of
• a towel for wiping away any moisture AEDs delivering inappropriate shocks. If
on the chest, and • Follow the spoken/visual directions, someone has a sudden cardiac arrest,
using an AED and giving CPR can
• a razor for shaving extensively hairy • ensure that no one is touching the
improve the person’s chance of survival.
chests. patient while the AED is analyzing the
rhythm.
How to use an AED?
1. recognize abnormal status in case of • If a shock is indicated, push the References and Further Reading, click
BLS. When facing an unconscious shock button as directed (fully here
person, you should decide if he/she is automatic AEDs will deliver the
alive or not (unresponsive and not shock automatically). Immediately
breathing normally) by the BLS restart CPR 30-2 and continue as
algorithm. directed by the voice and visual
directions.
2. If the person is not breathing normally,
call the emergency services and send • If no shock is indicated, continue
someone to get AED. CPR until emergency medical service
(EMS) arrives.
3. begin chest compressions with rescue
breaths 30-2 (if trained or able to do). Please watch the video
585
Section 2
Case Presentation
by Matija Ambooz and Gregor Prosen A 23 years old pregnant woman was admitted with a history of
polyuria, dysuria, fever, and thirst. She is an insulin dependent
diabetic patient. She is febrile. Her chest is clear, and
circulation is adequate. Urinalysis shows the presence of
ketones, glucose, and leukocytes. Her lab results on
admission are:
Na+ 136 mmol/L, K+ 4.8 mmol/L, Cl- 101 mmol/L, Glucose
23.2 mmol/L, Urea 8.1 mmol/L, Creatinine 0.09 mmol/L
586
Low pCO2 and low HCO3- Partial pressures of carbon dioxide Image 16.1 An example of an arterial
(PaCO2) and oxygen (PaO2), hydrogen blood gas analysis result.
indicates metabolic acidosis.
ion activity (pH), total hemoglobin (Hb),
Hyperglycemia, glycosuria, and oxyhemoglobin saturation (HbO2), and
ketonuria indicate DKA. There carboxyhemoglobin (COHb) and
methemoglobin (MetHb) are directly
might be an underlying UTI that
measured.
triggered DKA. Respiratory
Oxygen (O2) and carbon dioxide (CO2)
alkalosis is a compensation.
are the most important respiratory gases,
and their partial pressures in arterial
Introduction
Arterial blood gas (ABG) analysis is an blood show the overall adequacy of gas
important investigation to monitor the exchange. pH, which measures hydrogen
acid-base balance of critically ill patients. ion activity, is a regular part of every
arterial blood gas sampling (Image 16.1).
ABG help to determine treatment may To learn how to evaluate ABG analysis
indicate the severity of the condition and please click here.
can help to diagnose a disease. The
re s p i r a t o r y s t a t u s a n d a c i d - b a s e
equilibrium of individuals with pulmonary
disorders, drug overdose, and metabolic
disorders may be evaluated through this
procedure.
• Partial-thickness burns,
• to quantitate the patient’s response to
therapeutic intervention and/or • Atherosclerosis,
diagnostic evaluation (e.g., oxygen
therapy, exercise testing) • Anticoagulation or coagulopathy*.
• to monitor the progression and severity *ABG sampling can be performed safely
of the observed disease. We usually in patients who are on anticoagulants or
evaluate these parameters in patients have other coagulopathies. In patients
• 70% isopropyl alcohol or an antiseptic
with multi-organ failure, both chronic with severe disseminated coagulopathies,
solution,
and acute respiratory failure, ventilated extreme caution is required.
patients, critically ill trauma patients, • gauze or cotton-wool ball to be applied
Equipment and Patient over puncture site,
septic patients, patients with burns and
Preparation
poisoned patients.
Equipment used in arterial puncture • well-fitting non-sterile gloves
include;
Contraindications • puncture-resistant container.
• Inadequate circulation,
ABG syringe, for an adult, use a 20-
With an adult patient who is conscious,
• Burger’s disease, gauge, 2.5-inch needle for a femoral
follow the steps below (adapted from
sample and a 22 gauge, 1.25-inch needle
588
W.H.O. best phlebotomy practice commonly punctured for blood gas inadequate, repeat the test on the
guidelines). sampling in adults. The first choice is the other hand.
radial artery due to its superficial
• Introduce yourself to the patient and • Video 1: Modified Allen test;
anatomical location. It has good collateral
ask their full name. Radial and Ulnar Artery are both
circulation and is not surrounded by
pressed to prevent blood flow.
• Check that the laboratory form matches structures that could be easily damaged
Ulnar artery is released after the
the patient’s identity. by puncturing.
hand becomes pale. If the hand
• Ask whether the patient has allergies, The procedure as defined by W.H.O. flushes after 5s – 15s, the ulnar
phobias or has ever fainted during guidelines consists of 16 steps for radial artery has sufficient blood flow
previous injections or blood draws. artery puncture. and radial artery may be
punctured. If it takes more than
• Discuss the procedure and obtain 1. Approach the patient, introduce
15s for hand to flush, the ulnar
verbal consent. yourself and ask the patient to state
artery has inadequate blood flow
their full name.
and this hand should not be
• If the patient is afraid or anxious, help
2. Place the patient on their back, lying punctured.
him relax and make him more
comfortable. flat. Ask the nurse for assistance if the
4. Perform hand hygiene, clear off a
patient’s position needs to be altered
bedside work area and prepare
• Make the patient comfortable in a to make them comfortable. If the
supplies.
supine position. patient is clenching their fist, holding
their breath or crying, this can change 5. Disinfect the sampling site on the
• Place a clean paper or towel under the
breathing and thus alter the test result. patient with 70% alcohol and allow it
patient’s arm.
to dry.
3. Locate the radial artery by performing
Procedure Steps an Allen test for collateral circulation 6. Assemble the needle and heparinized
Various arteries can be used for blood
(Video 1). If the test fails to locate the syringe and pull the syringe plunger to
c o l l e c t i o n . T h e r a d i a l , b r a c h i a l ,
radial artery or collateral flow is
and femoralarteries are the sites most
589
the required fill level recommended by 9. Withdraw the needle and syringe; a l t e r n a t i v e l y, u s e a l c o h o l r u b
the local laboratory. (1 – 3 mL) place a clean, dry piece of gauze or solution.Check the patient site for
cotton wool over the site and have the bleeding and thank the patient.
patient or an assistant apply firm
Image 16.3 Syringe and needle 15.Check the patient site for bleeding and
pressure for sufficient time to stop the
prepared for puncturing. thank the patient.
bleeding. Check whether bleeding has
stopped after 2–3 minutes. 16.Transport the sample immediately to
the laboratory, following laboratory
10.Activate the mechanisms of a safety
handling procedures.
needle to cover the needle before
placing it in the ice cup. ABG Sampling video 1 and video 2
592
Section 3
Arthrocentesis
593
arthritic joint, and this condition may • Various syringes (5 mL, 20 mL, 30 mL, b e taken. To avoid infection, aseptic
mimic a soft tissue infection. 60 mL) technique is essential, including the use
of sterile gloves and instruments. After
• C o a g u l o p a t h y i s a n a b s o l u t e • Various size of needles, 18 or 20 G and
s k i n p re p a r a t i o n w i t h a n t i s e p t i c
contraindication. However, few studies 25 or 27 G
solutions, the clinician should allow the
are demonstrating whether it is
• Morbidly obese patients might require solution to dry for several minutes
dangerous performing arthrocentesis in
a 2 1 - g a u g e s p i n a l
because the bactericidal effects of iodine
patients using anticoagulants. It was
needle for arthrocentesis are dependent on both concentration
found safe even in those who have
and time. Iodine solution should be
international normalized ratios as high • Specimen tubes removed with an alcohol sponge. This
as 4.5.
will prevent iodine transfer into the joint
• Bandage
• Prosthetic joints increase the risk for space, which can cause an inflammation.
infection. Therefore arthrocentesis General Arthrocentesis Without anesthesia, arthrocentesis may
should be avoided for these joints. Technique be quite painful. Entire route of the
However, if an infected prosthesis is Arthrocentesis is a relatively simple
needle should be anesthesized from skin
suspected, arthrocentesis should be procedure. Knowledge of anatomic
to joint capsule. 1% or 2 % lidocaine can
performed. landmarks and patient positioning will
b e u s e d .
aid in the successful completion of joint
Rigid needles are preferred whereas
Equipment aspiration. Defining the anatomy is the
some clinicians can use sturdy catheters.
• Sterile gloves and drapes most important part of the procedure.
As a general rule, one should try to
The clinician should be familiar with the
• Gauze pads (5), 4 × 4 inches. remove as much fluid or blood as
anatomy of the specific joint and
possible.
• Skin cleaning agent landmarks in order to avoid puncture of
tendons, blood vessels, and nerves. Arthrocentesis of the hip joint is generally
• Local anesthetic such as Lidocaine 1%
performed by an orthopedic surgeon.
The procedure should be explained to
İt may be difficult to aspirate fluid from
the patient and written consent should
594
small joints. If only one drop of fluid is • Pronate the patient’s forearm and rest it parallel to the radial shaft. The
obtained from small joints, it is best to with the palm down on a side table set landmarks can be found easily if the arm
send it for culture. at the appropriate height for comfort. is first extended. At this point, the
depression can be located. Then flex and
The common complications • Identify the olecranon process, lateral
pronate the arm for the procedure.
of procedure epicondyle, and radial head, and find
• Iatrogenic infection the depression (or bulge, if the effusion Because of the risk of ulnar nerve and
is large) in the soft triangle. This site is superior ulnar collateral artery injury, the
• Iatrogenic hemorrhage used for all approaches. medial approach should not be used.
• Pain during the time of the procedure • Identify the entry site, and mark the site How to locate the entry site; please
with a plastic needle sheath or a sterile watch the video.
• Reaccumulation of the joint fluid
surgical marker.
Real patient example (watch the video)
Specific Arthrocentesis
• Carefully examine the elbow before
Techniques arthrocentesis. Radiocarpal Joint (Wrist)
Landmarks and positioning are important The wrist joint is anatomically complex.
while performing arthrocentesis. For small • Olecranon bursitis is located posteriorly The dorsal site is the preferred site of
joints, application of traction is often very over the olecranon and can be aspiration of the wrist joint.
helpful in obtaining fluid. confused with the elbow joint.
The landmark of this joint is the dorsal
Radiohumeral Joint (Elbow) The alternative is the posterolateral radial tubercle (Lister’s tubercle). The
approach can be used. However, there is extensor pollicis longus tendon runs in a
Lateral approach an increased risk of injury to the radial groove on the radial side of the tubercle.
• The patient sits upright on a stretcher.
nerve and triceps tendon. This approach The tendon can be palpated by active
• Bend the patient’s elbow to 90º. is useful if the bulge of effusion is extension of the wrist and thumb.
palpated inferior to the lateral epicondyle.
• The wrist should be slightly palmar
In the posterolateral approach, insert the
flexed to facilitate the performance of
needle perpendicular to the skin but
595
t h e p r o c e d u r e .
• First of all arthrocentesis of this joint is F o r the parapatellar approach, identify
The positioning of the wrist is moderately difficult. the midpoint of either the medial or the
approximately 20 to 30 degrees of lateral border of the patella. Insert an 18-
• The patient should sit upright with the
flexion with accompanying ulnar gauge needle 3-4 mm below the midpoint
arm at the side, with the shoulder held
deviation. of either the medial or the lateral border
in external rotation.
of the patella. Direct the needle toward
• Applying traction to the hand might be
• To find the landmark clinician should the intercondylar notch of the femur by
helpful.
palpate the coracoid process medially perpendicular to its’ long axis.
• Insert the needle dorsally just distal to and the proximal end of the humerus
For the suprapatellar approach, identify
the radius and just ulnar to the laterally.
the midpoint of either side of the
anatomic snuff box.
• The clinician should insert a 20-gauge superomedial or the superolateral border
• Avoid the associated tendons (extensor needle at a point inferior and lateral to of the patella. Insert an 18-gauge needle
carpi radialis brevis and extensor the coracoid process and direct it through the midpoint of either superior
pollicis longus). posteriorly toward the glenoid rim. borders. Direct the needle toward the
intercondylar notch of the femur.
• Direct the needle perpendicular to the The video shows posterior approach. The needle enters the suprapatellar
skin. bursa. Remember that in 10% of the
Knee Joint, Anteromedial
population, the suprapatellar bursa does
• If the bone is hit, pull the needle back Approach
not communicate with the knee joint.
and redirect it slightly toward the The medial surface of the patella at the
thumb. middle or superior portion of the patella is For the infrapatellar approach, position
the landmark for the knee joint. Knee the patient sitting upright with the knee
Watch the video 1 and video 2.
arthrocentesis may be done via the bent at 90° over the edge of the bed.
parapatellar approach (which is generally
Glenohumeral Joint (Shoulder), Identify either side of the inferior border
Anterior Approach preferred), suprapatellar approach, or of the patella and the patellar tendon.
infrapatellar approach. Insert an 18-gauge needle 5 mm below
596
the inferior border of the patella and just proximal interphalangeal and distal
lateral to the edge of the patellar tendon. interphalangeal joints. The extensor
Be careful not to go through the patellar tendon of the great toe can be located by
tendon while inserting the needle. active extension of the toe. The clinician
should insert the needle into the skin at a
Please watch the video 1 and video 2.
90-degree angle and enter the
dorsomedial aspect of the great toe
Tibiotalar Joint (Ankle)
The medial malleolar sulcus is bordered (MTP) joint, just medial to the extensor
medially by the medial malleolus and tendon.
laterally by the anterior tibial tendon. The
Please watch video.
tendon can easily be identified with active
dorsiflexion of the foot. The clinician
should insert the needle at a point just
References and Further Reading, click
medial to the anterior tibial tendon and
here
directed into the hollow at the anterior
edge of the medial malleolus. The needle
must be inserted 2 to 3 cm to penetrate
the joint space.
Metatarsophalangeal and
Interphalangeal Joints
For the first digit, landmarks are the distal
metatarsal head and the proximal base of
the first phalanx. For the other toes, the
landmarks are the prominences at the
597
Section 4
598
Types are based on time, place, the • Bruit or thrill Damaged subcutaneous capillaries.
cause of injury. A clean wound which is Slow dotted bleeding.
• Active or pulsatile bleeding
not older than 6-8 hours (18-24 hours on
face) can be closed right away. Wounds • Signs of limb ischemia
Assessment and Simple
that are older than 8 hours should be Procedures
thoroughly cleaned and cover with wet • Pulsatile or expanding hematoma
Initial evaluation when
gauze. They can be closed after 3-5 days
Soft Signs assessing wounds that are not
when they are clean, and there is no sign
• Proximity of injury to vascular structures life- or limb-threatening:
of infection. • past medical history and circumstances
• Major single nerve deficit surrounding the injury,
If blood vessels affected,
• Non-expanding hematoma • remove rings or other jewelry that
Arterial bleeding
encircle the injured body part,
It is a consequence of injury to the artery. • Reduced pulses
The blood is pulsating out of the wound • review the mechanism of injury,
• Posterior knee or anterior elbow
and has a bright red color. If the artery is
dislocation • ask about the presence of a foreign
lacerated through the whole lumen, it will
spontaneously shrink and limit the body sensation,
• Hypotension or moderate blood loss at
bleeding. However, if there is only injury the scene • determine the time that the injury
to the wall of an artery and it is not occurred
thoroughly dissected, this cause even Venous bleeding
more harm. It is a consequence of injury to the vein. • determine if the wound was the result of
The blood is leaving the wound more intentional, unintentional or workplace
How to recognize arterial bleeding slowly and is not pulsating; it has a dark event
red color.
Hard Signs • examine nerves’ motor and sensorial
• No pulses
Capillary bleeding function, and tendons.
599
Assessment of bleeding wounds Eschmarch tourniquet Eschmarch tourniquet. It can limit
that are potentially life- or limb- breathing when applied on the thorax. Lift
We can use cuff from blood pressure
threatening the injured limb. Place clean gauze over
monitor. It should be inflated with
Direct pressure the wound and maintain direct pressure
pressure over 250mmHg, especially on
on the wound. Place one bandage over
We should provide equal pressure over a lower extremities. However, inflating
the wound and wrap the other on around
gauze that covers the complete wound. It 20-30 mmHg over the systolic blood
the limb. Make sure to have firm and
is the first step of immediate bleeding pressure levels are also acceptable in
constant pressure. Place the limb in a
control, and applicable anywhere on the most of the bleeding. Use only to stop
brace and keep it elevated. Check pulse,
body. Replace skin flaps to their original life-threatening exsanguination or when a
mobility, and sensation distal from the
position, before applying pressure if tourniquet is needed for a short period of
dressing. Check the dressing every 5-10
possible. time to create a bloodless field for wound
minutes.
inspection. This technique can be used id
Some areas of the body can be painful,
above measures are not effective to stop Clamping and Cauterisation
and it is a limitation for some patients.
a fast bleeding. It has a time limit up to 2
Direct pressure has time limitations. It is fast and on point bleeding control.
hours. It is a painful procedure. Apply
Therefore, application of pressure One of the final steps, if the above
blood pressure cuff proximal to the
bandage may be necessary. measures do not work to stop bleeding. It
bleeding point, inflate it above systolic
should not be applied any wound and
Pressure on arteries blood pressure and clamp the tubing with
vessel having an amputation and possible
a hemostat. After procedure record the
We can stop blood flow to extremities re-anastomosis chance. But it is ideal for
time of application, do a neurological
w i t h p r e s s u r e o n m a i n a r t e r i e s .
continuously bleeding superficial arteries
exam and do not leave the tourniquet on
It is the second step of immediate in some wounds. Do not try to clamp
for more than 120 minutes.
b l e e d i n g c o n t r o l .
deeper vessels because clamping may
It is useful only on extremities. It is a Compression bandage damage other structures.
painful application and has time limitation
It is very fast, but a temporary bleeding Cauterization is a final step of bleeding
as direct pressure.
control maneuver. It is less effective than control in the ED, and applied by surgical
600
teams when the other measures used by
ER team are not effective to stop
bleeding.
601
Section 5
Cardiac Monitoring
Case Presentation
by Stacey Chamberlain A 44-year-old male patient with a history of hypertension and
end-stage renal disease on hemodialysis presents with
shortness of breath after missing dialysis for 6 days. He
reported gradual onset shortness of breath associated with
orthopnea and increased lower extremity edema. He denies
chest pain or palpitations. He does not have any cough or
fever. On physical exam, he is in no distress, afebrile with a
heart rate of 60, respiratory rate of 20, blood pressure of
140/78 and oxygen saturation of 98% on room air. He has a
regular rate and rhythm without murmurs and has crackles
bilaterally to the inferior 1/3 of the lung bases and 1+ pitting
edema of the bilateral lower extremities.
602
Image 16.4 ECG 1 What are the indications for include pulse oximetry, end tidal CO2
monitoring, central venous pressure
cardiac monitoring in this
monitoring, and continuous arterial blood
patient? What EKG pressure monitoring. Of note, telemetry is
abnormalities do you see? the ability to do cardiac monitoring from a
remote location; in practice, this is often a
What does the rhythm strip
centralized system that might be located
https://i2.wp.com/lifeinthefastlane.com/wp- show? What is the treatment? at a nursing station where multiple
content/uploads/2011/02/ECG-Potassium-7-
peaked-T-waves.jpg?ssl=1 patients can be monitored remotely.
Case discussion is at the end
of the chapter. Cardiac monitoring differs from a 12-lead
You send a blood chemistry
electrocardiogram in that it is done
test, place the patient on a continuously over a period of time rather
Introduction
cardiac monitor and one hour Cardiac monitoring in the emergency than capturing one moment in time in a
later note the following on the setting is continuous monitoring of a static image. The benefit of this, of
patient’s cardiac activity in order to course, is for capturing transient
monitor (EKG from
identify conditions that may require arrhythmias, ectopic beats, or monitoring
www.lifeinthefastlane.com): emergent intervention. These conditions for changes over time. A disadvantage of
include certain arrhythmias, ischemia and cardiac monitoring is that typically only 2
Image 16.5 ECG 2 infarction, and abnormal findings that leads are displayed instead of a full 12
could signal impending decompensation. leads, giving a less comprehensive view
This chapter focuses specifically on of the heart and limiting its utility to look
cardiac monitoring or for anatomic patterns. For example, on
electrocardiography. the 12 lead EKG, ED practitioners usually
group the inferior, anterior and lateral
https://i0.wp.com/lifeinthefastlane.com/wp- Additional methods of continuous
content/uploads/2011/02/disappearance-p- leads when looking for ischemic or infarct
waves-hyperk.jpg?ssl=1 hemodynamic monitoring in the ED patterns. These may be less evident on a
603
monitor with only two leads. Additionally, three classes. Cardiac monitoring is 3.Patients with unstable coronary
the static EKG allows for the ED considered indicated in “most, if not all” syndromes and newly diagnosed high-
physician to carefully study it for subtle patients in Class I, which includes 16 risk coronary lesions (for 24 hours)
fin d i n g s , f o r e x a m p l e , t o m a k e subcategories. In Class II, cardiac
4. Adults or children who have undergone
measurements of intervals, whereas, in monitoring “may be of benefit in some
c a r d i a c s u r g e r y
real-time monitoring, this is very difficult. patients but is not considered essential
(minimum of 48 to 72 hours)
I n p r a c t i c e , b o t h m o d a l i t i e s a re for all patients” and has 10
commonly used in conjunction for many subcategories. For Class III, cardiac 5. Patients who have undergone non-
ED patients. monitoring is not indicated. urgent percutaneous coronary
intervention with complications
The American Heart Association (AHA) Indications for Cardiac
published a consensus document in 2004 Monitoring 6. P a t i e n t s w h o h a v e u n d e r g o n e
establishing practice standards for Adopted from AHA consensus document implantation of an automatic
electrocardiographic monitoring in defibrillator lead or a pacemaker lead
hospital settings. This comprehensive Class I Indications and are considered pacemaker
document outlines the indications for Cardiac monitoring is considered
dependent
cardiac monitoring, the specific skills indicated in “most, if not all” patients in
required of the practitioner for cardiac Class I 7. Patients with a temporary pacemaker
m o n i t o r i n g , a n d s p e c i fic E C G or transcutaneous pacing pads
1. Patients who have been resuscitated
abnormalities that the practitioner should
from cardiac arrest 8. Patients with AV block
recognize.
2. Patients in the early phase of acute 9. Patients with arrhythmias complicating
Cardiac monitoring is essential for those
coronary syndromes (ST-elevation or Wolff-Parkinson-White syndrome with
patients who are at risk for an acute, life-
n o n – S T- e l e v a t i o n M I , u n s t a b l e rapid anterograde conduction over an
t h re a t e n i n g a r r h y t h m i a . T h e A H A
angina/“rule-out” MI) accessory pathway
guidelines divide indications for cardiac
monitoring in the inpatient setting into
604
10.Patients with long-QT syndrome and 2. Patients with chest pain syndromes Class III
associated ventricular arrhythmias Cardiac monitoring is not indicated
3. P a t i e n t s w h o h a v e u n d e r g o n e
11.Patients receiving intra-aortic balloon uncomplicated, non-urgent 1. Postoperative patients who are at low
counter-pulsation percutaneous coronary interventions risk for cardiac arrhythmias (e.g. young
patients without heart disease who
12.Patients with acute heart failure/ 4. Patients who are administered an
undergo uncomplicated surgical
pulmonary edema antiarrhythmic drug or who require
procedures)
adjustment of drugs for rate control
13.Patients with indications for intensive
with chronic atrial tachyarrhythmias 2. Obstetric patients, unless heart
care
disease is present
5. P a t i e n t s w h o h a v e u n d e r g o n e
14.Patients undergoing diagnostic/
implantation of a pacemaker lead and 3. P a t i e n t s w i t h p e r m a n e n t , r a t e -
therapeutic procedures requiring
are not pacemaker dependent controlled atrial fibrillation
conscious sedation or anesthesia
6. P a t i e n t s w h o h a v e u n d e r g o n e 4. Patients undergoing hemodialysis
15.P a t i e n t s w i t h a n y o t h e r
uncomplicated ablation of an (unless they have a class I or II
hemodynamically unstable arrhythmia
arrhythmia indication)
16.Diagnosis of arrhythmias in pediatric
7. Patients who have undergone routine 5. Stable patients with chronic ventricular
patients
coronary angiography premature beats
605
acute arrhythmias, recognizing which • Non-conducted atrial premature • Junctional ectopic tachycardia
arrhythmias necessitate immediate action beats
• Accelerated ventricular rhythm
and which are less worrisome. AHA
• Junctional rhythm
guidelines list the specific arrhythmias • Ventricular
that the ED physician must be able to • AV blocks
recognize. • Monomorphic and polymorphic
• 1st-degree ventricular tachycardia
Specific Arrhythmias (adopted
• 2nd-degree Mobitz I • Torsades de pointes
from AHA Scientific Statement)
• Normal rhythms (Wenckebach) or Mobitz II
• Ventricular fibrillation
• Normal sinus rhythm • 3rd-degree (complete heart block)
• Premature complexes
• Sinus bradycardia • Asystole
• Supraventricular (atrial, junctional)
• Sinus arrhythmia • Pulseless electrical activity (PEA)
• Ventricular
• Sinus tachycardia • Tachyarrhythmias
• Muscle or other artifacts simulating
• Intraventricular conduction defects • Supraventricular arrhythmias
608
Section 6
Case Presentation
by Elif Dilek Cakal A 22-year old female presented to the emergency department
15 minutes after she had committed suicide by taking 30 pills
of 500 mg acetaminophen. She had no known chronic
diseases. Her blood pressure was 134/87 mmHg;
temperature, 36.4°C; heart rate of 70 bpm and regular;
respiration 15 bpm; and O2 saturation 99%. At the time of
arrival, she was asymptomatic. Nothing was remarkable on
examination. Gastric lavage was performed. 1 mg/kg of
activated charcoal was given to the patient. IV N-
acetylcysteine treatment was started. She was admitted to the
hospital.
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Gastric Lavage Procedure • Hydrocarbons intake (unless containing •Local analgesics and lubricants
highly toxic substances such as
Emergency Indications • Intubation equipment
pesticides).
Gastric Lavage (GL) should not be
• Sedatives (if necessary)
undertaken routinely. Whether gastric • Oral intake of caustic substances.
lavage positively alters the morbidity or • Restraints (if necessary)
• Poisonings with toxic substances;
mortality of the poisoned patient, even
those are more toxic to lungs than to • Bite block or oral airway
applied shortly after the intake, is
gastrointestinal system.
controversial. GL is indicated only if: • Oral or nasogastric tubes
• Poisonings with pills that are known not
• Oral intake < 60 minutes • 36- to 40-French or 30 English-
to fit through the holes of the gastric
tube gauge tubes in adults (oral)
• The life-threatening dose of the toxic
substance is ingested • 24- to 28- French-gauge in
• Known esophageal structures.
children (oral)
Contraindications • History of gastric bypass surgery.
• Patients with compromised airway • Lavage systems
reflexes, unless they are intubated. If Emergency Physician (EP) must be
the critical situation of the patient cautious in combative patients and • Commercially available
indicates intubation, then, gastric patients with medical conditions such as
• Intermittent aliquots of lavage fluid
lavage may be performed. Intubation, bleeding disorders.
can be given and withdrawn
only for decontamination, is not
manually
recommended. Equipment and Patient
Preparation • Activated charcoal (see below)
• Non-toxic or non-life-threatening
intoxications. Equipment for GL includes: • Normal saline or water
• Intravenous access and monitoring
Before starting, the steps of the
• A large suction catheter procedure must be explained to patients
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in an attempt to gain cooperation. If the This video explains the steps of the 9. 9. Continue lavage until the
patient is too agitated, sedatives in insertion of the gastric tube fluid becomes clear
anxiolytic doses may be used. EP must
1. Explain the procedure to the patient. 10.Administer activated charcoal via tube
keep in mind that significantly altered
level of consciousness due to sedation 2. Collect the equipment and place the 11.Clamp off and remove the tube
warrants intubation. patient in the left lateral decubitus
position. Hints and Pitfalls
Although there is no adequate data in
• The procedure is intended to be
humans to show that tube diameter or 3. Put a bite block or oral airway into the therapeutic, not punitive.
route is important, the oral route is patient’s mouth.
primarily preferred for the gastric lavage. • In some situations, Gastric lavage may
Nasogastric tubes are less traumatic for 4. Introduce to pass the tube gently be helpful for up to 2 hours:
patients and are preferred in liquid
5. When the pharynx is reached, put the • Highly toxic drugs
ingestions and children.
patient’s chin on the chest to facilitate
passage of the tube into the • Drugs not absorbed by activated
Place all patients in the left lateral
esophagus. charcoal
decubitus position in Trendelenburg to
facilitate the content removal and to • Sustained release or enteric-
6. Confirm the placement
decrease the aspiration risk. Supine coated products
position greatly increases aspiration risk, 7. Aspirate and remove the gastric
unless the patient is intubated. contents before gastric irrigation • Auscultation of the stomach generally
confirms the placement of the tube
The tube must be measured from the 8. Repeatedly introduce 200–300 mL of during injection of air with a 50-mL
corner of the mouth to the mid- lavage solution (10 mL/kg body weight syringe and aspiration of gastric
epigastrium in order to avoid kinking and in children up to a maximum of 300 contents. Radiographic confirmation
complications. mL) into the stomach and then remove should be considered, especially in
them children and intubated patients.
Procedure Steps
611
• A cough, stridor, or cyanosis indicates • Esophageal lacerations or perforation. Elderly patients are susceptible to
that the tube has entered the trachea; cardiac consequences of both procedure
• Gastric perforation.
withdraw the tube immediately and and the poisoning; therefore, their vital
reattempt passage. • Fluid and electrolyte disturbances, signs should be monitored closely.
especially in children.
Post Procedure Care and Gastric lavage and activated charcoal are
612
• Quinine for decreased peristalsis (relative •Give the recurrent dose of charcoal
contraindication) by 0.5 g/kg (≤50 g) every 4 hours
• Theophylline
Equipment and Patient How to administer:
Contraindications
• For patients with compromised airway
Preparation • If the patient is awake and cooperative,
There is no specific equipment for
reflexes, unless they are intubated. If AC may be given orally. Alternatively, it
activated charcoal administration.
the critical situation of the patient may be given by gastric or nasogastric
However, drinking the charcoal can be
indicates intubation, then, gastric tube, if these procedures are indicated.
very unpleasant for many patients,
lavage may be performed. Intubation,
especially children. Therefore, mixing with • Mixing the activated charcoal with fruit
only for decontamination, is not
fruit juice can be an option. In addition, if juices increases tolerability.
recommended.
necessary nasogastric or orogastric tube
• If the patient is unconscious or airway is
• Oral intake of caustic substances placement can facilitate the active
compromised, gastric lavage should be
charcoal treatment.Procedure Steps
• Late presentation done, and activated charcoal should be
Procedure Steps g i v e n a f t e r i n t u b a t i o n . Tr a c h e a l
• Increased risk and severity of aspiration
Recommended empirical single-dose of intubation is not recommended solely in
associated with AC use (e.g.,
activated charcoal is as follows: order to give activated charcoal. Only
hydrocarbon ingestion)
activated charcoal is to be given, the
• <1 year – 0.5-1 g/kg or 10-25 g nasogastric tube is adequate and is
• Need for endoscopy (e.g., significant
caustic ingestion) preferred.
• 1-12 years – 0.5-1 g/kg or 25-50 g
614
Section 7
Introduction
by Keith A. Raymond Peripheral Intravenous (IV) cannulation is a nursing skill. Few countries throughout
the world require physicians to perform this procedure on a regular basis. Mastery
of technique, understanding nuances and anatomy, and daily performance are
required to maintain this skill. Therefore, if a nurse reports that he is unable to
obtain IV access, and it is required urgently, establishing an IV access or
intraosseous (IO) line should be considered to avoid delay.
IV lines can safely remain in place safely for up to 72 hours. In some cases, this is
up to 7 days.
615
most commonly used sites in • Any site where there is a concern for • Topical anesthetic, eg. EMLA
emergencies, as we must provide high vascular flow. ( 2.5% lidocaine and prilocaine),
volumes and medications to the patient
Equipment and Patient • transilluminator light,
quickly.
Preparation
• ultrasound with a vascular probe.
Emergency Indications
Intravenous access is used when
Equipment
• gloves,
therapies cannot be used or are less
Illustration 16.1
effective by alternative routes. In critical • skin disinfectant (Povidine and Alcohol
situations, medication bioavailability, Swabs),
hydration, and blood products can be
given and provide rapid onset of action. • 16-18 gauge IV catheter (smaller
Peripheral access is typically safer, easier catheters may be used for pediatric
to obtain, and less painful than central patients, but larger is better in critical
616
Patient Preparation but prevent contamination of the clean 6.Attach the 3-way stopcock, then
• Obtain informed consent or implied, prepped site to be accessed. flush the stopcock and cannula of
f o l l o w i n g p ro c e d u re d i s c u s s i o n ,
blood with 5 ml of saline to prevent
risks, and benefits. Procedure clotting, and assess the flow of fluid
1. Apply the tourniquet or BP cuff (inflate through the catheter. Watch for skin
• If possible, have the patients wash their above diastolic reading) proximal to bulge suggesting extravasation of fluid.
forearms, including the antecubital the intravenous site.
space, three times with soap and water, 7. Secure the catheter with tape and
2. Using ‘no-touch’ technique, insert the release the tourniquet or BP cuff.
then pat dry.
IV catheter distal to and along the line
• Select the site starting distally, preferred of the vein at a 10 to 15-degree angle 8. Attach intravenous tubing to 3 way
Cephalic vein in the forearm, then to the skin. stopcock, attached to the fluid of
Medial Brachial Vein in Antecubital choice and initiate flow, watching again
3. Advance the needle and the catheter for fluid extravasation. Medications
Sulcus.
slowly; in most cases, a ‘flash’ of may be administered through another
• Always apply universal precautions blood will enter the catheter (but not port of the stopcock or added to the IV
(gloves as a minimum) to the procedural always). solution as desired.
list. Both visualize and palpate the vein
4. SLOWLY advance the needle an 9. Make sure that you removed the
to be cannulated.
additional 1 to 2 millimeters, then slide tourniqet before you give drug or fluid
• There is a slight give to the vessel the cannula into the vein, while infusion.
compared to surrounding tissue. securing the needle in place.
10.If fluid extravasation occurs at any
• Disinfect overlying skin, and provide 5. Remove the needle while pressing on time, remove the catheter, and repeat
topical anesthetic to site as desired. the overlying skin over the cannula the procedure at the more proximal
proximal to the insertion site to stem site (never distal to the previous
• Transillumination and/or ultrasound may
the blood flow. attempt).
be used to provide additional guidance,
617
Please watch the video. • Use an arm board in pediatric patients,
to prevent catheter displacement from
Post Procedure Care movement.
• All medications administered should be
followed by a 20 ml saline flush. • D o n o t u s e fl a s h l i g h t s f o r
transillumination as they can burn skin,
• A three-way stopcock should remain use transilluminator only. Lowering the
attached to the IV line if it is not in room light during transillumination
active use. maximizes visualization.
• Clean surrounding skin of blood and • Following two failed attempts, seek
other contaminants following insertion. assistance and/or switch to
an Intraosseousline.
• All IV catheters should be removed
within 7 days or as soon as no longer
Complications
necessary.
• Thrombosis and Hemorrhage
• Be vigilant during infusions for tissue
• Air embolism
swelling or catheter displacement.
• Extravasation of Drugs
Hints and Pitfalls
• Palpation is more important than • Vasculitis and Contusions
visualization.
618
Section 8
Introduction
by Keith A. Raymond Peripheral Intravenous (IV) cannulation is a nursing skill. Few countries throughout
the world require physicians to perform this procedure on a regular basis. Mastery
of technique, understanding nuances and anatomy, and daily performance are
required to maintain this skill. Therefore, if a nurse reports that he is unable to
obtain IV access, and it is required urgently, establishing an IV access or
intraosseous (IO) line should be considered to avoid delay.
Intraosseous lines can safely remain in place for up to 24 hours and are often a
bridge to either IV or Central Venous line placement.
619
infusions of catecholamines (epinephrine, • skin disinfectant (Povidine or • Yellow (45 mm) for large patients
norepinephrine, and dopamine). Chlorhexidine and Alcohol Swabs), or dense bone sites such as
proximal humerus or anterior
Contraindications • 16-18 gauge IO or Jamshidi-type
superior iliac spine.
Absolute: needle,
Patient Preparation
• fracture or crush injuries near or • tape,
• Obtain informed consent or implied,
proximal to the access site,
• syringe, following procedure discussion, risks,
• fragile bone conditions such as and benefits.
• isotonic crystalloid solution, and
Osteogenesis Imperfecta,
intravenous tubing. • Select site: humeral head, proximal
• previous attempts in the same bone, tibia, medial malleolus, sternum, distal
• Optional: radius, distal femur, and/or anterior
• the presence of infection in or on the superior iliac spine. (see illistration 16.2)
• IO drill or gun, Infusion pump,
overlying tissue of the bone,
• 2% Lidocaine for topical and • Proximal Tibia and Humeral Head are
• demineralized or immature bone. most commonly used during arrests as
subcutaneous infiltration (awake
patients tend to report pain with placement does not interfere with
Relative:
fluid infusion rather than insertion). intubation or other activities.
• IV access can be obtained readily.
• NOTE: Color coding of IO needles is • Always apply universal precautions
• Use for only ultra short-acting (gloves as a minimum) to the procedural
common
medications such as Adenosine. list.
• Pink (15 mm) for patients 3 – 39
Equipment and Patient kg,
Preparation
• Blue (25 mm) for patients 40 kg
Equipment and greater,
• gloves,
620
Illustration 16.2 Procedure 8.If properly positioned, the needle
1. Once the patient is prepared, identify will stand without support and be fixed
the designated site with a sterile in place.
gloved finger.
• Remove the stylet and attach the
2. Disinfect overlying skin, and provide syringe and aspirate, marrow and
local anesthetic as desired. blood confirms placement but
may not always appear.
3. Be sure the stylet is in place on the
needle prior to insertion. 9. Gently flush saline through the needle
and watch the insertion site for
4. Have a 20 ml Saline syringe flush, IV swelling.
tubing, tape, medications, fluids, and
pump prepared, as required. 10.If the test injection is unsuccessful or
swelling is seen on the opposite side
5. Place the needle through the skin, of the bone, repeat the above
perpendicular and down to the bone. procedure with a new IO needle on
needle anchors in place, OR manually 11.If successful, stabilize the needle with
TWIST the needle clockwise (don’t the tape; gauze padding may be used
push) with gentle firm pressure until as desired.
the bone gives (loss of resistance
technique) and the needle locks into 12.Attach the IV tubing to the needle hub
place. and infuse fluids, blood products, or
medications.
7. The bone give is an indication the
needle has passed through cortical Video – Intraosseous Needle Line
bone into the marrow. Insertion
621
Video – Intraosseous Needle Line • IO needle selection should be
Insertion in A Real Patient consistent with the site and marrow
cavity.
Post Procedure Care
• All medications administered should be • IO needle displacement sometimes can
followed by a 20 ml Saline flush. be avoided by properly securing it to
the skin.
• A three-way stopcock should be
attached to the IO line if it is not in Complications
active use. • Bone fracture
622
Section 9
Emergency Delivery
Case Presentation
by David F. Toro, Diana V. Yepes, Ryan H. As you begin the morning of your next weekend day shift in a
Holzhauer
small community hospital, the triage nurse comes in running
and asks you to evaluate a patient that is being registered in
the Emergency Department. You find a visibly pregnant 29-
year-old female patient complaining of having regular uterine
contractions for the last 10 hours and passed a significant
amount of clear liquid per vagina on the way to the hospital,
as well as a sensation of pelvic fullness and an increasing urge
to use the bathroom with every uterine contraction.
623
moment, you remember your Introduction Identifying True Labor
Every year around 4 million babies are Labor is the process by which the fetus is
hospital does not have a
born in the US; unfortunately, there is no expelled from the uterus and can be a
gynecologist in-house, and information on how many of these are lengthy process on nulliparous women
your nearest transfer center is 1 born outside the regular delivery units, but becomes a shorter process on
hour away. What would you do including the Emergency Department. subsequent pregnancies. It begins when
Fortunately, however, it is an uncommon an organized uterine activity starts,
next?
occurrence in Emergency Medicine. Just causing gradual effacement or thinning of
as it applies to many other emergency the cervix and dilatation in order to allow
procedures, the Emergency Medicine passage of the fetus during the final
provider needs to be familiar with the stages.
normal vaginal delivery. The provider
The labor process can be divided
must know preparations for it as well as
into latent and active phases. The latent
how to identify and treat immediate
phase begins when there is organized
complications for those cases where
and regular uterine activity causing a
immediate access to an obstetrician is
cervical dilatation and effacement; it is
not readily available or if delivery is
considered active phase when it causes 3
imminent before arrival to a birthing unit,
or more cm dilatation and/or effacement
such as in a patient arriving late to the
of 80%.
hospital or a precipitous delivery.
The active labor is normally divided into 4
This chapter describes the evaluation of
stages. The first stage concludes when
the patient in possible active labor, the
dilatation and effacement are complete.
normal delivery technique, and immediate
The second stage ends when the fetus is
post-delivery care.
delivered, the third stage ends when the
placenta is delivered, and the 4th stage is
624
the approximate period of 1 hour after the but may not occur until the moment of “Bloody show” is the common name
third stage concludes. delivery. given to the expulsion of the blood-tinged
cervical mucus plug as effacement and
Contractions occur since the 2nd Although Vaginal pH changes during
dilatation occur. Although by definition it
trimester as Braxton-Hicks contractions, pregnancy, normal vaginal fluid tends to
is always present, in practice, it may not
but they become more common as the have an acidic pH (4.5-6.0) where as
be noticed as it can occur gradually
3rd trimester goes by, transforming amniotic fluid is alkaline (pH 7.0-7.5).
instead of all at once. When noticed, it
gradually into active labor. Braxton-Hicks Therefore, another way of identifying
can precede the initiation of active labor
contractions tend to be limited to the amniotic fluid is using nitrazine or pH
by several days.
suprapubic area and thighs, are short and paper. Under acidic environment, this
irregular in duration, have a low strength paper changes color from yellow to Initial Examination
and are sporadic in timing. orange, and when amniotic fluid is In order to plan ahead for the imminent
present, it changes from orange to yellow, delivery, it is important to perform a
True labor contractions, in contrast, are
green or blue (Image 16.6). vaginal and abdominal exam to determine
progressively longer in duration, radiated
the fetal well-being, lie, position,
to the back and pelvic area, occur at
presentation, dilatation, effacement, and
regular intervals that become more Image 16.6 Under the presence of station.
frequent, are progressively stronger and amniotic fluid, nitrazine paper turns
cause effacement and dilatation of the from orange to yellow, green or blue.
Abdominal exam
cervix. The Leopold maneuvers are part of the
abdominal exam.
Other signs that indicate true labor are
rupture of membranes and “bloody • First, palpate the uterine fundus to
show.” The spontaneous rupture of determine if the fetus is in a vertical or
membranes manifests by a sudden gush transverse lie by feeling if the fetal pole
of clear fluid or by continuous leakage of represents the head, breech (buttocks)
vaginal fluid, with bleach or semen smell, or back.
625
• Second, apply pressure to the sides of In the situation of imminent delivery, there contraction are called late
the uterus with the entire hand, being is little use for advanced fetal monitoring decelerations and constitute a sign of
sure to utilize both hands, to determine in the ED. Nevertheless, an initial fetal distress or placental insufficiency.
where the spine and extremities are. assessment of the fetal well-being is
Decelerations occurring at any moment
appropriate if time allows. The most basic
• Third, with your dominant hand index without relation to the contractions are
way to assess the fetal wellbeing is by
and thumb, palpate just above pubic called variable decelerations and
listening to the fetal heart rate (FHR). This
symphysis to locate the presenting part represent an indication of umbilical cord
can be done by auscultating with a
and determine if it is engaged on the compression or umbilical cord prolapse.
stethoscope, Doppler US or bedside
pelvis. If the presenting part is movable,
ultrasound, placed on the mother’s In the case of late or variable
it is not yet engaged. If it is not
abdomen and in the area where the fetal decelerations, the patient should be given
movable, it is engaged.
thorax is located. oxygen, IV fluid bolus, placed on lateral
• Forth, while facing the maternal legs decubitus and immediate OB
The normal fetal heart rate is 110-160
from the abdomen palpate, enter the consultation should be obtained as
BPM and should be measured over 2
presenting part with both hands moving immediate emergency delivery may be
minutes, as it is normally variable. Higher
towards the birth canal while applying indicated.
rates represent fetal distress.
deep pressure. When the head is the
Decelerations on FHR can be normal or
presenting part, you will feel a round Vaginal Exam
abnormal. The effacement, dilatation, station, and
prominence in one of your hands. If this
position should be determined. On
cephalic prominence is on the same Decelerations occurring during the
vaginal exam, while using lubricated
side as the back and spine, the fetus is uterine contractions are called early
sterile gloves, locate the cervix and the
in face presentation. If the prominence decelerations and are due to the vagal
presenting part. Palpate the cervix to
is on the same side as the small parts, response to the compression of the fetal
determine effacement and dilatation,
the fetus is on vertex presentation. head on the mother’s pelvis.
palpate the presenting part to locate
Fetal Monitoring Decelerations occurring towards the end anterior and posterior fontanel, chin or
of the contractions and peaking after the
626
sacrum and locate the ischial spines and Illustration 16.3 Effacement stages permeable to 2 fingers is considered
determine the station. dilated to 3cm, which is considered
active labor.
The position is the relation of the occiput
or posterior fontanel in relation to the Station is the level of the presenting part
maternal pelvis. If the fetus is presenting in relation to the ischial spines. This
breech, the sacrum is used as fetal measurement is done by palpation, where
reference, and if it is presenting face, the the ischial spines are at 8- and 4-o’clock
chin is the point of reference. The most on the vaginal canal. It is also described
common presentation and what is in centimeters where 0 is at the level of
considered normal is left/right occiput the ischial spines, negative numbers (-1,
anterior. -2, -3, -4, -5) are above and positive
numbers (+1, +2, +3, +4, +5) are below
Effacement is the progressive thinning
the spines. (Illustration 16.4).
and shortening of the cervix that occurs
slowly during early labor and
progressively faster during active labor. It Illustration 16.4 Stations
may occur simultaneously with dilatation,
especially on multiparous women. It is
measured qualitatively from 0% (long and
rubbery) to 100% (very thin and soft) by
palpation of the cervix. (Illustration 16.3 2)
627
Fetal Movements During Engagement: During this stage, the bi- External rotation: The head returns to
Labor parietal diameter passes through the an anatomic position in relation to the
As the fetus descends on the birth canal, pelvic inlet and is considered engaged rest of the fetal torso. The head returns
several movements occur as a when the head reaches station 0. On now to a transverse position, just as
mechanical process where the fetus primigravid patient, this movement during engagement, while the fetal
follows the path of least resistance, occurs in the last 2 weeks of pregnancy, shoulders are passing between the ischial
adapting the position of the presenting but on multiparous patients, it may occur spines.
part to the dimensions of the birth canal when labor begins.
Expulsion: During this stage, the rest of
and producing the following movements:
Flexion: During this stage, the fetus neck the fetal body is born. The shoulders
(Illustration 16.5)
is flexed to present a shorter diameter on continue descending on an oblique
the pelvis. position as they finalize their descent on
Illustration 16.5 Fetal movements the pelvis and are delivered – first the
Internal Rotation: This occurs as the
anterior shoulder and then the posterior
presenting part crosses the ischial spines.
one at the level of the perineum. The fetal
At this point, the relative transverse
pelvis is the smallest of the large fetal
position on the head moves back to the
diameters and descends on the maternal
original occiput anterior position.
pelvis following the same path and is
Extension: The occiput reaches the delivered all at once, in contrast to the
vaginal introitus and passes under the fetal head and the shoulders.
Fetal positions for delivery. 1. Cephalic fetal symphysis pubis. During this stage, the
presentation before labor, 2. Engagement, 3.
head is born from the occipital area, the
The Delivery Procedure
Flexion, 4. Internal Rotation, 5. Extension, 6. The following materials are typically used
External rotation, 7. Expulsion of anterior bregma, forehead, nose and finally chin,
shoulder, 8. Expulsion of posterior shoulder. for a normal vaginal delivery procedure
at the perineal area of the vaginal
(does not include equipment for neonatal
introitus.
resuscitation):
628
• 0-0 absorbable (Chromic catgut or • Tissue Forceps provide additional space for the
undyed Vicryl ) suture material delivery maneuvers.
• Tissue scissors
• Basins The following videos describe and
• Umbilical cord clamp
illustrate a step by step guide to the
• Kelly clamps
Before you begin the procedure, as there normal vaginal delivery procedure.
• Light source is a high risk of exposure to body fluids,
This video demonstrates the hand
remember to wear sterile gloves, mask
• Long needle driver technique for spontaneous vaginal
with eye protection, waterproof sterile
delivery on a simulated environment.
• Mask with face shield gown, and shoe covers.
This video shows the baby’s process on a
• Material scissors Apply iodine solution to the perineal area
virtual simulation.
and clean with sterile water, then apply
• Povidone-Iodine solution sterile drapes to the patient’s thighs and Once the fetus has been delivered,
abdomen. It is likely that stool is expelled carefully place him/her on the sterile
• Shoe covers
during the birthing process; so, additional drape on the mother’s abdomen and
• Sterile drapes and towels sterile drapes should be available to stimulate while drying with sterile towels
prevent fecal contamination of the baby or gauze.
• Sterile gauze
or the perineal area.
After drying and stimulating, clamp the
• Sterile gloves
The ideal position of the patient is on a umbilical cord about 1 in or 3 cm from the
• Sterile lubricant gel birthing table with stirrups and lithotomy newborn’s abdominal skin using an
position. If this is not available, additional umbilical clamp, Kelly clamp with rubber
• Sterile waterproof gown personnel may help the patient maintain ligature or fabric ligature. Then place a
the knees flexed and the hips abducted. Kelly clamp about 1 in from the umbilical
• Suction device or bulb syringe
If a regular stretcher is used, it is helpful clamp and use the scissors to cut the
• Syringes (10-20mL), and needles (22-24 to place folded sheets or an inverted umbilical cord between the two clamps.
gauge) bedpan to elevate the patient’s pelvis and
629
Obtain a blood sample from the placental Once the placenta is delivered, inspect it During delivery of the head, gentle
end of the cord for neonatal testing.
to ensure it was delivered completely, and upward pressure with a sterile towel or
At this moment, follow the neonatal there are no remaining parts in the uterus. drape to prevent anal contamination on
resuscitation guidelines, calculate the the perineal area helps elevate the
After delivering the placenta, inspect the
initial APGAR scale and wrap the presenting part and decrease the
cervix, vaginal mucosa and the perineum
newborn to prevent hypothermia. Then, pressure the fetal chin exerts on the
for tears that may need to be repaired.
place the newborn under radiated heat. perineal skin.
The main mechanism for hemostasis after
Immediate Post-Delivery Immediately following delivery of the
the placenta has detached is uterine
Care head, palpate the fetal neck to inspect for
muscle contraction over the blood
Delivery of the placenta occurs up to 30 umbilical cord encircling the neck. This
vessels, so an infusion of oxytocin,
to 40 minutes after fetal delivery, and it is, cord needs to be reduced over the fetal
ergonovine or methylergonovine may be
for the most part, a passive process. head before delivery can continue.
given to aid in the process. Oxytocin
Once you see a slight increase in vaginal
(Pitocin) is the most commonly used As with any other procedure, don’t stand
bleeding and the remaining umbilical cord
agent. Add 20 units to a 1 Liter Normal too close to the patient as fluids may be
protrudes slightly, ask the mother to bear
Saline bag and infuse at 10 mL/min until suddenly expelled risking contamination.
down and apply very gentle traction on
bleeding is controlled. Once bleeding is
the umbilical cord to gently advance the Be very careful when holding the
controlled, finish the infusion at 1-2 mL/
placenta through the vaginal canal, while newborn, as he/she will be very slippery.
min.
applying cephalad suprapubic massage It is advisable to hold him/her close to
to the contracted uterus to prevent Key Additional Points your body.
uterine inversion. A controlled and gentle delivery of every
fetal part is preferred to an explosive
Never force the expulsion of the placenta
delivery and decreases, to some extent, References and Further Reading, click
or apply more than gentle traction as
the probability of vaginal tears. here
umbilical cord separation and uterine
inversion can cause major bleeding.
630
Section 10
Pericardiocentesis
631
are barely audible. Lungs are clear in all fields. Image 16.7
632
Image 16.8 A p e r i c a r d i a l e ffu s i o n develops when fluid accumulates in
the potential space between the visceral and parietal pericardium.
Pericardial effusion can be caused by a number of conditions
including trauma, malignancy, uremia, cardiac rupture, and
infectious causes such as tuberculosis and viral pathology. The
clinical effect of pericardial effusion can vary based on etiology,
volume, and particularly the speed at which the effusion
accumulates. If fluid accumulates very gradually, the pericardium
can remodel and stretch to accommodate the increased volume.
In these cases, symptoms are often insidious and progressive
over days to weeks. Alternatively, if fluid accumulates suddenly,
as in the case of penetrating chest trauma, the pericardium is not
able to stretch to accommodate the increased volume of fluid.
The result can be the rapid development of pericardial
tamponade and death.
Echocardiography of a pericardial effusion in the subcostal 4-chamber view.
Note the inward bowing of the right ventricle indicating cardiac tamponade Pericardial tamponade occurs when the pressure of a pericardial
and hemodynamic compromise. effusion becomes greater than the pressure in the right atrium,
resulting in the collapse of the right atrium during diastole.
Remember, the right side of the heart is a low flow system, and it
Pathophysiology and Indications does not take much pressure to impede flow. The increased
The heart is surrounded by a double layer fibrous sac known as
pressure within the pericardial space can eventually cause
the pericardial sac. The first layer, the visceral pericardium, is
compression of the entire right side of the heart, leading to the
adherent to the cardiac epicardium. The second layer, the parietal
restricted ventricular filling. This, in turn, can lead to decreased
pericardium, is separated by the visceral pericardium by 25-50
stroke volume and decreased cardiac output. If not treated, this
mL of physiologic serous fluid, allowing the heart to beat without
can result in hypotension, cardiogenic shock, and death. If an
friction.
effusion develops rapidly, as little as 150 mL of fluid, can cause
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tamponade physiology. A pericardial described in every textbook discussion of nonspecific. In the case of a chronic
effusion that restricts cardiac output pericardial tamponade, studies have pericardial effusion, a chest radiograph
resulting in tamponade is a true shown that these exam findings have may demonstrate an enlarged “water
cardiovascular emergency and is the poor sensitivity and specificity and are bottle” shaped cardiac silhouette (see
primary indication for present together with a minority of the image 16.7). However, if the effusion is
emergency pericardiocentesis. time. The most common signs and from an acute traumatic etiology, the
symptoms exhibited by patients with pericardial sac will not have had time to
At times, making the diagnosis of
tamponade include dyspnea, tachycardia, stretch to accommodate the increased
pericardial tamponade can be difficult
JVD, and a narrowed pulse volume, leaving the cardiac silhouette
because the condition can present in an
pressure. Pulsus paradoxus (a decrease unchanged.
i n s i d i o u s f a s h i o n i f t h e e ffu s i o n
in systolic blood pressure of greater than
accumulates slowly over many days to
12 mmHg during inspiration) has been Image 16.9
weeks. In these cases, the differential
found to be one of the more sensitive and
diagnosis will include many other causes
specific exam findings associated with
of shortness of breath. Alternatively,
cardiac tamponade. However, the tedious
pericardial tamponade should always be
and time-consuming nature of this exam
considered as a potentially reversible
technique makes it difficult at best and
cause in the patient who develops
often an impractical tool for diagnosing a
cardiac arrest shortly after chest trauma.
life-threatening condition in an unstable
Electrocardiogram demonstrating electrical
Cardiothoracic surgeon Claude Schaeffer patient in the emergency department. alternans in a patient with a large pericardial
effusion. Note the alternating QRS amplitude
Beck originally described the physical due to the swinging motion of the heart within
Electrocardiographic findings can include
exam findings of pericardial tamponade the pericardial sac.
low voltage QRS complexes, PR segment
in 1935 as what is now commonly known
depression, ST elevation and electrical
as Beck’s triad: muffled heart sounds,
alternans (see image 16.9), though these Ultrasound is the best and most
jugular venous distension (JVD), and
findings are also not specific or sensitive. applicable diagnostic imagining modality
hypotension. Though these findings are
Chest radiographs are equally used to identify a pericardial effusion or
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tamponade. It is noninvasive and safe, Image 16.10 Image 16.12
with no risk of radiation to the patient.
The increased availability of bedside
ultrasound in the emergency department
has allowed for instant point of care
diagnosis of this potentially life-
threatening condition. In addition to
offering direct visualization of the effusion
itself, sonography allows the operator to
assess for hemodynamic compromise
secondary to increased pericardial
Echocardiography of a pericardial effusion (PE) Echocardiography of a pericardial effusion (PE)
pressure. The initial sign of this process is in the subxiphoid view. Note that the effusion is in the apical 4-champer view. The arrow
the collapse of the right atrium in diastole, seen as a large anechoic stripe surrounding the indicates collapse of the right ventricle (RV) seen
heart. in cardiac tamponade.
followed by bowing of the right ventricle.
A pericardial effusion on ultrasound Image 16.11 Contraindications
appears as a dark (anechoic) stripe
between the myocardium and the Absolute contraindication
pericardium. Pericardial effusion can Aortic dissection.
Preparation for all providers in the room readily available, practitioners would
If the time permits and the patient is perform emergent pericardiocentesis in a
• Sterile drapes
a w a k e , t h e p ro c e d u re s h o u l d b e “blind” fashion, relying on anatomic
explained to the patient, and the • Sterile ultrasound transducer cover landmarks to guide the placement and
physician performing the procedure direction of the needle. This approach
• Sterile ultrasound gel can put surrounding structures at greater
should obtain written informed consent.
risk of injury. Bedside ultrasound allows
• Chlorhexidine sponge
Cardiopulmonary resuscitation equipment direct visualization of the heart, not only
should be readily available in the event of • 1% lidocaine with epinephrine leading to faster, more accurate diagnosis
a life-threatening arrhythmia or further of tamponade, but it also allows
hemodynamic decompensation. • 25 gauge needle (1.5 inches) and 10mL
practitioners to choose the approach that
syringe for lidocaine injection
offers them the best access to the
Intravenous sedation should be
• 16 or 18 gauge spinal needle (5-10cm) pericardial effusion while avoiding
considered but must be reconciled with
surrounding structures. The three most
the urgency of the procedure and the
• 1 empty 5mL syringe commonly used ultrasound approaches
patient’s hemodynamic stability.
are the Subxiphoid, parasternal and
• 5 mL syringe filled with 8cc of saline
If possible, elevate the chest wall apical approach (see Images
30-45%; this brings the heart itself closer • 3-way stopcock 16.13-16.15). Details regarding probe
to the chest wall. positions and the pros and cons of each
• 60 mL syringe
approach can be found in Table 1.
All providers involved in the procedure
• Central venous access kit/
should wear sterile protective clothing
Pericardiocentesis kit
including gown, gloves, and mask.
• Sterile gauze
Equipment
Procedure Steps
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Image 16.13 Image 16.14
To achieve a subxiphoid view of the heart, place the probe inferior to the
xiphoid process and angle it cephalad and towards the patient’s left. For a parasternal long approach, position the probe to the left of the
sternum, in the 4th or 5th intercostal space.
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Image 16.15
Table 16.1 Probe positions for ultrasound guided-
pericardiocentesis
PROBE
APPROACH PROS CONS
POSITION
To use an apical approach, place the probe slightly lateral to the 1. Clean and drape the patient in a sterile fashion.
midclavicular line, in the 5th or 6th intercostal space.
2. Prepare the ultrasound transducer with a sterile sheath.
Table 16.1 shows. probe positions for ultrasound-guided
pericardiocentesis • The ideal probe for this procedure is the 5 to 1 MHz
transducer due to its small footprint.
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• If that is not available, the 5 to 2 8. Once placement is confirmed, proceed Please watch video 1 and video 2.
MHz curvilinear probe should with Seldinger technique
provide adequate views. Hints and Pitfalls
• remove the syringe from the • Do not confuse the epicardial fat pad
3. V i s u a l i z e t h e a r e a o f m a x i m a l needle, with a pericardial effusion. Keep in mind
pericardial effusion with the ultrasound t h a t s i g n i fic a n t e ffu s i o n s a r e
• insert the guidewire into the
probe. circumferential, and the fat pad is only
needle tip and thread the wire.
an anterior structure. Also, fat pads will
4. If time allows and the patient is awake,
• Once the guidewire is in place, move with each contraction, whereas a
infiltrate the area of planned needle
remove the needle, keep the wire pericardial effusion does not and thus
insertion with 5 mL of 1% lidocaine.
in place. will appear to change size as the
5. Using an in-plane approach, insert the ventricular wall constricts inward away
• Thread a dilator over the
needle at a 45-degree angle (for from the pericardium with each
guidewire.
subxiphoid approach 30-45 degrees to contraction.
prevent liver puncture), maintaining • Remove the dilator, keep the wire
• Use the ultrasound to measure the
negative pressure on the syringe while in place.
depth of the pericardial effusion, and
keeping the needle tip in view on the
• Slide a catheter over the wire. make sure you use a needle that is long
screen at all times.
When the catheter is in place, the enough.
6. Observe the needle entering the guidewire can be removed.
• Keep your needle tip in view at all
pericardial sac.
9. Aspirate/drain the pericardial effusion/ times! This may require tilting or
7. Once the pericardial sac has been blood. adjusting the probe to maintain
penetrated, inject agitated saline and visualization around surrounding
look for the bubbles visible on 10.Check the vitals and check with structures as you progress.
ultrasound in the pericardial sac to ultrasound.
• Rapid drainage of pericardial effusion
confirm correct placement.
can lead to rapid increases in preload,
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which can rarely cause flash pulmonary • Immediately after the procedure, a s i g n i fic a n t l y d e c r e a s e d t h e s e
edema, bradycardia and rebound chest x-ray should be obtained to complications. A study of 1127
hypertension. ensure there is no pneumothorax or air ultrasound-guided pericardiocentesis at
under the diaphragm. Mayo Clinic showed a procedure success
• If there is a question about the source
rate of 97%. The rate of major
of bloody aspirate, look for clotting • If a pigtail catheter was inserted for
c o m p l i c a t i o n s , w h i c h w e re t h o s e
ability. If the blood is from a traumatic continuous drainage, it should be
requiring intervention, was 1.2%. The
effusion or intracardiac, it will clot sutured in place. Avoid tying the sutures
minor complication rate was 3.5%.
easily. If the blood has migrated into the so tightly that it occludes the catheter.
Similar findings have been repeated in
pericardial space and results from a
• Cover the catheter insertion site with more recent studies.
non-traumatic effusion, it will be
sterile gauze and tape.
defibrinated and thus will not clot or will Specific complications to be
take much longer to clot. • The patient should remain on a cardiac aware of include:
monitor. • Dry tap (often caused by blockage of
• Agitated saline can be prepared by
the needle with clot or tissue)
connecting two 5mL syringes to the • Vital signs and cardiac rhythm should
needle catheter via a 3-way stopcock frequently be reassessed to monitor for • Dysrhythmias, though the literature
valve. One syringe contains saline, the findings that would suggest re- suggests dysrhythmias related directly
other air. Agitate the saline by rapidly accumulation of the effusion and to the pericardiocentesis procedure
pushing the saline from one syringe to inadvertent procedural complications. itself are rare
the other with the stopcock closed to
• Myocardial or coronary artery puncture
the needle catheter. The saline is Complications
Most complications of pericardiocentesis leading to hemopericardium
sufficiently agitated when it appears
cloudy. are related to needle penetration of either
• Liver laceration
the heart or surrounding structures.
Post Procedure Care and Studies have cited serious complication • Pneumothorax/hemothorax
Recommendations rates of 20-30% using the blind
• Pneumopericardium
approach. The use of ultrasound has
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• Vascular injury, most likely the internal mammary artery and the
intercostal neurovascular bundle
• Suppurative pericarditis
• Costochondritis
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Section 11
Lumbar Puncture
Case Presentation
by Khuloud Alqaran A16-year-old male, without a known case of any medical
illness, presented to the ED accompanied by his mother. His
chief complaint was altered mental status. Three days earlier
to his presentation, he had a fever, nausea, vomiting, and
headache. The symptoms worsened over time. His mother
noted that 2 weeks earlier he visited his grandmother at the
intensive care unit. On physical examination, he opened his
eyes once the doctor called his name; then, he said, “Where
am I, what is the time?” He was moving in the bed with no
neurological focal deficit. Vital signs as following: Temperature
38C, heart rate of 110/min and blood pressure of 100/45
mmHg. Nuchal rigidity was positive, and he had skin rashes
over his shins as shown in the picture below.
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Image 16.16 IIH) by measuring the opening pressure investigations may be needed with
of the Cerebrospinal fluid (CSF) the CT scan.
• Sterile dressing
• Sterile drape
• Alcohol Swabs
• Syringe 3mL
• 3 Way stopcock
• Monometer
• Syringe 10mL
• 2×2 Gauze
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• Infant 1.5in or 3.8cm • Lateral recumbent with spine parallel to columns of L4 at the level of the
bed: in this position, the patient’s hips, posterior superior iliac crests. (Adult
• Child 2.5in or 6.3cm
knees, and chin are flexed toward his/ injection site – any interspinous space
• Adult 3.5in or 8.8cm her chest (fetal position). Analgesia, from L2-S1 as the spinal cord
sedation or anxiolytic (e.g., terminates at L1 level. However,
The registered nurse or any doctor benzodiazepine) can be considered if pediatrics injection site should be only
colleague to help position the patient appropriate to reduce patient anxiety. from L3-L4/L4-L5 interspinous space
during the procedure as the conus medularis ends at the
• Sitting upright with hips flexed with feet
level of L1-L3).
Place/order CSF tests needed prior to the on a stool: in this position, the patient is
procedure awake and cooperative. It’s preferred in 3. U s e a s k i n - m a r k i n g p e n t o
obese patients when it would ease approximate the entry site.
Patient preparation
midline localization. The patient would
• Informed consent needs to be taken 4. Gown up and maintain universal
sit upright; his/her lumbar spine should
from the patient or the legal guardian. precautions (sterile gloves, surgical
be perpendicular to the table. His/her
facemask, and head cap).
• Speak to your patient during the foot should be supported by a stool and
procedure; the patient is already not hanging down. A pillow can be 5. Apply the antiseptic solution in a
anxious and can’t see what you are placed at the patient lap so he/she can circular motion starting from the entry
doing. Talk to the patient and explain bend forward and keep his/her chin site to the periphery.
what you are doing in a calm manner. towards his/her chest (angry cat
For example, say: “ Now I am going to position). 6. Apply the sterile drape.
numb the site with a smaller needle; it
7. Create a skin wheal of 1% Lidocaine;
may have a burning sensation. Please Procedure Steps
make sure it is no more than 1mL to
don’t move.” 1. Position the patient as mentioned
avoid losing the landmark. Then inject
above
• Patient placed in two positions upon into the deeper tissues.
preference and patient condition or age 2. Identify the landmarks anatomically by
palpating the midline vertebral
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8. Advanced the needle at the midline Please watch video 1 and video 2. • Ask someone to help you hold the
with your dominant hand holding the patient and maintain his position
hub and your non-dominant hand Hints and Pitfalls during the procedure.
supporting the needle by placing the • Like any other procedure, preparation is
a must. Position the patient, palpate his • If still anxious, give him/her some
thumb/index finger on the shaft of the
back, get to know his anatomy, then anxiolytic or even sedation if
needle for balance, parallel to the bed.
mark it with a marking pen. necessary.
The angle should be facing upward,
aiming at the umbilicus. • Injecting lidocaine can sometimes
• Your patient is elderly, and you are
hitting a bone only after insertion of obscure your landmark.
9. Characteristic “pop” is occasionally
felt when the needle passes the dura. 25% of your needle. In most patients,
• Try not to inject more than 1mL to
If there is no sound, draw the stylet the needle should be inserted 50-75%
make a wheal; then, inject the
periodically checking for the CSF after of its length prior to obtaining CSF flow.
remaining in the deeper tissues.
approximately 4-5 cm.
• You may be hitting calcified
• The traditional teaching “feel the first
10.Once CSF starts to drain, attach the supraspinal ligament.
pop then the second pop, CSF will
manometer to measure the pressure. flow.”
• Try to enter from the lateral aspect
Then, start collecting the fluid from to avoid the calcified ligament.
tube number 1 to 4 in sequence • Never depend on the pop. Most of
pattern. No more than 1mL in 1-3 • The patient can get very anxious and the time a series of pops are felt
tubes, then 3-4mL in tube 4. alarmed. instead, as several spinal
ligaments are encountered prior to
11.Replace the stylet before removing the • Talk to the patient; he can’t see entering the space.
needle; then, remove both of them what you are doing. Tell him what
together. step you are going to do. • In obese patients,
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• Use the full length of the needle to • RBC counts taper down from • Protein (mg/dL)
3.5-inch, or use the 6-inch tube 1 to tube 4. This is not
• Culture or gram stain
“harpoon” needle. fully reliable unless it is
completely clear by the 4th • Normal values include 5-20 cmH2O
• Try to do it in a sitting position.
tube, but classically, the RBC opening pressure, equal to or less
• CSF is red or tinged red count decreases by 30%. than 5 WBC per mm3, no
neutrophils, 50-80 mg/dL glucose
• The needle is too deep and hits a • Examining the 4th tube as a
and 20-45 mg/dL protein.
venous plexus leading to a separate entity can also help
traumatic tap. On the other hand, rule out SAH • The bacterial CSF sample shows
it’s subarachnoid hemorrhage or elevated opening pressure >500
• <100 RBC: almost certainly
meningitis. WBC per mm3, >80% PMNL, low
traumatic
glucose (<40 mg/dL), and increased
• Signs of a traumatic tap
• <500 RBC: probably protein (>50 mg/dL). In addition,
• The absence of traumatic culture or gram stain indicates
xanthochromia (shows up bacteria. The viral sample, however,
• >10K RBC: likely SAH
within 12 hours and persists shows normal or slightly elevated
2-4 weeks). If present at the • Is it bacterial or viral? opening pressure, 100 – 500 WBC,
time of the taping then its neutrophils less than 50% and
• There are couple measures helping lymphocytic predominance, normal
highly suggest SAH.
us to identify the cause. These are glucose, protein is normal or slightly
• RBC count 400-500 RBCs or elevated, and culture or gram stain
• Opening pressure (cmH2O)
less suggestive of the indicates the virus.
traumatic tap. Must become • WBC count (per mm3)
zero at one of the last tubes. Post-procedure Care and
• Neutrophils (%) Recommendations
• Glucose (mg/dL)
647
• The patient may lie flat; however, there (e.g. bed rest, oral analgesia, in some
is controversial evidence that it may cases caffeine drinks can help). A
reduce headache incident. refractory headache, an epidural blood
patch is recommended. Using non-
• Vital sign should be recorded
cutting, smaller diameter needle can
depending on the hospital guidelines.
decrease the occurance. 20-22 gauge
• Neurological examination at least every atraumatic needles are the best choice.
4 hours within the first 24 hours.
Other complications are;
• Encourage fluid intakes up to 3L/24hrs • Infection
(tea and caffeine may help).
• Heriniation syndrome
• Monitor the puncture site for any
• Formation of subarachnoid epidermal
bleeding, CSF leakage or infection.
cyst
• Ensure the patient void after 8 hours
• Backache and radicular syndrome
post procedure.
• Spinal epidural hemorrhage
• Administer analgesia accordingly.
Case Presentation
by Sara Nikolić and Gregor Prosen A 47-year-old man presents to your ER complaining of nausea
and vomiting. He tells you that vomiting started a couple of
hours after eating dinner the night before. It was a normal
vomit, consist of digested food; however, it is not associated
with meals. He has barely eaten during the past 36 hours. The
pain consists of cramping and is vaguely umbilical, but it is
not well localized. He gets mild relief from vomiting and says
the pain is severe (9/10). He has felt generally unwell and has
not taken his temperature. None of his close contacts have
reported any vomiting. His last bowel movement was
yesterday morning, and he cannot recall passing any flatus
today. About 20 years ago he had an appendicectomy.
649
and mild distension of his small bowel with numerous Introduction
Nasogastric (NG) tube placement is one
abdomen. You hear high- valvule conniventes and
of the most common procedures
pitched bowel sounds on increased peristalsis with performed in intensive care settings, the
auscultation. whirling motion of the bowel emergency department, and hospital
• Explain the procedure and gain consent • Place the kidney plate near the patient
in case there is leakage.
652
• War n patient you will start the auscultating a rush of air over the inability to speak, or significant nasal
procedure and in case of pain they stomach using the 60 mL Toomey hemorrhage occurs.
should tip you on the hand. syringe is not as helpful because the
sounds of air in the bronchial tree can Hints and Pitfalls
• Gently insert the NG tube along the • During insertion, if concern exists that
be mistaken for gastric insufflation.
floor of the nose. Advance NG tube the NG tube is in the wrong place, ask
parallel to the nasal floor (not angled up • Apply benzoin or another skin the patient to speak. If the patient can
into the nose) until it reaches the back preparation solution to the nose bridge. speak, then the tube has not passed
of the nasopharynx, where resistance Tape the NG tube to the nose to secure through the vocal cords and/or lungs.
will be met (10-20 cm). it in place.
• To improve the success rate of
• At this moment, ask the patient to sip • If clinically indicated, attach the tube to nasogastric tube placement, provide
water through the straw and start wall suction after verification of correct external and medially directed pressure
swallowing. With each sip you continue placement. on the ipsilateral neck at the level of the
to advance the NG tube until the thyrohyoid membrane. It will collapse
• Dispose of used equipment into a
distance of the previously estimated the piriform sinus and eliminate it as a
clinical waste bin and wash hands.
length is reached. potential site for impaction. This
• Explain to patient that the procedure is maneuver was successful for difficult
• Confirm the tube’s placement in the
over. Reassure that the NG tube will nasogastric intubation in 85 percent of
stomach by radiographic imaging.
become more comfortable over the patients.
Alternatively, gently aspirate gastric
next few hours. Offer patient paper
contents with a 3-cc syringe, and check • The nasogastric tube may coil in the
towels to clean their face and nose.
the pH. A pH < 4 suggests the tip is in a oropharynx, mouth, or hypopharynx.
Document clearly the procedure.
gastric location. A pH > 5 does not Cool the tube in cold tap water or ice
reliably predict location because the Please watch video 1 and video 2. water for 5 minutes to make the tube
respiratory system and intestinal tract stiffer and then reinsert it. A larger bore
distal to the pylorus often have a pH > Withdraw the nasogastric tube if, at any
tube may be inserted more easily. A
5 . Ve r i f y i n g t u b e p o s i t i o n b y time resistance, respiratory distress, the
final option is to place several fingers
653
through the patient’s mouth and into the tube in anesthetized and tracheally perforation or errant placement of the
oropharynx. The fingers can be used to intubated patients after the first nasogastric tube.
guide the tube against the posterior attempt.
• Although auscultation of air in the
oropharyngeal wall and into the
• American Association of Critical-Care stomach has been classically used to
hypopharynx. Do not attempt this
Nurses partook a survey about feeding determine correct placement, air
unless the patient is unconscious or
tube practices in adult intensive care insufflated into the pleural space or the
paralyzed to prevent them from biting
units. The recommendations were to esophagus after misplacement of the
the fingers.
obtain radiographic confirmation that tube can be just as easily heard over
• The risk for tube misplacement is each blindly inserted tube is correctly the upper abdomen.
greater in the intubated patient who is positioned before the first use, which is
• Gastric contents should be able to be
unable to assist with nasogastric currently not adequately implemented.
aspirated through the nasogastric tube.
intubation. Observe that there are no Also, auscultation is widely used
changes in the patient’s oxygen despite recommendations to the • Testing the pH of the gastric contents
saturation when inserting the contrary. can help predict the placement of the
nasogastric tube. It is very easy for the nasogastric tube. However, in one trial,
nasogastric tube to pass by the cuff of Post Procedure Care and pH of 4 was able to accurately identify
an endotracheal tube without much Recommendations the location of only 56% of all NG
resistance. • The patient should be able to speak
feeding tubes when compared with the
without respiratory distress immediately
reference standard radiography. The
• GlideScope facilitates NG tube insertion after placement of the nasogastric tube.
use of H2 blockers makes the
and reduces the duration of the Observe the patient for complaints of
assessment of gastric pH difficult.
procedure in anesthetized patients. neck pain, substernal chest pain,
Radiographic demonstration of the tube
Also, esophageal guidewire-assisted dysphagia, drooling, trismus, fever, or
in the antral or fundal portion of the
insertion with manual forward laryngeal subcutaneous and mediastinal air.
stomach is the preferred method of
displacement technique most frequently These would be signs of esophageal
confirmation.
results correct positioning of the NG
654
Complications a cuffed endotracheal tube does not often results in mediastinitis with a
• The most common complication of preclude passage into the respiratory subsequent mortality rate of up to 30%.
nasogastric intubation is discomfort in tree. The nasogastric tube will pass the Prompt recognition, surgical repair, and
the nasopharynx and oropharynx. cuff of the endotracheal tube without parenteral antibiotics can reduce the
significant resistance. Advancing the mortality rate to less than 10%. The use
• Placement in the nares can result in tube into the airway can result in of softer and smaller nasogastric tubes
epistaxis if the nasal mucosa is irritated, perforation of a bronchus or the lung with generous lubrication can reduce
abraded, or ulcerated. a n d re s u l t i n a p n e u m o t h o r a x , the risk of esophageal perforation.
hydropneumothorax, pulmonary
• These complications can be reduced or
hemorrhage, empyema, or Pediatric, Geriatric,
avoided with generous lubrication of the
bronchopulmonary fistula. These Pregnant Patient, and Other
nasogastric tube and the installation of
topical anesthetics and complications are increased if Considerations
medication or alimentation is infused The placement of a nasogastric tube in
vasoconstrictors.
into the respiratory tree. children is often difficult. Their large
• Sinusitis may occur from the tonsils and adenoids may hinder the
nasogastric tube obstructing the sinus • The most serious complication of passage of the nasogastric tube. These
ostia. These complications are usually nasogastric tube placement is tissues are soft, easily injured, and may
of no clinical significance. the esophageal perforation. This most bleed as the nasogastric tube is passed.
often occurs in the posterior wall of the The tongue, large by comparison with
• A more serious consequence of cervical portion of the esophagus and adults, may push into the oropharynx and
nasogastric intubation is misplacement through the cricopharyngeus muscle. impede the passage of the nasogastric
into the respiratory tree. This is Risk factors for esophageal perforation tube. Their nostrils and nasal passage are
estimated to occur in up to 15% of include a preexisting esophageal quite small and limit the size of
cases. The incidence increases in abnormality, altered mental status, nasogastric tube that may be passed.
frequency with a patient who has a cervical osteophytes, cardiomegaly, Also, size is calculated by the formula
diminished gag reflex or a decreased tracheal intubation, a rigid nasogastric ((age in years + 16) / 2). Typical sizes
level of consciousness. The presence of tube, and multiple attempts. Perforation include 8 French for infants, 10 to 12
655
French for small children, and 12 to 14 French for older children.
Most common complications are nasal ala pressure sores that are
usually not associated with significant morbidity and mortality.
656
Section 13
Introduction Definition
by Nik Rahman When working in the emergency room, Procedural sedation is defined as the
one often finds himself in a situation use of short-acting analgesic and
where painful diagnostic or therapeutic sedative agents in order to enable
procedures are needed to be clinicians to perform procedures
performed. These procedures cause effectively while monitoring the patient
major pain and anxiety to the patient closely for potential adverse effects.
and using local anesthesia on its own
does not suffice in some situations. Terminology
Procedural sedation reduces anxiety, A n x i o l y s i s i s a s t a t e i n w h i c h
657
Dissociation is a trancelike cataleptic may appear somnolent but is 5.General anesthesia refers to the
state induced by an agent such as arousable to voice or light touch. drug-induced loss of consciousness
Ketamine and is characterized by (Reflex withdrawal from the painful which patients are not arousable to
profound analgesia and amnesia. In this stimulus is not considered a painful stimulation. In this state, the
state, protective reflexes, spontaneous purposeful response.) ventilatory function is often impaired,
respirations, and cardiopulmonary and assistance may be required to
3. Dissociative sedation is a cataleptic
stability are preserved. maintain the airway and respiration.
state induced by a dissociative agent
Positive-pressure ventilation may be
The controlled reduction of environmental (i.e., Ketamine). This state is
required as spontaneous ventilation is
awareness is called sedation. characterized by profound analgesia
o f t e n i m p a i re d . C a rd i o v a s c u l a r
and amnesia. This state is achieved
function may be impaired as well.
Levels of Sedation while airway protective reflexes are
1. Minimal sedation (anxiolysis) refers a maintained along with spontaneous The different levels of sedation need to be
patient in this state responds normally respiration. Cardiopulmonary stability understood as each scenario may require
to verbal commands, although is also maintained. a certain level to be achieved to facilitate
cognitive functions and coordination t h e p e r f o r m a n c e o f t h e re q u i re d
may be impaired. Respiratory and 4. Deep sedation/analgesia is a state
procedure.
cardiovascular functions are where the patient has a depressed
unaffected as this state essentially level of consciousness in which he/she Steps for PSA
involves mild anxiolysis or pain control. requires painful or repeated stimulation Early planning and preparation are key to
to evoke a purposeful response. preventing adverse events that may occur
2. Moderate sedation/analgesia involves Patients may require assistance to and can be catastrophic if procedural
depression of consciousness while maintain a patent airway. Spontaneous sedation is poorly managed.
patients still respond purposefully to v e n t i l a t i o n m a y b e i n e ffic i e n t .
verbal commands or light tactile Cardiovascular function is usually Adequate staffing needs to be ensured;
stimulation. Airway, ventilation and preserved. this is done by having a nurse or another
cardiovascular functions are all qualified individual present for continuous
spontaneously maintained. The patient monitoring of vital signs and airway
658
patency as well as having a separate provider performing the Anesthesiology consultation may be required for a
procedure. patient with an anticipated difficult airway or an ASA classification
of III. It may be wise to have the anesthesiologist perform the
Pre-procedural evaluation sedation in the operating room which is a better-controlled
The patient should be evaluated for sedation. PSA may not be
environment.
suitable for every patient in the ED. This can be done objectively
by using the ASA classification and difficult airway assessment Consent
(Table 16.2). When possible, a written consent should be obtained that
discusses the risks, benefits, and potential side effects of PSA.
Table 16.2 American Society of Anesthesiologists Physical The patient or direct family members need to sign the consent
Status Classification
before the procedure takes place.
SEDATION
CLASS DESCRIPTION EXAMPLES
RISK
Equipment Preparation
Normal and No past medical Minimal 1. High-flow oxygen source: ASA guidelines recommend
I healthy patien history
considering oxygen for moderate sedation and strongly
Mild systemic Mild asthma, Low
recommend it for deep sedation.
disease without controlled
II functional diabetes
limitations 2. Suction should be prepared in case any secretions accumulate
Severe systemic Pneumonia, Intermediate in the airway, which in turn need to be suctioned.
disease with poorly controlled
III functional seizure disorder
limitations 3. Airway management equipment: there may be a need for
Severe systemic Advanced cardiac High airway support during PSA. An appropriate size endotracheal
disease that is a disease, renal
IV tube should be prepared with an intubating blade, an oral
constant threat to failure, sepsis
life airway and a bag valve mask (BVM).
Moribund patient Septic shock, Extremely high
who may not severe trauma 4. Monitoring equipment includes a pulse oximeter, ECG monitor/
V
survive without defibrillator, transcutaneous pacing pads, Blood pressure
procedure monitor, and Capnography. Capnography measures end-tidal
carbon dioxide (CO2) partial pressure. The ASA recommends
659
the use of capnography for monitoring patients during PSA • Respiratory depression and hypoxia are possible
whether they are on supplemental oxygen or not. The aim is to
Generally, Etomidate has been shown to be safe and effective
detect if the patient’s ventilatory drive is affected during the
when used for procedural sedation.
procedure in order to perform corrective measures when
needed.
KETAMINE
Ketamine is a rapidly acting dissociative anesthetic that also
5. Vascular access equipment
produces a profound analgesic effect. Doses can be repeated
Medications used in PSA and titrated to effect with no risk of cumulative adverse events.
Onset, duration, and dosing vary according to the route of
ETOMIDATE administration.
Etomidate is a fast-acting sedative with little analgesic effect. The
onset of action is usually within 1 minute with a short duration of Contraindications:
action. It lasts between 3 to 5 minutes with standard dosing.
• Hypersensitivity to the medication
Elimination is done rapidly by the liver; therefore, duration of
action may be longer in patients with liver failure. It has few • Can lead to a hyper-sympathetic state, which might be
hemodynamic effects, and its neutral cardiovascular profile deleterious especially in patients with Coronary Artery Disease
makes it one of the most appealing agents for use.
• Avoided in patients who are predisposed to psychotic behavior
The contraindication is hypersensitivity to the medication.
Ketamine is a Pregnancy Category C medication
Etomidate is a Pregnancy Category C medication
Side Effects:
Side Effects:
• Ketamine is a derivative of the street drug Phencyclidine; it
• Muscle twitching is a well-known side effect that is generally causes an increase in systemic and pulmonary blood pressures,
well tolerated heart rate, cardiac output, cardiac workload and myocardial
oxygen demand. It should be avoided in elderly or patients with
• Nausea and vomiting may occur after emergence
cardiac diseases.
660
• Most common side effect seen with Ketamine is the emergence should be preceded by an opioid when performing painful
phenomenon. It occurs in approximately 15% of patients and is procedures.
mild in almost all of them. Less than 1 to 2% of patients have
Contraindications: in patients with allergy to eggs or soy
significant emergence agitation.
Side Effects:
• Transient airway laryngospasm (0.4%)
• Respiratory depression
• Emesis
• Apnea
FENTANYL
A rapid-acting synthetic opioid administered intravenously. • Hypotension
Duration of action may last from 30 to 60 minutes. It is a pure
analgesic with no sedative properties; therefore, it must not be • Pain over the injection site
used alone for PSA.
MIDAZOLAM
It is a Pregnancy Category C medication Midazolam is a benzodiazepine sedative, amnestic and anxiolytic
agent with no analgesic properties. It is usually combined with
Side Effects: opioids like Fentanyl to provide a good combination of sedation
and analgesia during PSA. It is eliminated by hepatic metabolism
• Respiratory depression is more likely at higher doses
and renal excretion; therefore, prolonged effects may be seen
• Hypotension and bradycardia are rare but may occur with high with dysfunction of any of those two organs.
doses
Side Effects:
PROPOFOL
• Cardiopulmonary depression
This is an ultra-short-acting sedative-hypnotic agent that has no
analgesic properties. It is quickly cleared from the body, It is a Pregnancy Category D medication
permitting superior titration, earlier recovery, and discharge. It
also possesses potent antiemetic properties and decreases The following table 16.3 summarized the list of all medications
intracranial pressure. Because of lack of analgesic effect, it used during procedural sedation.
661
Table 16.3 Agents Used in Procedural Sedation
ONSET OF DURATION OF
AGENT RECOMMENDED DOSE SIDE EFFECTS AND COMMENTS
ACTION ACTION
Initial dose in adults: 1 to 1.5 1 to 2 minutes 30 minutes Cough, hiccup, itching, vomiting, respiratory depression
mcg/kg intravenously
Fentanyl Titrate: 1 mcg/kg every 3 Requires another agent for sedation, repeat dosing may be required
minutes intravenously
Initial dose in adults: 0.02 mg/kg 1 to 2 minutes 30 minutes Respiratory depression, hypotension
Titrate: 1 mg intravenously every
Midazolam 3 minutes Requires another agent for analgesia, poor reliability, repeat dosing
Initial dose in children (6 months may be required
- 5 years of age): 0.1 mg/kg
1 mg/kg Intravenously, then 0.5 15 to 30 seconds 5 to 10 min Respiratory depression, apnea, hypotension, pain over injection site
mg every 3 minutes if needed Advantages: Rapid onset, short duration, antiemetic, cerebral
Propofol protective.
Contraindications: allergy to eggs or soy
Reversal Agents exceed that of the reversal agents. If used, it should be followed
Fentanyl and Midazolam both have antagonists that can be used by an extended observation period to ensure recovery.
to reverse their effects.
Caution: when using Flumazenil, it may lead to Status Epilepticus,
Agents like Naloxone for opioids (i.e., Fentanyl) and Flumazenil for especially in patients with unidentified benzodiazepine use or in
benzodiazepines (i.e., Midazolam) are the ones commonly used patients with a known seizure disorder.
for this purpose. However, the routine use of reversal agents
should be avoided as the duration of the sedation agents may
662
Recovery and Discharge
Finally, it is important to monitor all patients until the moment of
recovery. Drowsy patients should not be left unattended. Patients
should be monitored until they spontaneously wake up and are
able to perform their normal functions independently. Complete
recovery to baseline function may not be necessary for discharge.
Generally, an awake patient who is able to drink without vomiting,
able to ambulate and voids normally is capable of going home
ideally with family members or friends as an escort. Appropriate
discharge instructions should be given.
663
Section 14
664
• Cardiac/respiratory arrest (this will go to • Assessment of airway: Anticipating hyoid bone? Submandibular space is
crash intubation) difficulty in establishing an airway in adequate to accommodate the tongue
emergency patients is the first step in making the visualization of the glottis
Steps of RSI (7 Ps) avoiding major complications. This easy. Is the larynx low enough in the neck
1. Preparation & Plan helps us to think about alternatives to be accessible? The distance from the
2. Preoxygenation of RSI. For example, neuromuscular hyoid to the thyroid. 2 fingers are what
paralysis should generally be we are looking for.
3. Pre-treatment avoided in patients with a high level
M – Mallampati: Oral access is assessed
of intubation difficulty.
4. Paralysis and induction with the Mallampati scale. Visibility of the
LEMON oral pharynx ranges from complete
5. Protection and positioning
visualization, including the tonsillar pillars
L – Look externally: Look for external
6. Placement with proof (class I), to no visualization at all, with the
markers of difficult intubation; these may
tongue pressed against the hard palate
7. Post-intubation management include the following body habitus, head
(class IV). Class I and class II predict
and neck anatomy (short neck), mouth
adequate oral access, class III predicts
Preparation (small opening, loose teeth or prominent
moderate difficulty, and class IV predicts
• Equipment (tube, blade, Oxygen, teeth), jaw abnormalities (significant
suction, capnography, monitoring (ECG, a high degree of difficulty. (illustration
malocclusion), and beards.
BP, SpO2)) 16.6)
E – Evaluate 3-3-2: 3-3-2 rule is to assess
O – Obstruction or obesity. Upper airway
• Peds tube size: (age+4) /4 or use the patient’s airway geometry to
Braselow tape obstruction can make visualization of the
determine his or her suitability for direct
glottis, or intubation itself, mechanically
• The depth of the tube: size x 3 laryngoscopy. Can the patient fit 3 fingers
impossible. This may present as stridor,
between the incisors? For optimum
inability to swallow secretions or
• Asses for difficult airway, and set plan B glottis visualization, an adequate mouth
alteration in voice quality. Conditions
for failed airway opening is required. Is the mandible
such as epiglottitis, head and neck
length 3 fingers from the mentum to the
665
Illustration 16.6 Mallampati extension is the most important •Very ill patient <2 minutes
maneuver, and simple extension may be
as effective as the “sniffing” position in Pretreatment
It is used to blunt the adverse effect of
achieving an optimal laryngeal view. Neck
laryngoscopy and intubation but scant
mobility can be significantly reduced in
evidence
patients with trauma (cervical collar) or
the elderly and those with arthritis. Medication of pretreatment
666
Indication for pretreatment: • Rapid action, and short duration. It has approximately 1 minute, and has a
PREMED no analgesic effect. clinical duration of 10 to 15 minutes.
• Pediatric
• It’s the most hemodynamically stable • Many protective reflexes are preserved
• Resistance (asthma) induction agent. This is an advantage with Ketamine, including airway
over other agents in shock, anaphylaxis reflexes. Ketamine has a direct
• Elevated ICP
or any case where the further drop in bronchodilator effect and causes
• MI blood pressure can be catastrophic. catecholamine release. Therefore, it is
mainly used in patients with asthma,
• Elevated BP • Etomidate has a potential
anaphylaxis and hemodynamically
cerebroprotective effect as it decreases
unstable patients. Because of its
• Dissection cerebral metabolic oxygen consumption
features, it’s an excellent alternative to
and reduces cerebral blood flow and
Paralysis and Induction etomidate.
intracranial hypertension while
You don’t want an awake paralyzed
maintaining cerebral perfusion pressure • Side effects are the raise of BP (avoid in
patient!!
elderly) and emergence phenomena
• Side effects are nausea, vomiting,
First induction agent is given, then it is (visual, auditory, proprioceptive and
m y o c l o n u s a n d a d re n a l c o r t i c a l
followed by a paralytic agent. The confessional illusions which may
depression with multiple doses.
induction agents main aim is to induce progress to delirium after waking up
rapid loss of consciousness to facilitate Ketamine from sedation)
ease of intubation.
• 1-2mg/kg IV, 4-5mg/kg IM. Propofol
Medication for induction
• NMDA receptor antagonist. • 1.5 to 2.0 mg/kg IV,
Etomidate
• Ketamine produces a loss of awareness • It produces significant venous dilation,
• 0.2-0.3 mg/kg IV within 30 seconds, peaks in myocardial depression and can reduce
cerebral perfusion pressure.
667
• Because of the propensity of propofol • It can rise serum potassium levels, and minutes. It can be reversed by
to cause hypotension, through both is contraindicated in the following Sugammadex which can be an
vasodilation and direct myocardial circumstances: advantage in some circumstances.
depression, the dosage is reduced, or
• Hyperkalemia A video about RSI drugs.
the drug is avoided altogether in
hemodynamically compromised • Patient ≥5 hours post burn Protection and Positioning
patients. In-line Stabilization: In cases of trauma in
• Patient ≥5 days post crush injury
which cervical spine injury is suspected
Other agents: Benzodiazepines like or denervation
and not yet ruled out, protection of the
midazolam and barbiturates like
• Neuromuscular diseases cervical spine is a priority and intubation
thiopental and methohexital
(amyotrophic lateral sclerosis, must be performed without movement of
Paralytic agents multiple sclerosis, muscular the head. An assistant is required to
dystrophy) maintain inline stabilization. This allows
Neuromuscular blocking agent (NMB) are
the cervical collar to be opened giving
mainly divided into depolarizing agents • Denervation (stroke, spinal cord better access. The head and neck are
(DPA) and non-depolarizing agents injury) >5 days until 6 months post maintained in the neutral position.
(NDPA) injury
If no cervical spine injury is suspected
Succinylcholine • Intra-abdominal sepsis >5 days flexing the neck and extending the head
until resolution to the so-called sniffing position helps to
• 1.5 -2 mg/kg.
align the axes and facilitates visualization
Rocuronium
• It is the only DPA used in the of the glottic opening.
emergency room having a rapid onset • 1-1.2 mg/kg.
and short half-life. It takes 45-60 Placement with proof
seconds to induce paralysis and takes • NDPA. Intubation should be performed carefully
8-10 min to recover. and gently. After flaccidity is achieved
• It has a comparable time to paralysis
laryngoscopy glottis is visualized, the
but a longer recovery time of 35-45
668
clinician places the endotracheal tube prepared and started as soon as
between the cords, inflates the cuff, possible. A post-procedural chest x-ray is
withdraws the stylet, and confirms obtained to confirm the depth of tube
placement. placement and to evaluate for evidence
of barotrauma as a consequence of
A video about intubation details.
positive pressure ventilation. Oro-Gastric
Intubation video. tube and urinary catheter insertion used
to decompress the stomach and monitor
Confirmation of proper endotracheal tube urine output respectively.
(ETT) placement is crucial; unrecognized
esophageal intubation leads to
devastating complications.
References and Further Reading, click
C o n fir m t h e p l a c e m e n t b y a here
combination of
Post-intubation management
After intubating the patient, the tube is
tied or taped in place. Maintaining
sedation is essential; infusions should be
669
Section 15
Introduction
by Dejvid Ahmetović and Gregor Prosen Most of the orthopedic injuries can be predicted considering the chief complaint,
the age of the patient and the mechanism of the injury itself. Additionally, a careful
physical examination and the patient’s history can often predict radiographic
findings with great accuracy. If an injury is suspected by clinical examination but
cannot be completely confirmed by evaluating the radiograph, the patient should
be treated as if the injury is present and discharged with detailed instructions on
how to look out for any additional signs of neurovascular complications,
compressions, and cast care.
670
Dislocation: Complete disruption of a joint, whereby articular Illustration 16.7 Type of fractures
surfaces are forced from their normal position, which immobilizes
the joint temporarily. In the case of a subluxation, there is still a
partial contact of the articular surfaces.
Fractures
Orthopedic injuries commonly result from accidents and often
involve otherwise healthy individuals, especially in the younger
population. Accurate diagnosis and treatment are of great
importance both economically and medically.
671
Description of Common adolescents. Damage to the growth plate Illustration 16.8 SALTER-HARRIS
during growth may destroy part or all of Classification
Fractures
Pathologic fractures: A type of injury its ability to produce new bone, thus
that results from a relatively small force preventing elongation of the bone, which
applied to otherwise diseased or may lead to anatomical and functional
weakened bone, which in normal deformities.
circumstances would not disrupt the
Conveniently, the Salter-Harris fracture
cortex. Examples of such types of injuries
types can be memorized by the
are fractures through metastatic lesions,
mnemonic SALTR.
fractures through benign bone cyst and
vertebral compression fractures in S – (slipped), fracture plane passes all the
individuals with advanced osteoporosis. w a y t h r o u g h t h e g r o w t h p l a t e .
A – (above), Fracture passes through
Stress fractures: These types of
most of the growth plate and up to the
fractures involve ‘fatigued’ bone tissue
m e t a p h y s i s .
that was exposed to repetitive forces. The
L – (lower), A fracture that passes through
bone and supportive tissue did not have
the growth plate and extends down
enough time to adequately accommodate
t h r o u g h t h e e p i p h y s i s .
such forces. A common example is the Open fractures: An open fracture is a
T – (through, transverse or together), A
fracture of the metatarsal shaft in fracture associated with overlying soft
f r a c t u re p a s s i n g d i re c t l y t h ro u g h
unconditioned foot soldiers and athletes. t i s s u e i n j u r y, c a u s i n g a n o p e n
metaphysis, growth plate and epiphysis.
It is known as ‘march fracture.’ communication between the fracture or
R – (rammed, ruined), An uncommon
crushing type of injury that does not dislocation and the environment.
Salter-Harris fractures: Fractures
involving the physis and cartilaginous displace the growth plate but damages it
by direct compression.
Reduction
epiphyseal plate near the ends of the long Reduction of fractures includes many
bones in still growing children and options, some of which are appropriate
672
for one type of injury and some for reduction must be anatomical, or it could o r closed fixation of the bone defect.
another. The reduction can be either lead to joint incongruity and arthrosis. O p e n re d u c t i o n re q u i re s s u rg i c a l
anatomical or non-anatomical. intervention for alignment of the fracture
Treatment Options
fragments; however, in closed reduction,
Non-anatomical reduction in children is
General steps in fracture treatment the fracture is reduced by manual
used for extra-articular fractures.
a r e r e d u c t i o n , i m m o b i l i z a t i o n , manipulation of the affected area. There
Because of the remodeling potential in
and rehabilitation. is also a difference between internal and
children, most deviations and anatomical
external fixation. The term internal fixation
positions will be corrected spontaneously, Conservative treatment involves either itself suggests that the immobilizing
but only if no rotation is present. In functional treatment or closed implant is under the skin (bone surface or
adults, for example, fractures of the immobilization with or without any closed intramedullary), and external fixation
humeral shaft, deviations, and non- reduction. It is indicated in non-displaced presents in the case when most of the
anatomical positions are well tolerated fractures and when a certain degree of fixation material is outside the skin. (With
both functionally and cosmetically. The displacement is acceptable. Examples this method, the risk of infection of the
same applies to femoral and tibial shaft include clavicular, scapular and rib fracture is minimal. It is mostly used in
fractures when length, rotation, and axis fractures, most stable vertebral types of severe open fractures.)
remain the same. fractures and pelvic fractures, also when
the pelvis is stable, most extra-articular Generally, the indications for surgical
Anatomical reduction in children is
fractures in children because of their treatment are open fractures, displaced
indicated in the case of some epiphyseal
remodeling potential, and any extra- intra-articular fractures, avulsion fractures
fractures, especially in those that are
articular fractures when the anatomical and all femoral shaft fractures.
intra-articular because if the reduction is
position can be reached by closed
not perfect, the gap will be filled with Reductions of Selected
reduction and maintained by closed
callus, which can consequently cause Fractures
external immobilization.
premature closure of the growth plate. In Any standard reduction procedure should
intraarticular fractures in adults, the Surgical treatment involves open or include these steps
closed reduction of the fracture and open
673
1. Confirming fracture with imaging if 7. Axial traction, rotation, or angulation Image 16.18
there is no neurovascular compromise maneuvers may be necessary for the
and immediate reduction is needed different type of fractures. Therefore,
apply proper technique accordingly.
2. Defining the need of reduction
procedure 8. After the reduction, please make sure
the reduction is acceptable. Therefore,
3. Explaining the procedure to the patient
you can use imaging for the
and getting his/her consent for
confirmation.
reduction and sedation and analgesia.
You may also prefer to use hematoma 9. S t a b i l i z e t h e e x t r e m i t y a s
or regional blocks. recommended in the Splinting /
Casting chapter.
4. Prepare the team and the equipment.
Some fracture reductions may need 10.If you are going to discharge the
more than one person if you are not patient do not forget to give discharge Image shows comminuted fracture of the middle
phalanx of 2nd finger.
using special traction devices for the instructions and arrange follow up with
reduction purpose. Prepare the post- orthopedic clinic. Pain, swelling, typical angulation because
reduction splinting/casting equipment of extensor tendon are typical
as discussed in the Splinting / Casting Fracture of the middle phalanx
presentation.
chapter.
Treatment is conservative in case of
The mechanisms;
5. Properly place the patient and injured proper reduction. However often surgical
extremity. • direct force caused by fall, fixation required. In general, simple axial
traction is enough to align the fractured
6. Properly position yourself and other • blow from a heavy object, phalanx. However, keeping the fractured
team members.
• twisting force. parts in an acceptable alignment can be
674
difficult. Therefore, immediate splinting/ different specific maneuvers, please fracture in the elderly. Fall on
casting required. watch sample videos (video 1 and video 2 an outstretched hand is the primary
and Video 3) mechanism of injury.
Boxer’s fracture
Colles’ fracture Treatment options are conservative
Image 16.19 treatment with marginally displaced
Image 16.20 fractures and surgical (open reduction
internal fixation (ORIF), external fixation)
with severe displacement and unstable
reduction.
Nightstick fracture
Image 16.21
It is a fracture of the neck of the 4th. or
5th metacarpal. Image shows 5th
metacarpal neck fracture. Swelling, pain
and obvious deformity are seen in the
presentation. Striking a clenched fist into
Fracture of the distal radius, with dorsal
an immovable object is the most
displacement and volar angulation.
common mechanism.
Swelling and reduced movement and
Treatment is conservative for acceptable
characteristic clinical deformity named
angulation (30° for 5th metacarpal) after
‘dinner fork deformity’ are seen in the
reduction, surgical with severe
presentation. It is the most common wrist
displacement. The reduction requires
675
It is a fracture of the shaft of either radius Fracture of the femoral shaft T o learn how to apply Hare Traction
or ulna or both. Splint, please watch video.
Image 16.22
Deformity and pain are prominent in the Dislocations
presentation. The name of the fracture Any standard reduction procedure should
derived from citizen trying to defend include these steps
against baton or nightstick, offering
forearm. Caused by direct force, blow or 1. Confirming dislocation with imaging if
elbow 90°. The surgical option is ORIF 3. Explaining the procedure to the patient
with plate fixation in unstable fractures. The figure shows a complex segmental
and getting his/her consent for
fracture of the shaft.
Forearm reduction video. reduction and sedation and analgesia.
Swelling, deformity, loss of function, pain, Yo u m a y a l s o p r e f e r t o u s e
exter nal rotation are presentation the intraarticular anesthetic agent.
findings.
4. Prepare the team and the equipment.
The mechanism is a direct or axial force Many dislocation reductions may need
of high energy. The reduction with axial more than one person if you are not
traction should be applied in order to using special traction devices for the
d e c re a s e p a i n , h e m o r r h a g e , a n d reduction purpose. Prepare the post-
anatomical alignment. After the reduction, reduction splinting/casting/sling
traction splint should be placed. The equipment as discussed in
definitive treatment is surgical (ORIF) with the Splinting / Casting chapter.
plate or nail.
676
5. Properly place the patient and injured Dislocation of the Pain, deformity are two main
extremity. interphalangeal joints of the characteristics at the presentation.
fingers
6. Properly position yourself and other Axial loading and hyperextension cause
team members. the dislocation. Dislocations are usually
Image 16.23
dorsal.
7. Axial traction, rotation, or angulation
maneuvers may be necessary for the Longitudinal traction and hyperextension
d i ffe r e n t t y p e o f d i s l o c a t i o n s . with applying dorsal pressure to the base
Therefore, apply proper technique of the dislocated phalanx usually
accordingly. reduce the dislocation.
8. After the reduction, please make sure Finger dislocation reduction video.
the joint is in normal anatomy.
Figer dislocation metacarpal block video.
Therefore, you can use imaging for the
confirmation.
Shoulder dislocation
9. S t a b i l i z e t h e e x t r e m i t y a s
recommended in the Splinting / Image 16.24
Casting chapter.
10.If you are going to discharge the The image shows a fracture and subluxation at
patient do not forget to give discharge the distal and fracture and dislocation at the
proximal phalangeal joint.
instructions and arrange a follow up
with the orthopedic clinic. Dislocations of the PIP joint are a The images show loss of shoulder curve on the
common hand injury, as opposed to DIP left, and X-ray of the same patient with anterior
Reductions of Selected dislocation, which is rare, because of the
shoulder dislocation and severe Hill Sacks
deformity (cortical depression in the
Dislocations firm attachments of the skin and posterolateral head of the humerus) + fracture.
The majority of the cases are successfully Watch the video for reduction of the hip.
Image 16.25
reduced with simple maneuvers
(conservative reduction). Traction and Artificial hip dislocation - reduction -
external rotation-elevation, scapular video.
rotation, Cunningham are the most
popular techniques. However, there are
many other successful methods. Please References and Further Reading, click
do not use the Hippocrates and Kocher here
techniques because of their high The images show posterior hip dislocation.
679
• Barton Fracture (Dorsal or volar rim • Contraindicated if overlying cellulitis •The plaster should be measured
fracture of the distal radius) or grossly contaminated wound prior to placement and should be
8-10 layers thick
Precaution • Clean skin with an antiseptic solution
4. Place the patient in a sling and perform
The presence of an open fracture requires • First, anesthetize skin with a small
post-reduction plain radiographs
a n e m e rg e n t o r t h o p e d i c s u rg i c a l wheal of lidocaine
consultation and surgical fixation with Please watch the video.
• Then dive deeper into the largest
open reduction and internal fixation.
area of swelling and hematoma and Hints and Pitfalls
Equipment and Patient Preparation aspirate blood. Once confirmed that
• Using too much padding can
you are within the hematoma, gently
• Syringe cause your splint not to provide enough
inject 10-15 cc of anesthetic.
support, resulting in malunion.
• Lidocaine • Wait at least 10 minutes for the
• Using too little padding can
anesthetic to be absorbed prior to
• 4” Plaster result in plaster burning the skin.
beginning your manipulation.
• Soft web roll lining
3. Perform a closed reduction with the Post Procedure Care and
• 4” ace wrap aim of creating a neutral volar tilt (15- Recommendations
degree angulation in wrist flexion)
• Sling Always take post-reduction radiographs
○ The sugar tong splint should be
Procedure Steps applied by placing a U-shaped splint Complications
from the dorsal metacarpal-phalangeal
1. Obtain standard radiographs including • Malunion
joints down around the elbow joint and
posteroanterior and lateral films
wrap back around to come up to just • Nonunion
2. Local anesthesia via hematoma block below the metacarpal-phalangeal
joints on the palmar surface. • Median nerve injury
680
Case Presentation 2 Procedure: Posterior Long •4” Plaster
11-year-old male with no past Arm Splint • Soft web roll lining
Emergency Indication
medical history presents with
• 4” ace wrap
right arm pain around the • Supracondylar fracture
• Sling
elbow after falling off of the • Distal Humerus fracture
monkey bars at the playground Procedure Steps
• Monteggia’s fracture
earlier today. Plain radiographic 1. Obtain standard radiographs including
• Proximal forearm fractures
films will show a supracondylar posteroanterior and lateral films
681
wrist joint without crossing into the Complications Case Presentation 3
hand.
• Malunion
26-year-old male with no past
• The plaster should be layered at medical history presents with
8-10 layers thick, as this is a long • Nonunion
left ankle pain after landing on
arm splint and will be heavier than • Median nerve injury
the average short arm splint.
another player’s foot while
• Pressure ulcers jumping up during a basketball
• The elbow should be placed at 90
degrees of flexion with the wrist in a • Decreased range of motion game.
neutral position, which is neither
supinated nor pronated.
Image 16.28
5. Place the patient in a sling and
perform post-reduction plain
r a d i o g r a p h s .
Hints and Pitfalls
682
Procedure: Short Leg Splint • 4” or 6” Plaster (depending on the size •Wait at least 10 minutes for the
Emergency Indication of the leg) anesthetic to be absorbed prior to
beginning your manipulation.
• Ankle fracture • Soft web roll lining
3. Placing a short leg splint for this type
• Tibia fracture • 6” ace wrap
of fracture involves pre-measuring two
• Crutches separate strips of plaster.
• Severe ankle sprain
Hints and Pitfalls show a fracture of the distal • Distal femur fracture
• Lidocaine
684
• 4” or 6” Plaster (depending on the size • Wait at least 10 minutes for the Please watch video.
of the leg) anesthetic to be absorbed prior to
beginning your manipulation.
• Soft web roll lining
Post Procedure Care and
3. Placing a long leg splint for this type of
• 6” ace wrap Recommendations
fracture involves pre-measuring three
• Crutches strips of plaster: one from the plantar Make sure to provide adequate analgesia
surface of the toes to the gluteal fold, both before and after the placement of
Procedure Steps one support strut from the medial the splint.
ankle up to the proximal inner thigh,
1. Obtain standard radiographs including
and the last support strut from the Complications
posteroanterior and lateral films
lateral ankle up to the greater
• Malunion
2. Local Anesthesia via hematoma block trochanter of the femur.
• Nonunion
• Contraindicated if overlying cellulitis 4. Wrap the leg in web roll padding
or grossly contaminated wound • Pressure ulcers
5. Firmly secure the splint with a top layer
• Clean skin with an antiseptic solution o f w e b r o l l a n d a c e w r a p
• Decreased range of motion
Hints and Pitfalls
• First, anesthetize skin with a small • Early onset arthritis
wheal of lidocaine 6. Test for neurovascular function
• Then dive deeper into the wound 7. If the fracture is in the midshaft of the
overlying the largest area of swelling femur or proximal femur, casting is not
and hematoma and aspirate blood. an appropriate option. Orthopedic
Once confirmed that you are within consultation and traction fixation will
the hematoma, gently inject 10-15 cc be required temporarily, prior to
of anesthetic. surgical fixation.
685
Case Presentation 5 Procedure: Short Leg Cast •Soft web roll lining
• Chucks (or any material that you can • Clean the skin with an antiseptic
use to keep the counters and floors solution
clean)
• First, anesthetize skin with a small
• Water source (basin half full of water will wheal of lidocaine
suffice), lukewarm temperature
• Then dive deeper into the wound
• Syringe overlying the largest area of swelling
and hematoma and aspirate blood.
• Lidocaine
Once confirmed that you are within
• 4” and 6” Plaster (depending on the the hematoma, gently inject 10-15 cc
size of the leg) of anesthetic.
686
• Wait at least 10 minutes for the prevent “bananaing” of the plaster tibial plateau) to prevent pressure
anesthetic to be absorbed prior to when applying. ulcers.
manipulation.
• Plaster or fiberglass is then wrapped • Test for neurovascular function after
3. Placing a short leg cast for this type of around the foot and ankle up to the casting
fracture involves first ensuring the foot proximal tibia ensuring it remains in
• Short leg casts are often “bi-valved” or
is sitting in proper anatomical 90 degrees of flexion.
cut in half prior to discharge from the
alignment ankle flexed at 90 degrees.
• A foot plate can be added by placing hospital. This is done in order to allow
• The first step is to adequately pad 6 layers of plaster on the bottom of for some room for swelling.
the entire area of casting (from them for support.
Post Procedure Care and
1-2cm distal to the tibial plateau) to
• To prevent cutting off blood flow to Recommendations
the distal foot (covering the base of
the distal foot when the injury swells,
the phalanges) leaving the tips of the Make sure to provide adequate analgesia
bi-valving of the cast should be done
toes uncovered. Extra padding both before and after the placement of
by cutting along the medial and
should be placed at the areas of the splint.
lateral shin, through the plaster or
pressure (the ends of the cast) and
fiberglass.
the heal to prevent ulcers. Complications
4. Give the patient crutches and perform
• The second step is to apply the • Malunion
post-reduction plain radiographs
plaster ensuring the ankle remains at
• Nonunion
90 degrees of flexion. The entire rolls Please watch video.
of plaster are dipped and soaked in • Pressure ulcers
lukewarm water and then squeezed Hints and Pitfalls
to remove some of the water. The • Decreased range of motion
• Extra padding should be applied to
thumb and index finger should be
areas of pressure (tips of toes, heal at • Early onset arthritis
placed at each end of the plaster to
the malleoli and top of the cast at the
687
• Contracture of the Achilles tendon if the foot is <90 degrees of
flexion
688
Section 17
Case Presentation
by Gul Pamucu Gunaydin A 75-year-old male patient was admitted to the emergency
department with difficulty voiding. He had this complaint for
over a year, and tonight, although he felt pain and distention in
his lower abdomen, he could not urinate at all. On his physical
exam, the patient had a palpable mass that was thought to be
the distended bladder. He was agitated and tachycardic. He
was diagnosed with acute urinary retention, and initial attempt
to insert urinary indwelling catheter was failed. The second
attempt with a Coude catheter was successful and 2 liters of
urine was drained gradually. His rectal exam revealed prostate
enlargement. He was discharged with instructions,
uneventfully.
689
with incontinence, who can void • Draining urine in acute urinary retention, Absolute
spontaneously. Suprapubic catheters are urinary obstruction, inability to void
an option if urethral catheters fail. This • Trauma patient presenting with the
• Irrigation of bladder to remove gross following signs (known or suspected
chapter focuses solely on urethral urinary
hematuria and clots/debris urethral damage):
catheterization.
• Palliative care for terminally ill (e.g.to • Blood at meatus
Emergency Indications
assist treatment of decubitus ulcers in
incontinent patients by maintaining • Penile deformity
Short-term catheterization
moisture free environment) • High riding prostate
• Diagnostic sampling (sterile urine • Intubated patient • Allergy to latex, rubber or lubricants
sampling)
• Emergency Surgery Relative
• Monitoring urinary output (trauma,
critically ill, burns) Long-term catheterization • Uncooperative patient
• Bladder outlet obstruction
• Filling the bladder prior to pelvic • Recent bladder or urethral surgery
• To reduce changes in patients who are
ultrasound
terminally ill or cannot care for • Urethral Stricture
• Cystogram, cystourethrogram themselves
Equipment and Patient
• Urine collection • Neurogenic bladder Preparation
Urinary catheter: Catheters are classified
• Monitoring core body temperature • Urinary incontinence according to the material it is made of,
number of lumens and shape of the tip.
Therapeutic Contraindications
Number of lumens
690
• One way-non balloon also known as • The Roberts tip catheter has an eye •Sterile local anesthetic lubricant gel:
straight, Nelaton or Robinson catheters above and below the balloon to reduce (% 2 lidocaine gel) anesthetizing the
are used for one time or intermittent the residual urine. urethra with topical lidocaine gel
drainage. instilled through a pre-loaded syringe
Catheter size is described in French units.
reduces discomfort. The catheter tip is
• Two-way catheters have a balloon It refers to the catheter’s circumference in
also lubricated prior to its insertion.
inflation channel and a urine drainage millimeters. Start with 12-16 F for adults.
channel. Choose the smallest size that is enough • 10 ml syringe filled with sterile saline or
for adequate drainage. If obstruction of sterile water
• Foley catheter, which has a self-
the catheter due to blood or debris is
retaining balloon, is the most commonly • Sterile urine bag
expected, use a larger bore catheter (e.g.,
used.
18-24 F). • Tape to secure the urine collection
• The triple lumen (three-way) indwelling system
Catheter length: Adult indwelling
catheter is used for bladder irrigation.
catheters are available in a standard
Procedure Steps
Shape of Tip (male) length (40-45cm) and a shorter Universal precautions should be taken in
female length (20-26cm). Female length all steps. Patient consent should be
• Coude or Tieman catheter curves 45 catheters should not be used in male obtained before starting any procedure.
degrees at the tip and is designed to patients because of the risk of inflating Ensure the privacy of the patient. Aseptic
pass urethra in patients with prostatic the balloon in the urethra. insertion technique is recommended.
enlargement; it offers rigidity too.
Other Equipment:
• The Whistle Tip (Couvelaire Tip)
Female Patients
• Sterile gloves and drapes 1. Prepare all equipment on a tray
catheter has a terminal and a lateral
covered with a sterile drape in a sterile
drainage eye used for large blood clots.
• Sterile gauze sponge or cotton balls fashion.
691
3. Wear your sterile gloves. 11.Inflate the balloon with 10 ml of sterile solution and paint the area in a sterile
water or saline using the filling port. fashion with the antiseptic solution.
4. Check the balloon for patency.
12.Pull the catheter back until resistance 7. Alternatively, you may change gloves
5. Place a fenestrated drape over the
is felt. after cleansing external genitals.
perineum.
13.Attach the urine collection bag. 8. Inject 10 mL of 2% lidocaine gel into
6. Spread the labia with your non-
the urethra through the meatus before
dominant hand. 14.Secure the catheter to the anterior
insertion of the catheter.
thigh.
7. Use the forceps/pickups to hold the
9. P e r f o r m s t e p 1 0 - 1 5 o f f e m a l e
sterile sponge, soak it in the antiseptic 15.Remove gloves, dispose of waste
catheterization.
solution, and clean the area from appropriately, and wash hands.
anterior to posterior and central to 10.When the procedure is finished, don’t
Please watch below videos (manikin and
peripheral. forget to reduce foreskin to prevent
patient examples)
iatrogenic paraphimosis.
8. Alternatively, you may change gloves
after cleansing external genitals. Male Patients Please watch below videos (manikin and
Perform step 1 to 4 of female patient
patient examples)
9. Lubricate the tip of the catheter with catheterization.
%2 lidocaine gel. Hints and Pitfalls
5. Firmly hold the penis with the non-
• Universal availability and ease of
10.Pass the catheter through the meatus dominant hand, and position the penis
insertion of urinary catheters often lead
and advance it until the hub meets the 45 to 90 degrees to the coronal plane,
to the inappropriate and prolonged use
urethral meatus, you should be able to apply gentle traction. Retract the
of these catheters. Insert catheters only
see urine flowing. Insert the catheter foreskin if the patient is not
for appropriate indications and leave
2-3 inch or 5-7.5 cm more, preferably circumcised.
catheters in place only as long as
until the hub to avoid inflating the
6. Use the forceps/pickups to hold the needed.
balloon inside the urethra.
sterile sponge, soak it in antiseptic
692
• A tense patient means a tight urethral • Place the urinary drainage bag below •Patients’ follow up with urology
sphincter; encourage the patients to the level of the patient’s bladder, not should be arranged.
relax by taking deep breaths and relax allowing it to touch the floor.
• Discharge instructions:
urinary sphincter muscles as if going to
• For difficult urinary catheterization,
void. • If you develop any symptoms of a
change the size: 20-24 F catheter for
urinary tract infection, contact your
• Always be gentle; never force the benign prostate hyperplasia, small
doctor immediately.
catheter since this may cause urethral caliber for the urethral stricture (12-16
trauma. F). • Take enough fluids to maintain
adequate urine flow.
• If no urine has returned, do not inflate • If catheterization is unsuccessful, it is
the balloon. best to avoid multiple blind attempts • Be careful not to pull the catheter
since they increase the risk of infection, accidentally, avoid twisting and
• Even when urine is flowing, it is
exacerbate the patient’s discomfort, kinking of the catheter.
possible for the eye of the catheter to
and produce urethral congestion and
lie within the bladder while the balloon • Keep the bag lower than the bladder
edema, rendering further attempts even
remains within the prostatic urethra; so, to prevent back flowing.
more challenging.
always advance the catheter until the
hub. • Patients occasionally experience • Avoid disconnecting the catheter and
hypotension and hematuria when the drain tube.
• If there is pain during inflation of the
large volume from the bladder is
balloon, stop immediately since the • Empty the bag regularly. The
drained rapidly but has little clinical
balloon may still be in the urethra. drainage spout should not touch
significance, and gradual emptying is
anything while emptying the bag.
• Once inserted, the catheter should be not necessary.
secured to prevent traction and damage • Alpha blockers may be started to
Post-Procedure Care and patients with prostate enlargement.
from movement and catheter kinks.
Recommendations
Complications
693
• Discomfort, pain • Vena cava air embolism • Pyelonephritis
• Inability to pass the catheter • Infections: UTI accounts for 32% of all • Bacteriemia, urosepsis
healthcare-associated infections. A
• Misplacement of the catheter • Latex allergies
majority of these infections are
• Vagina attributable to the use of an indwelling • Obstruction or blockage of catheter
c a t h e t e r. U s e o f b e s t p r a c t i c e results from precipitated mucus,
• Ureter techniques by emergency nurses can protein, crystals, blood clots, and
help prevent UTIs from occurring as a bacteria.
• Renal Pelvis
result of urinary catheter insertions in
• Traumatic complications to lower the emergency department. Earlier • Urine leakage around the catheter
urinary tract – proper insertion catheter removals, use of smaller bore
• Fragmentation or fracture and
technique is the single most important catheters, a closed drainage system,
retainment of the catheter
factor for preventing injury. optimal hygienic techniques (hand-
washing, sterile catheterization • Catheter knotting
• Passage of the catheter into a false
techniques) by health care workers, and
lumen • Balloon rupture
removal of the catheter when infection
• Intraurethral balloon distention is suspected are effective in minimizing • Calculi formation
the incidence of infection.
• Hematuria • Bladder spasms contraction
• Urinary tract infection
• Rupture of urethra 11 (may cause • Accidental removal of the catheter
urethral stricture in the long term) 5 • Urethritis
• Stricture formation in long-term
• Bladder perforation • Prostatitis
Pediatric, Geriatric, Pregnant
• Hydro uterus • Epididymoorchitis Patients and Other
Considerations
• Paraphimosis • Cystitis
694
• Use 6-10 F catheters for pediatric
patients, 12F for patients age >12
years, 5F for infants
• To prevent infections:
695
Chapter 17
Selected
Diagnostic Tests
Section 1
Indications for arterial blood Generally, the radial, brachial and the
gas (ABG) analysis are femoral arteries are used for this
• Diagnosis and follow-up of metabolic purpose. The choice of the artery is
and respiratory acidosis and alkalosis associated with many factors. It mainly
depends on the physician’s experience
• Determination of the type of
and the patient’s clinical condition.
respiratory failure
Primarily, the radial artery is preferred.
The Allen test should be performed
697
prior to the procedure to evaluate the PaCO2: Alveolar ventilation •PaO2: Between 40-59 mm Hg,
adequacy of the collateral circulation in “moderate hypoxemia.”
PaO2 and PCO2: Gas exchange
hand. The obtained blood gas sample
• PaO2: Below 40 mmHg, “severe
should be delivered to the laboratory as Ph, PCO2, and HCO3: These are used to
hypoxemia.”
soon as possible. evaluate the acid-base status.
of arterial blood gas?” has been raised, oxygenation. Arterial and venous blood
• Brain lesion or diseases gases provide similar and very close
and many studies have been performed
on this subject. Since venous blood gas measurements in terms of PC02, HCO3,
• Centrally acting drugs or chemicals
is easy to sample from the peripheral and pH levels.
• Salicylate,
veins or the central veins in patients with
702
Table 17.1 The comparison of arterial, peripheral vein and
central blood gases
PERIPHERAL
CENTRAL VENOUS
VENOUS BLOOD
BLOOD GAS
GAS
3 to 8 mmHg higher than 4 to 5 mmHg higher than
PCO2 the arterial pH the arterial pH
703
Section 2
704
• <20 mg/dl in children Color
• Purulent :bacterial /TB manengitis.
Normal LP opening pressure
• Xanthochromia [yellow color] in case of SAH,
• In adults: 60-200 mmH2O [6-20 cm H2O].
Hyperbilirubinemia.
• In children who are < 8 years 10-100 mmH2O.
Image 17.2 Xanthochromia
• In neonate: 30-60 mmH2O
Image 17.1
• High Opening pressure: overproduction, infection, bleeding, The sample on the left represents xanthochromia. Retrieved from http://
www.medfriendly.com/xanthochromia.html
tumor, false measurement [sitting position, Valsalva or crying].
705
Cytology • Blood [traumatic Taps /SAH). References and Further Reading,
High WBC count click here
• Multiple sclerosis.
• Viral meningitis [ predominant
• Guillain-Barre syndrome.
lymphocytes].
Miscellaneous test
• Bacterial meningitis [ predominant
PMNs ]. • India ink for Cryptococcus
Opening
• SAH Pressure (cm 7-18 >20 cm H2O Normal/high High
H2O)
Biochemistry WBC/mm3 0-5 25-10000+ 10-500 Slightly high
Glucose level
WBC/RBC ratio
Differentials Lymphocytes PMNs Lymphocytes
same to serum
• Decreases in case of bacterial/TB
RBC/mm3 0-5 Normal Normal >500
meningitis or CNS tumor.
Glucose mg/
45-80 <20 Normal/low Normal
100ml
Protein
Protein mg/
15-50 50-10000 50-200 60-150
• Increases in: 100ml
Urine Analysis
707
• Clear or yellow pale – normal due to • Reflects the ability of the kidney to •High
pigments called urochrome maintain normal hydrogen ion
• All causes of oliguria,
concentration in plasma & ECF
• Milky – Purulent UTI, chyluria
• Glycosuria,
• Acidic urine
• Orange/Red – Urobilinogen, Red
• DM,
Beetroot ingestion, Hemoglobinuria, • Ketosis-diabetes,
Haematuria • Dehydration,
• starvation, fever,
• Brown/Black – alkaptonuria, melanin • nephrotic syndrome
• systemic acidosis,
Odor • Low
• UTI by E.coli,
• Normal – aromatic due to the volatile • All causes of polyuria except
• acidification therapy and high
fatty acids glycosuria DI,
protein diet
• Ammonical – bacterial action(E. coli) • pyelonephritis,
• Alkaline urine
Fruity- ketonuria, starvation
• glomerulonephritis
• Strict vegetarian,
• Musty – Phenylketonuria
Osmolality
• Systemic alkalosis,
• Fishy – UTI with Proteus
• Normal – able to produce 500-850
• UIT by pseudomonas or Proteus,
• Rancid – Tyrosinemia mOsm/kg water
• alkalinization therapy,
Urinary pH • Dehydrated with normal renal function –
• CRF 800 – 1400mOsm/kg water
• Normal pH 4.6 – 8
Specific Gravity • Diuresis with normal renal function – 40
– 80 mOsm/kg water
• Normal range- 1.003 to 1.035
708
Chemical Examination • A prognostic marker for kidney • acromegaly,
disease
Proteinuria • Cushing’s disease,
• in diabetes mellitus (earliest sign
• Glomerular proteinuria, e.g., nephrotic • hyperthyroidism,
of renal damage in DM)
syndrome
• drugs like corticosteroids
• in hypertension (sign of end-organ
• Tubular proteinuria: e.g., acute n damage) • Glycosuria without hyperglycemia
chronic pyelonephritis, heavy metal
poisoning, TB kidney • i n c re a s i n g m i c ro a l b u m i n u r i a • renal tubular dysfunction
during the first 48 hours after
• Overflow proteinuria: Bence Jones admission predicts an elevated Ketones
p ro t e i n s ( p l a s m a c e l l d y s c r a s i a ) , risk for acute respiratory failure,
hemoglobin( intravascular hemolysis), • Acetone, Acetoacetic acid, β-
multiple organ failure, and overall
myoglobin(skeletal muscle trauma) hydroxybutyric acid
mortality
709
• Early hepatitis • trauma, •Pigment casts – include those
produced endogenously, such as
• hepatocellular jaundice • tumors of the urinary tract
hemoglobin in hemolytic anemia,
Blood myoglobin in rhabdomyolysis, and
Microscopic Examination
The centrifuged sample of urine sediment bilirubin in liver disease.
• Prerenal
is examined on a glass slide under high
Cellular casts – Red cell casts, White
• bleeding diathesis, magnification after the supernatant is
cell casts, and Epithelial cell cast
discarded
• hemoglobinopathies, • Red Cell casts – The presence of red
Acellular casts – Hyaline casts, Granular,
blood cells within the cast is always
• malignant hypertension Waxy, Fatty, Pigment casts and Crystal
pathologic, and is strongly indicative of
casts
• Renal glomerular damage, usually associated
Clarity Clear
pH 4.5-7.4
Glucose Negative
Protein Negative
Ketones Negative
Blood Negative
Bilirubin Negative
Nitrite Negative
711
Section 4
712
Red blood cell (RBC) count • RDC Red cell distribution width result in abnormalities due to cell
713
• Inflammation (i.e., vasculitis) • Underlying hematopoietic disease •H e m o c o n c e n t r a t e d s t a t e s
(aplastic anemia, agranulocytosis) (dehydration, burns, diarrhea)
• Myeloproliferative disorder
• Immunosuppression, • High altitude,
• Tissue necrosis (burns)
• Medications (antibiotics, • Exercise,
• Myocardial infarction
chemotherapeutic agents)
• Polycythemia Vera
• Physiological stress (e.g., exercise,
Patient presenting with neutropenia is at
pain, surgery, prolonged crying in • Chronic obstructive lung disease
risk of infections from common and
infants)
opportunistic organisms.
Decreased Hb
• Medications (steroids) • Iron deficiency, vitamin deficiencies,
Decreased HCT
e.g., vitamin B12
• Vomiting • Blood loss
• Bleeding,
• Dysrhythmias • Hemolysis
• Kidney disease
• Acute myocardial infarction (AMI), • Long-standing anemia
• Inflammatory disorders (rheumatoid
• Pregnancy • Pregnancy
arthritis or infections)
The physician should look for a “left shift” If suspecting acute loss, the physician
• Hemolysis (accelerated loss of red
which indicates the presence of immature should look for schistocytes on the
blood cells through destruction)
forms in the peripheral circulation peripheral blood smear. Long-standing
(bands). Usually, this represents an anemia can be evaluated by the RBC • Inherited hemoglobin defects
infectious state. indices. Administration of fluids in (thalassemia or sickle cell anemia)
hypovolemic patients or trauma
Decreased WBC resuscitation will cause a decreased HCT. • Cirrhosis of the liver
• Infection (overwhelming sepsis or viral),
Increased HCT
714
• Bone marrow failure and cancers that • Infections (SBE, HIV, septicemia, Toxic granulations, Döhle Bodies,
affect the bone marrow mononucleosis) and cytoplasmic vacuolization are
remnants of phagocytosis found in
Causes of increased Hb are similar to • Drug-induced destruction (penicillin,
neutrophils. These are indicative of more
HCT. heparin, sulfonamide, quinine)
serious bacterial infections.
716
Chapter 18
Selected Imaging
Modalities
Section 1
eFAST
718
Image 18.4 Left Upper Quadrant to the operating room where he abdominal and cardiac injuries at
your institution, transfer the patient to a
undergoes a midline
facility with this capability. A stable
laparotomy. A spleen injury is patient with free intraabdominal fluid
identified intraoperatively. should undergo further diagnostic testing
such as CT to ascertain the specific
Introduction injury.
The objective of the extended focused
While peritoneal lavage has been
assessment for sonography in trauma
traditionally utilized to evaluate for
(eFAST) is to detect free fluid in the
intraabdominal blood in the hypotensive
peritoneal, pleural and pericardial spaces,
trauma patient, the eFAST exam offers
and also to detect free air in thoracic
Image 18.3 Suprapubic view several advantages over peritoneal
cavities. In the setting of trauma, we
lavage. The eFAST exam is non-invasive,
assume this fluid is blood; however, it can
repeatable, rapid and sensitive for injuries
be urine or bowel contents as a result of
requiring surgical intervention. It also
organ rupture or it can be pre-existing
does not interfere with computed
ascites. An eFAST exam should take less
tomography (CT) interpretation. Rozycki
than 5 minutes to complete.
et al. reported that the FAST exam was
In the peritoneal cavity, 200 ml of fluid shown to be 100% sensitive and 100%
can be detected via ultrasound in the specific for hypotensive blunt abdominal
ideal patient. In reality, however, the trauma patients. Conversely, peritoneal
smallest detectable amount is usually lavage is invasive, can only be performed
After 1 Liter of normal saline, around 500 ml. Hypotensive trauma once, may require laboratory processing
patients with free abdominal fluid need and has a high false positive rate.
the patient remains
urgent operative intervention. (Protocol 1) Peritoneal lavage may also confound
hypotensive and is transferred If there is not a surgeon who can repair interpretation of abdominal CT imaging.
719
Rapid detection of pericardial tamponade detected by the eFAST exam in which hemithorax for the presence of
and cardiac injuries is of critical case, the eFAST should be repeated. hemothorax or pneumothorax. Finally, the
importance in the trauma patient. inferior vena cava is imaged to estimate
Fortunately, ultrasound is very sensitive Procedure the patient’s volume status. While
for the detection of pericardial fluid. As The premise behind the eFAST exam is performing the exam, we ask four yes/no
little as 10 to 20 ml of fluid can be readily that free fluid accumulates in the questions. These are;
identified in the pericardium. In one of the dependent areas of the abdomen. An
extended FAST exam involves several 1. Is there fluid in the peritoneal cavity?
original studies on the FAST exam,
pericardial fluid had a sensitivity of 100% views. These are;
2. Is there a pericardial effusion?
and a specificity over 99% for cardiac 1. Subcostal or Parasternal Long Axis
injury. Therefore, trauma patients with a 3. Is there fluid in the thorax?
Cardiac
pericardial effusion have a presumed
4. Is there a pneumothorax?
cardiac injury requiring evaluation in the 2. Right Upper Quadrant
operating room. (Protocol 2)
3. Left Upper Quadrant Emergency Indications
Indications for the eFAST include both
Hypotensive trauma patients who do not
4. Suprapubic blunt and penetrating traumatic injuries
have free fluid in their abdominal,
as well presentations of unexplained
pericardial, or plural spaces should be 5. T h o r a x f o r H e m o t h o r a x a n d
hypotension as part of an ultrasound
investigated for further injury. For Pneumothorax
shock protocol (i.e., RUSH exam) to
instance, the patient may have spinal
6. IVC for volume status rapidly diagnose the cause of low blood
shock, a long bone fracture causing
pressure.
blood loss, or lost a significant amount of Perform either a subcostal view or
blood at the scene of the trauma. Other parasternal long axis view of the heart to Contraindications
non-traumatic causes should also be l o o k f o r p e r i c a r d i a l e ffu s i o n o r Contraindications to the eFAST are
considered such as myocardial infarction. tamponade. Views of the abdomen primarily situations in which performing
Another possibility is that there is not yet include the right and left upper quadrants the study would delay or interfere with
a large enough amount of blood to be as well as a suprapubic view. Image each
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critical life-saving interventions including Image 18.6 Curvilinear Transducer Image 18.7 Linear Transducer
emergent surgical intervention.
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Image 18.8 Ultrasound and Patient side. When the transducer marker is point Image 18.9 Transducer marker
Bed Position towards the patient’s head (longitudinal
orientation), the patient’s head will be
toward the left side of the screen, and
their feet will be toward the right side of
the screen. When the probe marker is
pointed to the patient’s right side, the
patient’s right will be toward the left side
of the screen, and the patient’s left will be
toward the right side of the screen.
Procedure Steps
Perform the eFAST exam immediately Image 18.10 Longitudinal Orientation
after the primary ATLS survey. Some
Transducer Orientation
Each transducer has a marker, which is authorities recommend applying e-FAST
oriented in the same direction as the during the circulation phase of the
except the parasternal long axis cardiac should be performed before the patient is
view, the probe marker should be pointed rolled to minimize shifts independent fluid
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Image 18.11 Transverse Orientation Image 18.12 Subcostal Transducer Video: Normal Subcostal Cardiac
(pelvis) Position View. Again, the right ventricle is the
closest cardiac chamber to the chest
wall. The left ventricle and both atria are
also visible. The bright white line is the
pericardium. No anechoic fluid is
visualized between the heart and the
pericardium. There is a normal heart rate
and good contractility.
parasternal long axis view. A low- pressure from the pericardial fluid is
Image 18.14 Parasternal Long Axis Video: Hyperdynamic Heart. This patient
Transducer Position has a hyperdynamic heart with an
ejection fraction close to 100%.
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2. Imaging of the Abdomen for Image 18.17 Normal Right Upper n o fluid collection between the kidney
Quadrant View and the liver. As a patient breathes, the
Free Intraperitoneal Fluid
diaphragm lowers the position of the liver
Image 18.16 Right Upper Quadrant and kidney into a more inferior position.
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within a lumen has rounded edges. The Image 18.19 Left Upper Quadrant Image 18.20 Normal Left Upper
image shows free “pointy” fluid between Quadrant
the liver and the kidney.
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echogenicity as the spleen superior to Image 18.21 Pelvic Tranvers View Video: Normal Longitudinal
the diaphragm (the left of the screen). Suprapubic View
However, this is a mirror image artifact
and, later in this chapter, we will discuss Video: Abnormal Pelvic View. This video
how the absence of this artifact can demonstrates free fluid adjacent to the
indicate fluid within the chest cavity. bladder. The uterus is visualized floating
within the fluid.
Video: Abnormal Left Upper Quadrant. In
this abnormal left upper quadrant view, Video: Abnormal Pelvis View. Often the
there is fluid superior to the dome of the collection of free fluid is subtle as
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Image 18.22 Hemithorax Tranducer Image 18.24 Hemothorax or Pleural Video: Small Pleural Effusion or
Position Effusion Hemothorax. In this video of the chest,
there is an anechoic, pleural effusion
rather than the mirror image. The spine is
visualized in the chest cavity. The tip of
the lung floats into the picture as the
patient breaths.
The inferior rib and rib shadow are still visible, 4. Vena Cava Imaging for
but only the visceral pleura is visualized. The
parietal pleura covering the surface of the lung Volume Assessment
has dropped away from the chest wall. The two The inferior vena cava (IVC) normally has
pleural layers no longer slide over each other.
The patient’s head is to the right of the screen, respiratory variation. In a patient with
and his feet are to the left. Look for a rib and a
rib shadow as landmarks to help find the pleural normal volume status, the IVC will
line. The bright, white light line is the opposition collapse 30-70 percent as the patient
of both the visceral and the parietal pleura and
should shimmer, moving back and forth (a sliding inhales. The IVC caliber of hypovolemic
motion) with respirations.
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patients will be smaller and collapse Video: Hypovolemia. The walls of the •Always remember that free fluid may
greater than 70%. Conversely, patients vena cava completely collapse with not be blood – consider ascites,
with fluid overload will have an enlarged respiration in this hypovolemic patient. bladder rupture, and bowel rupture as
IVC with minimal collapse. causes of free intraperitoneal fluid.
IVC collapse estimates the patient’s
volume status. It does not predict the • Since the bladder is your acoustic
Image 18.28 Transducer Position for
Volume Assessment patient’s response to hydration. window, the pelvic view should be
imaged prior to insertion of catheter.
Video: Volume Overload. There is a large
vena cava with minimal change with • A normal echo does not definitively rule
respiration. out major pericardial injury.
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visualization such as repositioning the patient, or filling the Pregnant patients present s e v e r a l c h a l l e n g e s i n c l i n i c a l
bladder via foley catheter to obtain a better view of the pelvis assessment and use of the eFAST exam. Clinical instability may
should be considered. Clean ultrasound gel off the patient to help require placing the patient in the lateral position to maximize
maintain body temperature. Clean and decontaminate the blood flow to the uterus and require repositioning to complete the
ultrasound machine based on your institutionally approved exam. Uterine enlargement can limit the view of the bladder but
process by removing surface gel and using an appropriate also result in displacement of bowel loops making pelvic views
surface wipe or process. Complete any additional documentation variable and occasionally dependent on fetal positioning. Late
of the images along with a note describing the procedure and gestation is accompanied by other changes in addition to uterine
findings for inclusion into the medical record. enlargement including diaphragmatic elevation that may require
repositioning the probe to achieve adequate views. Test
Cautionary Note performance has been reported to mirror those in non-pregnant
Complications of the eFAST are typically a result of incorrect patients in spite of these challenges. Another important
performance or interpretation of results leading to false positive or requirement is rapid fetal assessment in trauma presentations.
false negative results. Difficult or limited exams should be Rapidly determining the fetal heart rate should be determined on
discussed or repeated by the most experienced sonographer on arrival and will likely precede initiation of continuous fetal
the resuscitation team. Team leadership should also interrupt or monitoring by the obstetric team. Fetal reassessment should be
delay the eFAST for critical interventions in the care of the patient. regularly performed until continuous monitoring is available.
And, please keep in your mind, e-FAST should not delay the Remember that ultrasound cannot exclude placental abruption –
definitive treatment of trauma patient. even in seemingly low force scenarios. Obstetric consultation and
prolonged fetal monitoring is advised in all trauma cases involving
Pediatric, Geriatric and Pregnant Patient
a fetus of potentially viable gestational age.
Considerations
In pediatric patient, the eFAST is highly specific but has
insufficient sensitivity to exclude intra-abdominal injury. Though
no change in test performance characteristics have been reported References and Further Reading, click here
731
Section 2
Equipment: Ultrasound machine with a linear probe (10-5 MHz) and phased array
(5-1 MHz) or curved array (5-2 MHz) probe.
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Table 18.1 Protocols for undifferentiated shock used to assess for pericardial
effusion.
Pericardial fat pad (Image 18.30) which is Interpretation: The contractility of the LV
not usually anechoic (black) but rather Image 18.31 pericardial effusion can be evaluated by visual assessment of
has some echogenicity (gray) and it is the difference in the LV volume between
usually confined to the anterior wall the end of systole and diastole. In normal
above the right ventricle. LV contractility, there is a significant
Pleural effusion can be confused with change in the volume of the LV between
734
Hyperdynamic LV is when the volume In the right clinical setting, hypotension Pitfalls:
changes between systole and diastole with signs of RV strain could be a sign of
• The apical 4 chamber view can be a
more than 70% or the walls of the LV massive pulmonary embolism causing
challenging view to obtain due to
touch during systole (Video). Studies obstructive shock.
technical difficulty the view might be
have shown that qualitative visual
Technique: using parasternal short view foreshortened (the apex appears
assessment correlates well with the
and apical 4 chamber view can identify rounded rather than bullet shape), this
quantitative techniques used by
signs of RV strain. will lead to overestimation of the RV
cardiologists.
size.
Interpretation: the signs of RV strain
Video: Normal Left Ventricular (LV)
include 1) RV enlargement: best assessed • An important pitfall to consider when
contractility in parasternal lone view (A)
in apical 4 chamber view. Normally, the evaluating for signs of RV strain is that
and parasternal short view (B)
RV is smaller than the LV with a normal RV dilation is not specific for massive
V i d e o : S e v e r e l y d e c r e a s e d LV RV:LV ratio of 0.6:1. If RV/LV ration > 0.9 pulmonary embolism. Any condition
contractility in parasternal long view (A) it suggests RV enlargement (Video). 2) that increases the pressure of the right
and parasternal short view (B) The D sign: In a parasternal short view, heart will lead to dilated RV including
bowing of the interventricular septum chronic COPD and pulmonary
Video: Hyperdynamic LV contractility in towards the LV indicate increase pressure hypertension. However, the RV wall is
parasternal long view in the RV (Video). likely to be thick in chronic conditions.
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A. Tank fullness: Inferior Vena percentage of IVC collapsibility with Image 18.32 M mode evaluation of the
Cava (IVC) evaluation respiratory variation also known as the IVC
In spontaneously breathing patient, Caval Index (CI). Using M mode, the IVC
during inspiration, the negative intra- size measured 2 cm from the right atrial
thoracic pressure will increase venous junction during inspiration and expiration.
return to the heart leading to IVC collapse The CI (%) = (IVC expiratory diameter –
which is reversed during expiration. This IVC inspiratory diameter)/ IVC expiratory
physiology is reversed in ventilated diameter × 100 (Image 18.32).
patients. During insufflation, the intra-
Video: Tutorial on ultrasound of the
thoracic pressure increases, decreasing
Inferior Vena Cava
the venous return and the IVC expands,
this is reversed during expiration. Studies M mode evaluation of the IVC: (A) shows a small
Video: A: small and collapsible IVC with and collapsible IVC with respiration and Caval
have shown that the degree of IVC size respiration. B: large and non-collapsible Index= 60%. (B) shows a large IVC with minimal
change during the respiratory cycle can respiratory variation and Caval Index = 3%
IVC with respiration
be used to predict volume
responsiveness. Interpretation: In spontaneously breathing
right atrium while the abdominal aorta
patients, collapsible IVC or caval index
Technique: using a low frequency probe passes behind the heart.
more than 40% is associated with volume
in a longitudinal plane in the subxiphoid responsiveness. While dilated non- • Interpreting the findings of IVC
area the IVC is identified as a vessel collapsible IVC does not rule out volume assessment alone can be misleading as
draining into the right atrium (Video). The responsiveness. there are numerous causes of dilated
IVC can be assessed using 2 methods:
non-collapsible IVC including tension
qualitative and quantitative. The Pitfalls:
pneumothorax, massive pulmonary
qualitative method is by visual
• The IVC can be mistaken for the embolism and pericardial tamponade.
assessment of the size and collapsibility
abdominal aorta. This can be avoided
with respiratory cycle (Video). The
by visualizing the IVC drain into the
quantitative method is by calculating the
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B. Tank Leakiness: FAST Exam Image 18.33 FAST exam I n the setting of hypotension,
In atraumatic hypotension, intrabdominal demonstrating free fluid decreased LV contractility, dilated non-
free fluid could be due to ruptured collapsible IVC, signs of pulmonary
abdominal aortic aneurysm, ruptured edema and bilateral pleural effusion
ectopic pregnancy or ruptured suggests cardiogenic shock.
hemorrhagic ovarian cyst.
Technique: Using a low frequency probe,
Technique: the scanning technique for assess for pleural effusion by obtaining
Intraperitoneal free fluid is described in the same views used for the FAST exam.
details in the eFAST chapter. Start with the coronal views of the right
upper quadrant and left upper quadrant
Interpretation: Intraperitoneal free fluid is then move the probe cephalad (towards
FAST exam demonstrating free fluid marked by
identified as anechoic (black) fluid (*) in the hepatorenal space (A), the head) to visualize the pleural cavity
collection in any of the following areas. In subdiaphragmatic and spleenorenal space (B),
rectovesical space(C) and pouch of Douglas (D) better; space above the diaphragm
the right upper quadrant view, fluids will
(Video). To assess for pulmonary edema,
accumulate in the hepatorenal space also
use a low frequency probe to obtain a
known as Morrison’s pouch. In the left P i t f a l l s :
longitudinal lung view of the anterior
u p p e r q u a d r a n t v i e w, flu i d s w i l l Free fluid in the peritoneal cavity can be chest wall, locate two ribs (hyperechoic
accumulate in the subdiaphragmatic urine or previous ascites. Ultrasound area with posterior shadowing) and
space that can extend into the cannot differentiate these fluids. However, identify the pleural line (hyperechoic line)
splenorenal space. In the pelvic view, in a patient with shock and hypotension, between the rib shadows (Video).
fluid will accumulate in rectouterine space this free fluid is considered as blood until
also known as the pouch of Douglas in proven otherwise. Video: Tutorial on lung ultrasound for
females and rectovesical space in males. pleural effusion
(Image 18.33) C. Tank Overload: Assessment
of pleural effusion and Video: Tutorial on lung ultrasound for
pulmonary edema pulmonary edema
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I n t e r p re t a t i o n : P l e u r a l e ffu s i o n i s alveoli, lung ultrasound will produce B Video: Tutorial on lung ultrasound for
confirmed if a black/anechoic fluid is lines: hyperechoic-white vertical lines pneumothorax
identified above the diaphragm or by extending from the pleural line into the far
Interpretation: Assess the pleural line for
visualizing the thoracic vertebra body field. In case of pulmonary edema, B lines
sliding with respiration either by visual
(hyperechoic-white line with posterior will be bilateral and in all lung zones
evaluation or using M-Mode. The
shadowing) extending above the (Video).
presence of lung sliding, seen as
diaphragm also known as positive spine
Video: Lung ultrasound (A) A-lines in the seashore sign on M mode rules out
sign (Image 18.34).
normal aerated lung. (B) B lines extended pneumothorax with 100% negative
Image 18.34 from the pleural line to the far field predictive value. In the absence of lung
indicating fluid-filled alveoli sliding also seen as barcode sign on M
mode (Video) continue following the
Pitfalls: B-lines are not specific for
pleural line inferiorly and laterally to
pulmonary edema. Any pathology that
identify the boundary of pneumothorax
will fill the alveoli with fluids including
known as lung point. A lung point on
ARDS and bilateral pneumonia will
ultrasound will appear as a boundary
produce bilateral B-lines on lung
between the absence of pleural sliding
ultrasound.
and normal pleural sliding (Video). The
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demonstrating barcode sign indicating the vertebral body. The aorta is traced 18.35) and the risk of rupture
absence of lung sliding caudad (toward the feet) until it bifurcates increases when it is greater than 5 cm.
into the common iliac arteries at the level
Video: Lung point which is the boundary Pitfalls: The majority of ruptured AAA are
of the umbilicus (Video).
between absence of lung sliding and retroperitoneal therefore when performing
normal lung sliding Video: Tutorial on ultrasound for the FAST exam, no intraperitoneal free
abdominal aortic aneurysm fluid will be identified. Always make sure
Pitfalls: The absence of lung sliding could
that you are measuring the aorta from the
be from numerous causes other than Interpretation: The abdominal aorta is outer wall to outer wall.
pneumothorax including: pleurodesis, measured from outer wall to outer wall at
pleural bleb, poor respiratory effort and the proximal, middle and distal aorta. B. Assessment for clogged
mainstem intubation. Normal abdominal aorta measures less pipes: Deep Venous Thrombosis
than 3 cm. AAA is defined as abdominal (DVT)
Step 3 – Pipes: Vascular aorta measuring greater than 3 cm (Image When considering pulmonary embolism
system Evaluation as a cause of obstructive shock,
obtaining adequate echocardiography
A. Assessment for Abdominal Image 18.35 Aorta evaluation
views to assess for RV strain can
Aortic Aneurysm (AAA)
challenging. In this situation, evaluating
A ruptured aortic aneurysm is a cause of
the extremities for DVT can be used as a
non-traumatic hemorrhagic shock.
surrogate marker for possible pulmonary
Technique: Using a low frequency probe. embolism as literature shows that
The aorta is scanned in a transverse view majority of pulmonary embolism originate
starting in the subxiphoid area. The from DVT.
landmark used to identify the aorta is the
Technique: using a low-frequency probe
vertebral body (hyperechoic-white
t h e 2 z o n e g r a d e d c o m p re s s i o n
structure with posterior shadowing). The
(A) Normal abdominal aorta. (B) Abdominal aortic technique is used to identify DVT.
aorta is located anterior and to the left of
aneurysm measuring 4.8 cm with intramural
thrombus
739
1) Assess the common femoral vein zone: Video: (A) Normal compressible left t h e protocol may be altered based on the
place the probe in a transverse plane just Common Femoral Vein (CFV). (B) Non- clinician’s assessment of the clinical
below the inguinal ligament, identify the compressible left CFV suggesting a DVT condition.
common femoral vein and greater
Video: Summary of the RUSH protocol
saphenous vein. Trace the common Image 18.36 DVT
femoral vein distally until it divides into
the superficial and deep femoral vein.
References and Further Reading, click
2) Assess the popliteal zone: place the here
probe in a transverse plane in the
popliteal fossa, identify the popliteal vein
which is located on top of the popliteal
artery. Trace the popliteal vein until it
t r i f u rc a t e s d i s t a l l y. A p p l y g r a d e d
compression on all the veins identified to
Echogenic material in the right Common
ensure complete collapsibility of the veins Femoral Vein (CFV) indicating a DV
(Video).
Pitfalls: The 2 zone technique can only be
Video: Tutorial on ultrasound for DVT used in ambulatory patients as studies
have shown that it might miss isolated
Interpretation: Normally the veins are
deep femoral vein DVTs which are seen in
collapsible, failure to compress the vein
patients with prolonged immobilization.
(Video) or identification of echogenic
material in the vein lumen suggests DVT The RUSH protocol provides a systematic
(Image 18.36). stepwise approach to help rapidly identify
the etiology of undifferentiated shock
summarized in video. The sequence of
740
Section 3
BLUE protocol
Case Presentation
by Toh Hong Chuen A 68-year-old man with a history of congestive cardiac failure
(CCF) and chronic obstructive pulmonary disease (COPD)
presented with breathlessness and a newly productive cough
for 3 days. He was non-compliant with neither medication nor
fluid restriction. At triage, he dyspneic and immediately
brought to the resuscitation bay. His vitals were BP
188/92mmHg, PR 119/min, RR 23/min, Temp 37.9C, SpO2
91% on 3L intranasal oxygen. Clinically, the JVP was elevated
to the earlobes. Heart sounds were S1S2, breath sounds were
diminished with prominent wheezing. There was mild pitting
edema in the lower limbs to the knee. The diagnostic dilemma
of acute exacerbation of CCF versus COPD needed to be
addressed urgently.
While cardiac monitors and peripheral IVs were being set up,
lung ultrasound was performed using the BLUE protocol.
741
Bilateral lung sliding were seen in Stage 1, Emergency Indication
Patients presenting with dyspnea or respiratory distress
negative DVT scan in Stage 2 and negative
posterior lateral alveolar pleural syndrome Contraindication
(PLAPS) in Stage 3. This clinched the diagnosis Absolute contraindication: NONE
maintenance fluids were started, and since he • Nevertheless, lung ultrasound can often provide information
fulfilled the Anthonisen criteria for infective that leads to the diagnosis of these life threats.
2. Set to lung preset, and apply gel to the Blue Protocol Scanning 2. Place the upper hand just below the
probe Sites clavicle, with the fingertips in the mid-
There are many proposed lung ultrasound sternum.
3. Scan sequentially, and up to the 3rd
scanning sites. In the original paper on
stage if required.
BLUE Protocol, the chest wall is divided • Upper BLUE Point is in the middle
A. Stage 1: Anterior Chest Wall into 6 zones (Anterior, Lateral and of the upper hand (i.e., between
Posterior zones of the right and left chest the root of 3rd and 4th fingers)
• Four sites: Right and Left – walls), which is further subdivided into
Upper and Lower Blue Points upper and lower halves (i.e., 12 sites). Image 18.37 Upper and Lower BLUE
Points
• Proceed to Stage 2 only if A Currently, the scanning sites have been
p r o fil e ( i . e . , “ n o r m a l ” ) i s simplified to the 2 BLUE Points on the
identified anterior chest wall (stage 1) and 1 PLAPS
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• Lower BLUE Point is in the middle The bat sign is critical for correct o n B mode at the pleural line, termed
of the palm of the lower hand. identification of the pleural line. Always lung sliding (Video: Lung Sliding).
begin lung ultrasound by identifying the
• PLAPS Point is the horizontal This motion artifact produces the sea-
bat sign before proceeding to look for
continuation of the lower BLUE shore sign on M-Mode (Image 18.39:
artifacts and pathologies.
Point, as posterior as possible to Seashore Sign).
the posterior axillary line with the This sign is formed when scanning across
patient remaining supine. 2 ribs with the intervening intercostal Image 18.39 Seashore Sign
space.
Image 18.38 PLAPS Points
The wings are formed by the 2 ribs,
casting an acoustic shadow. The body is
t h e fir s t c o n t i n u o u s h o r i z o n t a l
hyperechoic line that starts below one rib
and extends all the way to the other.
(Video: Bat Sign) The body is the pleural
line, i.e., parietal pleural. Normally, the
pleural line is opposed to and hence
indistinguishable from the lung line
Lung Ultrasound Findings
(formed by the visceral pleura). Absent lung sliding is always abnormal
These are the building blocks of the
BLUE Protocol. As they are mostly and occurs when the two pleural are
Lung Sliding
artifacts, settings on B mode imaging When the lung expands and contracts • Separated, for example by air in the
which minimizes artifacts (so as to with respiration, the parietal (pleural line) case of pneumothorax
improve image resolution) should be and visceral pleural (lung line) move and
switched off. slide over each other, creating a • Opposed but stuck to each other
shimmering or sparkling motion artifact (pleurodesis)
Bat Sign
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• Opposed but not moving (mainstem Image 18.41 Lung Point on M Mode repeated at regular intervals below
intubation) the pleural line, at a distance which is
equal to the distance between the probe-
The absence of lung sliding is readily
skin interface and pleural.
apparent in B mode (Video: Absent Lung
Sliding) and produces the stratosphere The presence of A-lines indicates good
sign on M-Mode. (Image 18.40: scanning technique, as the probe is
Stratosphere Sign) perpendicular to the pleural line – a
requisite for the generation of this artifact.
Image 18.40 Stratosphere Sign The converse is also true. This effect is
demonstrated in the clip (Video: A Lines),
where the A lines disappear when the
Lung Point is pathognomonic of
probe is tilted away from its initial
pneumothorax.
perpendicular position.
It reflects the size of the pneumothorax
B-lines
(moderate if seen anteriorly, large if seen
B-lines are artifacts with 7 characteristics,
posteriorly, and total collapse if absent)
of which the first three are always
and may guide the need for intervention.
present.
Lung Point Most pneumothoraces with lung point in
They are comet-tail artifacts arising
This refers to the appearance and the lateral chest wall requires chest tube
strictly from the pleural line and always
disappearance of lung sliding (Video: (90%), compared to those with anterior
move in concert with lung sliding (if lung
Lung Point on B Mode) with respiration at location (8%).
sliding is present). They are most often
a specific point on the pleural. It is
A-lines hyperechoic, well defined, long and laser-
equivalent to having alternating sea-shore
These are horizontal reverberation like, and erases the A lines along its path.
and stratosphere signs on M Mode
artifacts arising from the pleural line. (Video: B Lines)
(Image 18.41: Lung Point on M Mode).
Consequently, they appear and are
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They occur when the subpleural visceral interlobular septa are
Image 18.42 Pleural Effusion
edematous. This can be found in several conditions, such as
acute cardiogenic pulmonary edema, ARDS, pulmonary
contusion, and pneumonia.
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Image 18.43 Shred Sign 6. C profile = Shred sign or tissue-like 5.Pneumonia: Variable: A + PLAPS
sign (regardless of size or number) profile, A/B profile, B’ profile & C profile
747
the 5 major respiratory diseases, with a • It cannot be used for patients with the lung findings, in the form
reported accuracy of 90.5%. mixed or multiple respiratory of the FALLS protocol.
disorders.
• Perform lung ultrasound immediately Post Procedure Care and
after clinical examination, prior to CXR. • It does not identify rare respiratory Recommendations
It yields diagnostic information rapidly disorders (defined as occurring None
and can expedited treatment. with a frequency of <2% of ICU
patients in the single center that Complications
• Recognizing the B profile, for None
was studied)
example, takes only less than 10
seconds. • Massive pleural effusion is not Pediatric, Geriatric, and
included in the protocol, though Pregnant Patient
• Completing the entire protocol
diagnosis is not an issue) Considerations
(i.e., up to Stage 3) requires less
than 3 minutes. • It cannot be used for non- Geriatric
respiratory causes of The BLUE protocol is derived from a
• Stay focus and scan only the BLUE
breathlessness, e.g., study of 301 consecutive adult patients
points and PLAPS points.
hyperventilation from metabolic and is applicable to the geriatric
• Other sites can be scan when the acidosis or profound anemia. population.
time is available.
• It is not designed to provide Pregnant
• Always interpret ultrasound findings in information on the patient’s While there are no pregnant patients
the context of clinical findings; and hemodynamic status. which are reported in the original paper2,
integrate both in the clinical decision- the principles in the diagnostic algorithm
• This could also be performed
making process. are applicable in pregnancy.
using point of care
• Pitfalls of the BLUE Protocol: ultrasound, by integrating the
Pediatric
focused cardiac and IVC with
748
In the same way, the BLUE protocol can also be adapted for use
in the pediatric patients.
749
Section 4
Introduction
by Dejvid Ahmetović and Gregor Prosen C-spine x-ray interpretation is one of the fundamental skills of emergency
physicians. Although current guidelines lead us to use CT scan for a suspected c-
spine injury, c-spine x-rays are still valuable in some low resource settings and
patient groups who are susceptible to radiation. Therefore, this chapter will
summarize the basics of c-spine x-ray interpretation.
Visualisation
Plain radiographs, when they show the lateral projection of the cervical spine and
include an open mouth view, are fairly sensitive in identifying c-spine fractures. The
risk of missing a significant fracture is, according to statistics, less than 1%.
Addition of the anteroposterior (AP) projection increases sensitivity to
approximately 100%. All of the three essential above mentioned projections can
be seen in Image 18.44.
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Image 18.44 C-spine essential views Image 18.45 Inadequate c-spine lateral x-rays
Lateral view with normal slight lordosis (A), Odontoid or open mouth view of
the atlas and axis (B), Standard anteroposterior or AP view with open mouth,
it can also be taken with closed mouth (C).
Only c-spine radiograph one should be satisfied with is the one head to achieve the swimmer’s position, which better visualizes
showing all of the 7 cervical vertebrae (C1-Th1). the lower vertebrae.
The C7-Th1 vertebrae may be obscured in muscular or obese There are 3 basic views of c-spine
patients (Image 18.45), or in patients with spinal cord lesions that
1. Cross-Table Lateral View
affect the muscles which normally depress shoulders. Such
lesions that leave the trapezius muscle unopposed occur in the 2. Odontoid – Open Mouth View
lower cervical region. Shoulders can be depressed by pulling the
arms down slowly and steadily, or if the patient is capable, asking 3. Anteroposterior View
them to depress one shoulder and lift the other hand above his
751
Cross-Table Lateral View First, visualize the spine from the base of Image 18.47 Alignment and lines
The lateral (cross-table) view is the most the skull to the C7-Th1 junction. Next,
helpful x-ray study in diagnosing c-spine check if the x-ray is a real lateral view, or
injuries. Inspection of the x-ray should be if it is slightly rotated. Facet joints are
thorough, methodical and complete. At best visualized when we have a proper
this point it is not easy to differentiate lateral projection. (see Image 18.46).
‘ABCs’, because of all the acronyms
To check for proper alignment, look for a
across the field of medicine, but the
normal smooth lordotic curve and
‘ABCs’ in this case stands for: A –
imagine two lines, each running along the
alignment and adequacy, B – bone
anterior and posterior margins of
abnormalities, C – cartilage space
vertebral bodies. Additionally, a third line
assessment and S for soft tissues.
(spino-laminar line), running along the
752
Image 18.48 Lorem Ipsum dolor amet, Image 18.49 Predental space Image 18.50
consectetur
753
Image 18.51 Cartilage space S – Soft tissues Image 18.52 Soft tissues
The prevertebral soft tissues can be used
as an indicator of an acute swelling or
hemorrhage resulting from an injury, and
may sometimes be the only indicator of
an acute injury on an x-ray. The normal
width of the prevertebral tissue decreases
down from C1 to C4 and increases from
C4 downwards. Normal measurements
from C1 to C4 are less than 7 mm (less
than half of the vertebral body at this
level), and less than 22 mm below the C5
(less than the vertebral body at this level)
see Image 18.52. Air within soft tissue
could suggest rupture of the esophagus
or trachea.
755
Image 18.55 Image 18.56
Suspected fracture of the odontoid process, but with closed mouth teeth
might affect the view.
757
Section 5
758
there is a rotation, mediastinum may look Image 18.60 Image 18.61
abnormal.
Image 18.59
Position: PA, AP, or lateral view? The The right ribs (red arrows) and left ribs (green
The clavicular heads and spinous process standard chest X-Rays consists of a PA arrows) on the lateral chest X-Ray.
alignment. The x-ray shows minimal rotation.
Compare X and Y. and lateral chest X-Ray.
On the AP film, the chest has a different
The normal lateral chest x-ray view is appearance. The heart and mediastinal
Inspiration: On good inspiration, the
obtained with the left chest against the shadow are magnified because of
diaphragm should be seen at the level of
cassette. If the x-ray is a true lateral, the anterior structures, mainly sternum. This
the 8th – 10th posterior rib or 5th – 6th
right ribs are larger due to magnification view is taken mostly at the bedside as
anterior rib.
and usually projected posteriorly to the portable. Some patients are at semi-erect
left ribs (Image 18.61). or supine position. Therefore, mediastinal
structures are widened because of
gravity.
759
The pulmonary vasculature is altered Image 18.63 Image 18.64
when patients are examined in the supine
position. The size of the pulmonary
vasculature is more homogeneous
throughout the upper and the lower
lobes. (Image 18.62 and Image 18.63).
Supine views are less useful and should
be reserved for critical patients who
cannot stand erect position.
760
Image 18.65 A – AIRWAY push the trachea to the opposite side
The trachea, carina and both main and resulting in a deviation that will show
bronchi are called the upper airway and up on chest X-Ray.
should all be visible on an AP view (Image
18.66). B – BONES
A chest X-Ray provides a good view to
Image 18.66 look for ribs and clavicle fractures.
Clavicular fractures are usually at the
middle 3rd of the clavicle, which is easy
to see in chest X-Rays. Rib fractures,
however, can sometimes be hard to see.
Each rib should be followed across its
length to look for fracture lines or step-
offs that could indicate a fracture.
Overexposed PA X-Ray film. You are able to see
all vertebral bodies with obvious intervertebral Hyperinflated lungs are seen as the result
spaces.
of chronic obstructive pulmonary disease
• Airways where the patient is unable to fully expel
the air that is inhaled with every breath.
• Bones Because of this, overinflation will result in
Airway structures on the chest X-Ray. (Red
a greater number of ribs that can be
• Cardiac Arrows: trachea, Green Arrow: carina, Pink
Arrows: left and right main bronchus) visible on the chest X-Rays. Normally,
• Diaphragm 8-10 ribs are expected to be seen on the
Look for if there is any deviation of the
chest X-Ray (Image 18.67).
• Extrathoracic tissues trachea away from the midline.
Introduction of air into one side of the
• Fields and Fissures
chest cavity will cause that side of the
lung to collapse. The collapsed lung will
761
Image 18.67 Ray, it refers to cardiomegaly or further investigation is considered if it
pericardial effusion. is more than 8 cm.
762
Image 18.69 1.The gastric air • Middle zone: between 2nd and 4th costal cartilage.
bubble on the left.
• Lower zone:
2.The diaphragmatic between 4th and
Image 18.70 Radiological lung zones.
contour looks like a 6th costal
“dome” shape, and cartilage.
the right side
So you should
located little higher
compare the lung
than the left.
parenchyma left to
3.The costophrenic right in the upper,
angle is the lateral middle and lower
point of attachment zones and see
for the diaphragm, whether there is a
The view of the diaphragm on the AP chest X- and it should be a difference.
Ray. (Yellow dashed lines and arrows:
diaphragm, red arrow: gastric air bubble, pink clear, sharp, and a
dashed lines: costophrenic angles) Look for equal
triangle-shaped at
radiolucency
either end. If the
between the left and the right lungs zones. The horizontal fissure
angle is closer to 90 degrees, then the lungs could be
on the right divides the upper and middle lobes; from the hilum to
hyperexpanded (e.g., COPD) and be pushing the diaphragm
the 6th rib at the axillary line.
down into the abdomen. If the costophrenic angle is blunting,
that usually is indicative of pleural effusion. You should also check soft tissues outside the thorax for
subcutaneous air, foreign body, bizarre density, etc.
E – EXTRATHORACIC TISSUES
Mostly this means as the lung parenchyma. Lung fields can be F – FIELDS AND FISSURES
divided into zones: upper, middle, and lower zones (Figure-12); You should check lung fields for infiltrates. Identify the location of
infiltrates and identify the pattern of infiltration (interstitial or
• Upper zone: from the apex to 2nd costal cartilage.
alveolar pattern). Look for air bronchograms, nodules, Kerley B
763
lines. Pay attention to the apices. You should also check for
masses, consolidation, pneumothorax and vascular markings.
Vessels should be almost invisible at the lung periphery. Finally,
you should evaluate the major and minor fissures for fluid
collection (Image 18.71).
Image 18.71
764
Section 6
765
1.Brain Parenchyma posterior attachments of the falx cerebri.
Image 18.73
*: Bold and underlined structures are
Midline shift marked in accompanying figure.
Presence of mass effect from edema or
space-occupying lesions may cause a
shift in midline structures. The shift of Image 18.72
midline may cause compression on the
anterior cerebral artery and eventually
infarct. There are multiple sulci and
Axial non-contrast brain CT scan shows an ICH
cisterns in the brain that are filled with in the right parietotemporal lobe (arrow in a) with
CSF. The presence of effacement in these adjacent edema. SAH is seen in the brain sulci
(arrowhead in a). Red-line in (b) represents the
structures is another sign for the midline. Note the deviation of septum
pellucidum (blue line), third ventricle (yellow
presence of a space-occupying lesion or Axial brain C scan (a) and its corresponding line), and pineal gland (green line).
parenchymal edema. schematic view (b) depict the midline structures.
Falx cerebri (green), septum pellucidum
(magenta), third ventricle (yellow) and pineal Spontaneous hemorrhage
A note on anatomy (Image 18.72 and gland (orange) should be located in the midline.
Image 18.73): There are three midline Also known as hemorrhagic stroke,
structures that should be scrutinized Abnormal parenchymal spontaneous intracranial hemorrhages
when searching for midline shift: hyperdensity most commonly occur in hypertensive
Intraparenchymal hemorrhages manifest
patients. The most common locations are
1. Septum pellucidum: a membrane as hyperdense areas in brain parenchyma
basal ganglia, thalamus, pons, and
located between lateral ventricles and are really difficult to miss! They are
cerebellum. Hemorrhages outside these
generally categorized as spontaneous or
2. Third ventricle common locations may be secondary to
secondary to neoplasms, vascular
tumors or vascular malformation.
3. Pineal gland malformations or trauma, etc.
A note on anatomy (Image 18.74 and
All these three structures should be on Image 18.75)*: Deep grey matter nuclei
the line drawn between anterior and
766
are islands of grey matter located deep in *: Bold and underlined structures are i n the emergency departments are
the brain: marked in accompanying figure. traumatic. Traumatic hemorrhages may
be intra-axial (within brain parenchyma) or
• Thalamus Image 18.75 extra-axial. Intra-axial hemorrhages like
• Putamen contusions or hemorrhagic diffuse axonal
injuries are discussed here. Extra-axial
• Globus pallidus hemorrhaged will be discussed later.
767
Illustration 18.1 Image 18.76 Unfortunately, only 15% of DAIs are
visible on CT scan. MRI remains the most
sensitive modality for detecting these
lesions. When visible on CT, they present
as hemorrhagic foci in the grey-white
interface, near deep nuclei of the brain
and in the corpus callosum (Image 18.77).
Illustration 18.2
769
Image 18.80 with grey matter and contains supplying connection, and it takes a
capillaries), arachnoid network (that considerable amount of force for them to
contains CSF and absorbs it into dural be separated. In practice, epidural
veins via arachnoid granulations) and hematomas are mostly due to arterial
dura mater (that is in direct contact with hemorrhage (especially middle meningeal
periosteum). The layers are depicted artery) and are usually associated with
schematically in Illustration 18.3. skull fractures (Illustration 18.4).
Illustration 18.3
Illustration 18.4
Illustration 18.5
Image 18.83
Axial brain CT-scan reveals a midline shift. As a novice image interpreter, you
may see no other pathologies. Look carefully at the left hemisphere! What
appears as a thickened cortex, is actually an isodense subacute SDH, hence
known as thick cortex sign.
774
skull fracture), or fractures adjacent to Image 18.91 Illustration 18.7 How to read CT
dural veins or middle meningeal artery
(figure 28). Whenever you encounter a
skull fracture, look carefully at these red
flags!
Image 18.90
775
Section 7
Case Presentation
by Sara Nikolić and Gregor Prosen A 27-year-old woman was in a car accident. She is
hemodynamically stable with vital signs as follows:
temperature of 36.4°C, heart rate of 70 bpm, blood pressure
120/80 mmHg, respiratory rate 10/min, oxygen saturation 99%
on room air. During the secondary survey, pelvic bones are not
stable, and there is a pain on palpation. You placed a pelvic
binder and ordered a pelvic X-ray.
Introduction
Pelvic fractures carry life‐threatening injury potential which should be identified or
suspect during the primary assessment of patients with major trauma. The
prevalence of pelvic fracture in studies of patients with blunt trauma is between
5% and 11.9%. The mortality from pelvic fractures in patients who reach hospital
is reported to be between 7.6% and 19%. Usually, injuries are secondary to
massive force, such as a road traffic accident or fall from a height. Fractures may
be associated with vascular, soft tissue and visceral injuries. If the pelvic ring is
broken in two places, the fracture is likely to be unstable. Isolated ring fractures,
however, tend to be stable. Patients who survive a pelvic fracture are at risk for
776
significant complications such as chronic close to them, especially at the posterior, t h e femoral head impacts and fractures
pain, leg length discrepancy, sexual can also be injured. The bleeding is the posterior margin of the acetabular
dysfunction, or nerve palsy. usually venous and extraperitoneal and rim.
can be life-threatening.
Important Anatomical Lateral compression produces a
Considerations If bones fracture but the ligaments remain horizontal fracture through the ipsilateral
The three bones compose the pelvis (the intact, a tamponade effect can be pubic symphysis and momentary medial
sacrum and the two innominate bones). achieved, and the degree of hemorrhage displacement of the hemipelvis. A lateral
Strong ligaments keep these three bones limited. compression force can also impinge on
together. These are crucial for maintaining the upper femur causing central
pelvic stability. A large array of ligaments
Mechanism of Injury dislocation of the hip.
The Young-Burgess system identifies four
traverses the interior and exterior surface
types of pelvic ring disruption, based on Vertical shear forces the hemi-pelvis
of the posterior aspect of the pelvis.
interpretation of radiographic images: upwards and towards the midline and can
Two ligaments originate from the side and
anteroposterior compression, lateral tear all the sacroiliac ligaments on the
back of the sacrum and insert into the
c o m p re s s i o n , v e r t i c a l s h e a r a n d affected side as well as the pubic
ischial spine and ischial tuberosity.
combined mechanical injury. symphysis ligaments.
The pubic symphysis, a
Anteroposterior compression causes Complex pattern happens in less than
fibrocartilagenous joint, is supported by
“open book” look at one or both sides of 25% of cases. The pelvis is exposed to
ligaments. However, adds little to the
the pelvis. A diffuse force will disrupt the two or more of the forces mentioned
overall stability of the pelvis. The urethra
pubic symphysis, while a more direct above. A combination of injuries results in
and bladder lie close to the pubic
force fractures the pubic rami in a vertical a complex radiological picture.
symphysis, and there is a 20% risk of
plane. For the pubic bones to separate by
injury if symphysis is disrupted.
over 2,5 cm, one or both of the ligaments X-Ray Views
Torn or rupture of the ligaments can associated with sacroiliac joints have to The routine pelvic view is anteroposterior
cause separation of three bones. In this be torn. An anteroposterior force can also (AP) projection, and in 94% of cases, a
situation, the nerves and vessels running push the flexed femur backward so that correct diagnosis can be made from this
777
view. When the fracture is noted in the AP Normal findings •Check the pubic symphysis
view, special views (inlet and outlet view AP View Interpretation Summary
• Check the sacroiliac joints
and oblique views) for further
investigations are recommended. A • Check the acetabulum
• A d e q u a c y a n d q u a l i t y
Radiographic interpretation is Ensure that the whole of the pelvis is S
systematized with ABCS approach: visible Soft Tissues
Image 18.95
780
Abnormal Findings Image 18.101 Complex pelvic fracture Image 18.104 Hip dislocation (antero-
– open book fracture. inferior)
Image 18.100 Pubic rami and ischium Image 18.102 Femoral neck fracture Image 18.103 Hip dislocation
fracture (posterior)
781
Image 18.105 Acetabular fracture joints. Failing to trace around the bony edges, especially
the iliac crests and sacral foramina, will lead to fractures being
missed.
782
Chapter 19
Selected
Emergency Drugs
Section 1
Antidotes
784
Antidotes and their • Infusion of 10-20% of stabilizing dose/ • Hypermagnesaemia
characteristics hour
Precautions
Atropine • Large doses may be required
• Calcium chloride extravasation can lead
General information
• There are auto-injectors for rapid use to soft tissue necrosis, preferably
• Anticholinergic agent administered via central line
Other
• Competitive muscarinic antagonist • Continuous monitoring is
• Drying of respiratory secretions is the
recommended
Indications goal
Dose
• Organophosphate poisoning • Tachycardia is not the endpoint
• 1 gram calcium chloride (10 mL),
• Carbamates Calcium (0.15mL/kg in children)
General information
• Nerve agents • 10-30 mL of calcium gluconate
• Calcium chloride 10% (1 g /10 mL),
Precautions (27.2 mg/mL elemental Ca) Administration
• Excessive doses lead to anticholinergic • Calcium gluconate 10% (9 mg/mL • IV bolus over 5 minutes
symptoms elemental Ca), one-third of the calcium in
• Repeated doses every 10-20 minutes if
strength of calcium chloride
Dose needed
Indications
• Start with 1-2 mg IV (adults), 0.02 mg/kg • Infusion can be administered
IV (children) • Calcium channel blockers toxicity
Other
• Double the dose every 2-3 minute to • Hydrofluoric acid exposure
achieve atropinization
• Hyperkalemia
Administration
785
• Topical calcium gel or local • 8 mg (adults), 4 mg • Cardiac monitoring is • Reverse the dangerous
injection of calcium gluconate (children) not approved needed cardiac effects of digitalis
for hydrofluoric acid skin
Administration • Avoid infusion more than 24 Indications
burns
hours
• Oral • Acute and chronic digoxin
• Intra-arterial or IV with a Bier
Dose overdose
block for extremity exposure • Can be repeated every 8
hours until 24 hours • Start with15 mg/kg/h • Other cardiac glycosides
Ciproheptadine
poisoning
General information Administration
Deferoxamin
General information Precautions
• An antihistaminic and • IV infusion
antiserotonergic agent • Iron-chelating agent • Close monitoring; ready for
• Infusion rate could be
resuscitation
• Has anticholinergic effects • Converts it to a water- increased
as well soluble complex excreted by • Monitor serum free level of
Other
urine digoxin
Indications
• Evaluate patient after 6
Indications Dose
• Control of symptoms in hours
serotonin syndrome • Systemic iron toxicity • Acute overdose: 5 vials; for
• The urine color will become
unstable patients 10-20 vials;
Precautions • Iron levels > 500 µg/dL red
can be calculated if the
• May cause anticholinergic ingested dose is known
• Multiple pills on radiography Digoxin immune Fab
effects General information
Precautions • Chronic overdose: can be
Dose • Fab fragments of antibodies calculated by serum digoxin
• Hypotension may occur at level; start with 2 vials
to digoxin
rapid rates
786
Administration • 3 mg/kg • Oral: loading (1.5-2 mL/kg 80-proof
liquor), maintenance (0.2-0.5 mL/kg/h)
• Bolus in life threatening conditions, Administration
otherwise infusion Other
• IM every 4 hours for 48 hours
Other • Maintain blood ethanol concentration
Ethanol between 100-150 mg/dl
• For other cardiac glycoside poisoning General information
start with 5 vials Flumazenil
• Blocks the formation of toxic
General information
Dimercaprol metabolites of alcohols
(BAL) • Competitive benzodiazepine antagonist
Indications
General information • Not used routinely in benzodiazepine
• Methanol and ethylene glycol poisoning
poisoning
• Heavy metal chelator
Precautions
Indications
Indications
• Serum ethanol levels monitored every
• Reversal of procedural sedation
• Severe lead, inorganic arsenic and 1-2 hours
mercury poisoning • Pediatric poisoning (limited use)
• The dose should be doubled during
Precautions dialysis Precautions
787
• Repeat up to the desired effect or 3 mg • In dialyzed patients is given every 4 Hydroxocobalamin
hours or continuous infusion General information
Administration
Glucagon • A precursor of Vitamin B12
• IV over 30 seconds
General information
• Hydroxyl group is displaced by cyanide
Other
• Increase cAMP** and form cyanocobalamin
• Not used in mixed drug overdose
• Positive inotropic and chronotropic Indications
similar to beta-agonists
Fomepizole • Cyanide toxicity
General information
Indications
Precautions
• An alcohol dehydrogenase inhibitor
• β-blocker toxicity
• It's a safe drug
Indications • Calcium channel blocker toxicity
Dose
• Methanol and ethylene glycol toxicity
Precautions
• 5 g, repeat if needed; 70 mg/kg
Dose • Induces vomiting, consider airway (children)
• Loading dose = 15 mg/kg management
Administration
• Maintenance dose = 10 mg/kg q12 Dose
• Infusion in 100 normal saline in 15
hours
• 5-10 mg (adults), 0.05-0.1 mg/kg minutes
Administration (children)
Other
• Infusion in 100 ml normal saline or 5% Administration
• Skin and urine orange-red discoloration
dextrose in 30 minutes
• The first dose is IV bolus, if there is a
788
Insulin (High dose) Intravenous Lipid Emulsion • Methemoglobin-forming agents
General information General information toxicity
• It has strong inotropic effects • 20% lipid emulsion as a parenteral • Symptomatic methemoglobinemia
nutrient
Indications • MetHb levels >20% in asymptomatic
Indications patients
• Calcium channel blocker toxicity
• Overdose by drugs with high protein Precautions
• Βeta-blocker toxicity
binding and large volume of distribution,
• Pulse oximetry is unreliable in
Precautions e.g. Local anesthetics, β-blockers and
methemoglobinemia
calcium channel blockers
• Glucose level should be monitored • Hemolysis in G6PD deficiency
every 10 minutes Dose/Administration
Dose
• Hypokalemia be considered • 1.5 ml/kg IV bolus
• 1-2 mg/kg IV, 1 mg/kg (children)
Dose/ Administration • 0.25 ml/kg/minute
Administration
• 1 IU/kg IV bolus of short acting insulin, Other
followed by 0.5-1 IU/kg/hr • Slow IV injection, may repeat 30-60
• Until hemodynamic stability restored
minutes later
• Glucose 25 g (dextrose 50%) before
Methylen blue Other
starting insulin, then 25 g/hr according to
General information
glucose level
• MetHb levels measured frequently
• It reduces methemoglobin (MetHb) to
Other
hemoglobin N-acetylcysteine
• Higher doses were administered in General information
Indications
studies
789
• Preventing hepatocellular injury in • For reversing the opioid effects, • Synthetic analogue of somatostatin
severe acetaminophen toxicity respiratory and CNS depression
Indications
Indications Precautions
• Hypoglycemia due to sulfonylurea
• Serum acetaminophen concentration • Re-sedation may occur due to short
Precautions
above toxic level half-life of naloxone
• Break through hypoglycemia may occur
• Hepatocellular injury • Withdrawal in chronic users
Dose/Administration
Precautions Dose
• 50 µg IV then 25 µg/h or
• Oral therapy may not be tolerated due • Start: 0.1 to 0.4 mg; 0.01 mg/kg
to its taste and odor (children) • 100 µg IM or SC every 6 hours
790
• 0.5 – 1 mg (adults), 0.02 mg/kg • Maintenance: 500 mg/hr or 1-2 g q4-6h; • 50 mg IV every 6 hours for ethylene
(children) 10-20 mg/kg/hour (children) glycol toxicity
791
Administration • 25-75 mg/kg/day • Repeat after 30 minutes if clinically
needed
• First dose administered bolus Administration
Succimer (DMSA)
• Other bolus doses or infusion if required • Continuous infusion for 5 days
General information
Other Other
• Oral metal chelator
• Given only if there is evidence of • Usually starts 4 hours after first
Indications
cardiotoxicity, such as QRS widening and dimercaprol (BAL) injection
ventricular dysrhythmias • Symptomatic lead poisoning
Sodium thiosulfate
Sodium calcium edetate (EDTA) General information • Asymptomatic lead poisoning, lead level
General information > 60 µg/dl (adults), > 45 µg/dl (children)
• Help the body to detoxify cyanide
• IV heavy metal chelator Precautions
Indications
Indications • May cause neutropenia, gastrointestinal
• Cyanide poisoning
upset and liver abnormalities
• Severe lead toxicity
Precautions
Dose
• Lead level > 70 µg/dl
• In severe cases with other antidotes
• 10 mg/kg three times a day for 1 week,
Precautions
Dose then two times a day for 2 weeks
• Patient should be admitted in hospital
• 50 ml of 25% (12.5 g; 1 ampoule) in Administration
• Nephrotoxicity, ECG changes and liver adults; 1.65 ml/kg (children)
• Orally
test disturbance may occur
Administration
Other
Dose
• IV over 10 minutes
• The serum level should be monitored
792
References and Further Reading, click here
793
Section 2
794
different pain mechanisms of chronic pain 5. Others: Medications with no direct
as well as evidence-based multi- pain-relieving properties may also be
mechanistic treatment. It is also essential prescribed as part of a pain
to provide individualized treatment. management plan e.g. laxative, anti-
Pharmacological and non- emetic, steroids, bisphosphonates,
pharmacological aspect is as equally muscle relaxant and anti-spasmodic
important in chronic pain management at
The tables below shows some specific
decreasing pain and increasing
information about these agents.
functioning of chronic pain patients
during activity of daily livings.
Table 19.1 Non-opiods (Simple analgesic)
The classes of medications used in the RECOMMENDED SIDE CAUTIONS AND
DRUG DOSAGES EFFECTS CONTRAINDICATIONS
COMMENTS
treatment of pain (Adapted from ACPA
Paracetamol 0.5 - 1gm, 6 - 8 hourly Rare Hepatic impairment Preferred drug in elderly.
resource guide to chronic pain Max: 4g/day
Reduce maximum dose Liver damage following over
medication & treatment, 2015) include: 50%-70% in patients with dosage.
hepatic impairment
Maximum dose 4 g daily.
1. Non-opioids (simple, non-selective and
Perfalgan (IV) >50 kg, 1 g 6 hourly up to max Hepatic impairment Important to consider the
selective COX-2 inhibitors) e.g. aspirin, Aqueous 4g/day total dosage of paracetamol
solution: 10mg/ 10-50 kg, 15 mg/kg/dose used i.e. to include dosage
NSAIDs, and acetaminophen and ml paracetamol, max 60mg/kg in 4 divided doses of suppositories and oral
available in 50ml preparations.
celecoxib. and 100ml vials Administration:
Infusion over 15 minutes.
Renal & hepatic impairement:
2. Opioids (weak and strong) e.g., minimum interval between doses
should not be less than 6 hours
tramadol, morphine, codeine,
Provided by authors
hydrocodone, and oxycodone.
3. A d j u v a n t a n a l g e s i c s e . g .
antidepressants, anticonvulsants
Aspirin 325 to 650 mg orally or rectally Peptic ulcer, Gastroduodenal ulcer Current data suggest that increased CVS risk may be
every 4 hours as needed, not to GI bleed, Asthma an effect of the NSAIDs/Coxib class.
exceed 4 g/day. Platelet dysfunction, Bleeding disorder
Renal failure, Renal dysfunction Physicians and patients should weigh the benefits
Hypertension Ischaemic heart disease and risks of NSAIDs/Coxib therapy.
Allergic reaction in susceptible individuals, Cerebrovascular disease
Increase in CVS events Inflammatory bowel disease Concurrent use with aspirin inhibits aspirin‟s
antiplatelet effect (mechanism unclear)
Same for below agents Same for below agents
Same for below agents
Naproxen 500-550mg BD
Elderly patients; 220 mg BD
Provided by authors
796
Table 19.4 Non-Opioids ( Selective Cox-2 Inhibitors)
CAUTIONS AND
DRUG RECOMMENDED DOSAGES SIDE EFFECTS
CONTRAINDICATIONS
COMMENTS
Celecoxib 400mg BD in acute pain (48 hours only) Renal impairment Ischaemic heart disease Associated with lower risk of serious upper
200-400 mg daily (for longer term use) Allergy reaction in susceptible individuals Cerebrovascular disease gastrointestinal side effects compared to traditional
<18 years : not recommended Increase in CVS events Hypersensitivity to sulfonamides. NSAIDs
Elderly patients: 100 mg daily Hypertension Higher doses associated with higher
incidence of GIT, CVS side effects. Use the lowest effective dose for the shortest duration
Same for below agents Patients with indications for necessary
cardioprotection require aspirin
supplement
Uncontrolled Hypertension
Provide by authors
Table 19.3 Opioids (Weak opioids)
CAUTIONS AND
DRUG RECOMMENDED DOSAGES SIDE EFFECTS
CONTRAINDICATIONS
COMMENTS
Tramadol 50 - 100 mg, 6 - 8 hourly Dizziness Risk of seizures in patients with Interaction with TCA, SSRI and SNRI
Max: 400 mg/day Nausea history of seizures and with high
Vomitting doses
Constipation In elderly, start at lowest dose (50
Drowsiness mg) and maximum 300 mg daily
Dihydrocodeine 30 - 60 mg, Nausea Respiratory depression Metabolites can accumulate causing adverse effects
tartrate 6 - 8 hourly Vomiting Constipation Drowsiness Acute alcoholism
(DF118) Max: 240 mg/day Paralytic ileus In severe hepatic impairment, codeine may not be
Raised intracranial pressure converted to the active metabolite- morphine.
Renal dysfunction &:dialysis patient:
do not use
Hepatic dysfunction:
do not use
Paracetamol 500 mg + 1 - 2 tablets, 6 - 8 hourly Constipation Hepatic impairment Decrease in side effect profile of Codein/ tramadol
Codeine 8 mg Max: 8 tablets/day respectively and paracetamol while maintaining
efficacy
Paracetamol 325 mg + 1 - 2 tablets, 6 - 8 hourly Nausea Hepatic impairment, Epilepsy Same as above
Tramadol 37.5 mg Max: 8 tablets/day Vomiting
Drowsiness
Provided by authors
798
Table 19.6 Opioids ( Strong opioids)
CAUTIONS AND
DRUG RECOMMENDED DOSAGES SIDE EFFECTS
CONTRAINDICATIONS
COMMENTS
Morphine SC (Adults): Nausea Acute bronchial asthma Metabolites can accumulate causing increased
<65 yrs: 5mg-10 mg 4 hrly Vomiting therapeutic and adverse effects
>65 yrs: 2.5 mg-5mg 4hrly Pruritus Respiratory depression
Sedation Both parent drug and metabolites can be removed with
IV: Follow morphine pain protocol (Appendix) Constipation Head injuries,Renal and hepatic dysfunction: dialysis, watch for “rebound” pain effect
Respiratory depression needs dose adjustment
Oral: Starting dose 5- 10 mg, Myoclonus
4 hourly of IR
Fentanyl To be prescribed by APS team only Nausea No active metabolites and appears to have no added risk
Vomiting of adverse effects; monitor with high long term user
Renal dysfunction : appears safe, however, a Sedation
dose reduction is necessary Constipation Metabolites are inactive, but use caution because fentanyl
Respiratory depression is poorly dialysable
Dialysis patients : appears safe Decrease hepatic blood flow affects metabolism more
than hepatic failure.
Hepatic dysfunction : appears safe, generally
no dose adjustment necessary
Oxycodone Starting dose (oral): Nausea Acute bronchial asthma Metabolites and parent drug can accumulate causing
IR 5 -10 mg 4 - 6 hourly Vomiting Respiratory depression toxic and CNS-depressant effects
(oxynorm) Sedation Con-comittent used of sedative drugs
Renal dysfunction : Use cautiously with careful Constipation Head injuries,Renal and hepatic dysfunction: In severe hepatic impairment, the parent drug may not be
monitoring, adjust dose if necessary Respiratory depression needs dose adjustment readily converted to metabolites
Dialysis patients:
do not use
Hepatic dysfunction:
Use cautiously and monitor patient carefully
for symptoms of opioid overdose
Decrease initial dose by 1/2 to 1/3 of the usual
amount
Elderly patients : 2.5-5 mg every 4-6 h
Provided by authors
799
Table 19.7 Adjuvant Therapies
CAUTIONS AND
DRUG RECOMMENDED DOSAGES SIDE EFFECTS
CONTRAINDICATIONS
COMMENTS
Antidepressant
Amitriptyline Start with 10 - 25 mg nocte. Anticholinergic effects Not recommended in elderly patients with Nortriptyline may be a suitable alternative and better
Increase weekly by 25 mg/day to a max of e.g. dry mouth, drowsiness, cardiac disease, glaucoma, renal disease tolerated in elderly at similar doses
150 mg/day urinary retention, arrhythmias
Interaction with Tramadol
Elderly patients: 10 mg ON Significant risk of adverse effects for the elderly
Anticonvulsants
Carbamazepine 100 - 1600 mg/day Dizziness Increased ocular pressure Well tolerated.
Ataxia Latent psychosis Serious adverse events are rare
Elderly patients: 100 mg daily Fatigue Confusion
Leucopenia Agitation
Nausea
Vomiting
Drowsiness
Gabapentin Day 1: start at 300mg Drowsiness Dose adjustment needed in renal impairment However, need to monitor sedation, ataxia, oedema,
Day 2: 300 mg 12 hourly dizziness hepatic trans-aminases, blood count , serum
Day 3: 300 mg 8 hourly GI symptoms creatinine, blood urea and electrolytes
Thereafter, increase by 300 mg/day every Mild peripheral oedema
1- 7 days
Max: 3600 mg/day
Pregabalin Start with 150 mg/day (in 2 divided doses). Same as above Same as above Same as above
If needed, increase to 300 mg/day after 3 -
7 days intervals,
then if needed, increase to 600 mg/day
after 7 days interval Max: 600 mg/day
Elderly patients : 50 mg at bedtime
Provided by authors
800
Table 19.8 Other agents used for analgesia or an adjunct to analgesics
RECOMMENDED CAUTIONS AND
DRUG DOSAGES
SIDE EFFECTS
CONTRAINDICATIONS
COMMENTS
Bisphosphonates
Pamidronate 60 - 90 mg as a single infusion over Asymptomatic hypocalcemia, Hypersensitivity to biphosphonates. Rehydrate patients with normal saline before or during
2 - 4 hrs every 4 weeks hypophosphataemia, hypomagnaesemia treatment.
Flu-like symptoms Hyperparathyroidism
Mild fever Not to be given as bolus injection
Local injection -site reactions In renal impairment, reduce dose and
Malaise increase infusion duration required
Rigor
In patients with poor dental hygiene,
there is higher risk of ONJ. Dental
referral is advised
Zoledronate Acid 4 mg as 15 min IV infusion every 3 Hypertermia Same as above Same as above
- 4 weeks Flu-like symptoms
Headache
Hypersensitivity
Osteonecrosis of jaw
Steroids as anti
inflammatory
Dexamethasone Oral/ IV/SC: Increased or decreased appetite Peptic ulcer disease Concomitant Should be given before 6 pm to reduce risk of insomnia
8 - 16 mg daily or divided doses Insomnia, Indigestion, Nervousness NSAIDs use
(initial dose), then to reduce to Myopathy, Oral candidiasis Liver or cardiac impairment Efficacy may reduce over 2 - 4 weeks
lowest possible dose (usually 2 Adrenal suppression Use lowest possible dose to prevent side effects.
mg/day)
Anticipate fluid retention and glycemic effects in short-
Elderly patients :5 mg daily and term use and CV and bone demineralization with long-
taper as soon as feasible term use
Monitor for rash or skin irritation
Lignocaine
(topical)
Lignocaine 5% Elderly patients : 1-3 patches for Monitor muscle weakness, urinary function, cognitive
12 hours per day effects, sedation
Muscle relaxant
Laxatives
801
Provided by authors
Table 19.9 Other agents used for analgesia or an adjunct to analgesics
RECOMMENDED CAUTIONS AND
DRUG DOSAGES
SIDE EFFECTS
CONTRAINDICATIONS
COMMENTS
Lactulose 15 - 45 ml orally 6 - 8 hourly Bloating, Epigastric pain Hypersensitivity to lactulose products May be mixed with fruit juice, water or milk
Flatulence, Nausea, Vomiting Galactosemia Reasonable fluid intake is required for efficacy
Cramping
Patients requiring a galactose free diet
Antiemetic
Granisetron 1 mg 12 hourly Constipation Progressive ileus and/or gastric Should not be used as first line.
distension may be masked Not for long term use.
Prochlorperazine 10 - 30 mg daily in divided doses Extrapyramidal symptoms May increased risk of seizure with
Severe nausea and vomiting: 20 Dry mouth Tramadol
mg stat followed by 10 mg after 2
hours
For prevention: 5 - 10 mg 8 - 12
hourly
Provided by authors
802
Management of Major Severe Vomiting supplemented with regular pain
805
References and Further Reading, click here
806
Section 3
Paralysing Agents
807
Contraindications • Malignant Hyperthermia: is a syndrome Category C
• Hyperkalemia characterized by rapid temperature rise
and rhabdomyolysis. Treatment for this Reversal agent
• Preexisting hyperkalemia Sugammadex
consists of cessation of any potential
Selected Clinical
Rules, Scores,
Mnemonics
Section 1
810
tool is derived (level 4 evidence), the tool The practitioner must also understand the judgment as to what you should do if
is validated in a limited patient setting purpose of the CDR and whether it is a the patient is “PERC positive.”
(level 3 evidence), then a broader one-way or two-way rule. As noted by
In addition to CDRs, there are many risk
validation setting (level 2 evidence) and Green, for example, the Ottawa Ankle
stratification tools or scales that are
finally, the impact of the tool is assessed Rules are intended to be a two-way rule;
currently used for serious conditions such
(level 1 evidence). These levels are if the patient meets criteria, you do an X-
as pulmonary embolism (PE) and acute
important to caution the novice learner ray. If they don’t meet criteria, you do not
coronary syndrome (ACS). Others are
against applying every CDR derived and do an X-ray. There are two paths you can
being developed for use in the ED setting
published automatically into their clinical take after you apply your CDR.
for common conditions such as
practice. The tool must be validated in a Alternatively, the pulmonary embolism
congestive heart failure (CHF), chronic
patient population with similar rule-out criteria (PERC) demonstrate a
obstructive pulmonary disease (COPD)
characteristics to the practitioner’s one-way rule. This tool was developed to
and transient ischemic attack (TIA) to
patient population. For example, the tool identify a subset of patients at very low
identify patients at higher risk for acute
may not perform the same (have the risk for PE such that no further testing
severe complications. From a practical
same sensitivity and specificity) if the need be done. If the patient is “PERC
perspective, the ED physician will often
prevalence of disease is different positive,” this should not imply that
use these risk stratification devices to
between the study and actual patient further testing for PE such as a D-dimer
help determine which patients require
populations. Also, the practitioner must should be done. Whether or not
admission. However, these tools are less
be familiar with the inclusion and additional testing should be done remains
prescriptive in that they are not rules that
exclusion criteria for a particular tool. If up to the practitioner and depends on
suggest what a practitioner should or
not, the tool could be misused. For many variables including whether an
should not do; rather, they help the
example, if the tool was derived and alternate diagnosis is much more likely.
physician more objectively look at the risk
validated for a patient population over the PERC was simply designed to help “rule
for an individual patient. Then the
age of 18, it should not be inappropriately out” the diagnosis of PE, not “rule in.”
practitioner must decide what level of risk
applied in a pediatric setting. This rule only guides you down one path,
they are comfortable with in regards to
potentially to do no testing; it makes no
inpatient or outpatient management,
811
which may greatly depend on the use online calculators, additional no point tenderness to the
resources available in those information on inclusion and exclusion
distal posterior malleoli
environments. Most of the risk criteria, and pearls and pitfalls for each
stratification tools encompass multiple tool. bilaterally.
variables with more complicated scoring
Orthopedic CDRs Should you get an X-ray to rule out
s y s t e m s ; a s t h e y a re n o t e a s i l y
fracture?
memorized, most of these would typically
Case 1
be used by ED physicians with real-time
A 28-year-old man presents to Ottawa Ankle Rule
access to a computer or smartphone with • Pain in the malleolar zone and any one
appropriate apps. the ED with left ankle pain after
of the following:
twisting his ankle playing
Given the many pitfalls noted above • Bone tenderness along the distal 6 cm
regarding CDRs, the goals of using basketball. He is able to bear
of the posterior edge or tip of the tibia
evidence-based medicine to reduce weight and notes pain and (medial malleolus), OR
practice variability, maximize use of
swelling to the lateral aspect of
resources, and help identify and diagnose • Bone tenderness along the distal 6 cm
high-risk conditions are important. It is the ankle (he points to just of the posterior edge or tip of the fibula
equally important that the ED physician below the lateral malleolus). He (lateral malleolus), OR
critically appraise these tools and denies weakness, numbness, • An inability to bear weight both
selectively apply them in appropriate
ways. The remainder of this chapter will
or tingling and has no other immediately after the trauma and in the
ED for four steps.
use case scenarios to review the most injuries. On exam, he is
commonly used CDRs in the ED setting. neurovascularly intact. Edema Ottawa Foot Rule
• Pain in the midfoot zone and any one of
The useful FOAM reference MDCalc.com and tenderness are noted
the following:
provides a summary of the most common slightly anterior and inferior to
tools that are being used with easy-to-
the lateral malleolus. There is
812
• Bone tenderness at the base of the Some of the longest standing and most b e 1 0 0 % s e n s i t i v e . Tw o s t u d i e s
fifth metatarsal, OR widely accepted CDRs are the Ottawa compared the PDR and Ottawa knee
knee, ankle, and foot rules. These rules rules and found the PDR to perform
• Bone tenderness at the navicular bone,
are to help practitioners identify patients better with similar sensitivities but better
OR
with an extremely low risk of fracture specificity for the PDR (51-60% versus
• An inability to bear weight both such that X-rays do not need to be done, 27%). However, one validation study for
immediately after the trauma and in the thus limiting the risks and costs of the PDR found the sensitivity to be as low
ED for four steps. unnecessary testing. The sensitivity of as 77%. Additionally, while the Ottawa
these rules has been found to be rule has been validated in children as
Ottawa Knee Rule 98.5-100%. In impact study of the young as two years old, the PDR
• Knee injury with any of the following: Ottawa knee rule, application of the rule excludes children younger than 12.
decreased the use of knee radiography
• Age 55 years or older Case 1 Discussion
without patient dissatisfaction or missed
• Tenderness at head of fibula fractures and was associated with In the above case, using either CDR, an
reduced waiting times and costs. These X-ray is unnecessary.
• Isolated tenderness of patella
rules have been validated in pediatric
• Inability to flex to 90° populations as well with similar Trauma CDRs
sensitivities (98.5-100%).
• Inability to bear weight both Case 2
immediately after the trauma and in the A less studied rule for knee trauma to A 57-year-old man fell from a
ED (4 steps) determine the need for radiography is the
height of 12 feet while on a
Pittsburgh Decision Rule (PDR). It differs
Pittsburgh Knee Decision Rule from the Ottawa rule in that it looks at the ladder. He did not pass out; he
• Mechanism: blunt trauma or fall mechanism of injury and applies to a reports that he simply lost his
d i ffe r e n t a g e g r o u p ; a l s o , p o i n t
• Age < 12 or > 50 footing. He fell onto a grassy
tenderness is not used in the PDR. Its
• Unable to bear weight 4 steps in the ED original derivation study found this rule to
area, hitting his head and
813
complains of neck pain. He did Canadian C-spine Rule tenderness and additional factors
• Age ≥ 65 that might limit a practitioner’s exam. The
not lose consciousness and
C C R c a n b e d i ffic u l t f o r s o m e
denied headache, blurry vision, • Extremity paresthesias
practitioners to remember all the criteria
vomiting, weakness, numbness • Dangerous mechanism (fall from ≥ 3ft / that qualify as a dangerous mechanism
and is limited to ages > 16 and < 65.
or tingling in any extremities. 5 stairs, axial load injury, high-
speed MVC/rollover/ejection, bicycle However, it can be used in intoxicated
He denies other injuries. He patients if the patients are alert and
collision, motorized recreational vehicle)
was able to get up and cooperative, allowing a full neurologic
ambulate after the fall and NEXUS Criteria for C-spine exam. The NEXUS Criteria are applicable
Imaging over any age range (> 1 year old), but the
came in by private vehicle. He • Focal neurologic deficit present sensitivity may be low in patients > 65
has not had previous spine years of age. A single comparison study
• Midline spinal tenderness present
surgery and does not have found the CCR to have better sensitivity
• Altered level of consciousness present (99.4% versus 90.7%); however, the
known vertebral disease. On
study was performed by hospitals
exam, he is neurologically • Intoxication present
involved in the initial CCR validation
intact with a GCS of 15, does • Distracting injury present study.
not appear intoxicated and has Both the Canadian C-spine Rule (CCR) Case 2 Discussion
moderate midline cervical and NEXUS Criteria are widely employed
By applying either criteria to this case,
spine tenderness. in clinical practice to reduce unnecessary
the patient would require C-spine imaging
cervical spine imaging in trauma patients
as by CCR, the patient would meet
Should you get imaging to rule out a with neck pain or obtunded trauma
criteria for dangerous mechanism, and by
cervical spine fracture? patients. The CCR uses mechanism and
NEXUS, the patient has midline
age criteria, whereas the NEXUS Criteria
tenderness to palpation.
incorporates criteria including midline
814
Case 3 Should you get a CT head for this The Canadian CT Head Rule (CCHR) only
patient to rule out a clinically applies to patients with an initial GCS of
A 36-year-old woman slipped
significant brain injury? 13-15, witnessed loss of consciousness
on ice and fell and hit her head. (LOC), amnesia to the head injury event,
She reports loss of Canadian CT Head Rule or confusion. The study was only for
consciousness for a minute • High-Risk Criteria (rules out the need patients > 16 years of age. Patients were
for neurosurgical intervention) excluded from the study if they had
after the event, witnessed by a
“minor head injuries” that didn’t even
bystander. She denies • GCS < 15 at two hours post-injury
meet these criteria. Patients were also
headache. She denies • Suspected open or depressed excluded if they had signs or symptoms
skull fracture of moderate or severe head injury
weakness, numbness or
including GCS < 13, post-traumatic
tingling in her extremities and • Any sign of basilar skull fracture seizure, focal neurologic deficits, or
(hemotympanum, Raccoon eyes,
no changes in vision or speech. coagulopathy. Other studies have looked
B a t t l e ’s s i g n , C S F o t o o r
at different CDRs for traumatic brain
She has not vomited. She rhinorrhea)
injury including the New Orleans Criteria
remembers the event except (NOC). However, CCHR has been found
• Medium Risk Criteria (rules out clinically
for the transient loss of important brain injury) to have superior sensitivity and
consciousness. She doesn’t specificity.
• Retrograde amnesia to event ≥ 30
use any blood thinners. On minutes Case 3 Discussion
physical exam, she has a GCS By applying this rule to the above case,
• Dangerous mechanism
of 15, no palpable skull fracture (pedestrian struck by motor the patient should be considered for
and no signs of a basilar skull vehicle, ejection from the motor imaging due to the mechanism. A fall
vehicle, fall from > 3 feet or > 5 from standing for an adult patient would
fracture.
stairs) constitute a fall from > 3 feet; therefore,
815
although the patient would not likely be hematoma measuring The PECARN (Pediatric Emergency Care
high risk and need neurosurgical Applied Research Network) Pediatric
approximately 4×4 cm.
intervention, the patient might have a Head Trauma Algorithm was developed
positive finding on CT that in many Should you get CT imaging of this child as a CDR to minimize unnecessary
practice settings would warrant an to rule out clinically significant head radiation exposure to young children. The
observation admission. estimated risk of lethal malignancy from a
injury?
single head CT in a 1-year-old is 1 in
Case 4 PECARN Pediatric Head Trauma 1000-1500 and decreases to 1 in 5000 in
A 20-month-old female was Algorithm a 10-year-old. Due to these risks, in
going up some wooden stairs, • Age < 2 addition to costs, length of stay and
potential risks of procedural sedation, this
slipped, fell down four stairs, • GCS < 15, palpable skull fracture,
CDR is widely employed given the
and hit the back of her head on or signs of altered mental status
frequency of pediatric head trauma ED
the wooden landing at the • Occipital, parietal or temporal visits. This CDR has the practitioner use a
prediction tree to determine risk, but
bottom of the stairs. She did scalp hematoma; History
of LOC≥5 sec; Not acting normally unlike some other risk stratification tools,
not lose consciousness and the PECARN group does make
per parent or Severe Mechanism
cried immediately. She was of Injury? recommendations based on what they
consolable after a couple of consider acceptable levels of risk. In the
• Age ≥ 2 less than 2-year-old group, the rule was
minutes and is acting normal
found to be 100% sensitive with
• GCS < 15, palpable skull fracture,
per her parents. She has not sensitivities ranging from 96.8%-100%
or signs of altered mental status
vomited. On exam, she is well- sensitive in the greater than two-year-old
• History of LOC or history of group.
appearing, alert, and has a
vomiting or Severe headache or
normal neurologic exam. She is Severe Mechanism of Injury?
This algorithm does have some
complexity and ambiguity. It requires the
noted to have a left parietal
816
practitioner to know what were However, a sub-analysis of patients less •Thoracic wall trauma, complaints of
considered signs of altered mental status than two years old with isolated scalp abdominal pain, decreased breath
and what were considered severe hematomas suggests that patients were sounds, vomiting
mechanisms of injury. In addition, certain higher risk if they were < 3 months of age,
• 0.7% risk of intra-abdominal injury
paths of the decision tree lead to had non-frontal scalp hematomas, large
intervention
intermediate risk zones. In these cases, scalp hematomas (> 3cm), and severe
the recommendation is “observation mechanism of injury. Given the large A CDR for pediatric blunt abdominal
versus CT,” allowing for the ED physician hematoma in the case study patient and trauma has been derived by the PECARN
to base his/her decision to image or not a severe mechanism of injury (a fall of > 3 group but not yet validated. This CDR
based on numerous contributory factors feet in the under two age group), one uses a seven-point decision rule. If the
including physician experience, multiple might more strongly consider imaging patient does not have any of these
versus isolated findings, and parental due to these two additional higher risk findings, the patient would be considered
preference, among others. factors. “very low risk” with a 0.1% risk of intra-
abdominal injury intervention required. A
Other pediatric head trauma CDRs rules PECARN Abdominal Trauma
study did compare the PECARN CDR
have been derived and validated; • Evidence of abdominal wall trauma/
versus clinical suspicion and found that
however, in comparison trials, PECARN seatbelt sign or GCS < 14 with blunt
the CDR had significantly higher
performed better than the other CDRs.1 abdominal trauma (if no, go to next
sensitivity (97.0% vs. 82.8%) but lower
Of note, in this study, physician practice point)
specificity (42.5% vs. 78.7%). However,
(without the use of a specific CDR)
• 5.4% risk of needing intra- abdominal CTs were done in 33% of
performed as well as PECARN with only
abdominal injury intervention patients with clinical suspicion < 1%,
slightly lower specificity.
meaning that even though clinical
• Abdominal tenderness (if no, go to next
Case 4 Discussion suspicion had higher specificity, this often
point)
did not translate into clinical practice.
For purposes of the case study, the
• 1.4 % risk of intra-abdominal Validation of the PECARN rule has the
patient falls into an intermediate risk zone
injury intervention potential to therefore improve both
of clinically important brain injury.
817
sensitivity and specificity compared to anything for the headache. She A CDR to determine risk for sub-
physician practice, but this remains to be arachnoid hemorrhage (SAH) was derived
does not have a family history
seen. and has been externally validated in a
of cerebral aneurysms or single study. The CDR’s purpose was to
Additional CDRs polycystic kidney disease. On identify those at high risk for SAH and
included those with acute non-traumatic
Case 5 physical exam, she has a
headaches that reached maximal
A 24-year-old woman presents normal neurologic exam and intensity within one hour and who had
with headache that began normal neck flexion. normal neurologic exams. Of note, the
three hours prior to arrival to rule has many inclusion and exclusion
Should you do a head CT and/or a criteria that the ED physician must be
the ED. The patient was at rest lumbar puncture to evaluate for a sub- familiar with and was only derived for
when the headache began. The arachnoid hemorrhage in this patient? patients 16 years or older. The study
headache was not described authors note that the CDR is to identify
Ottawa SAH Rule
as “thunderclap,” but it did patients with SAH; it is not an acute
• Investigate if ≥1 high-risk variables
headache rule. In the validation study, of
reach maximum severity within present:
over 5,000 ED visits with acute headache,
the first 30 minutes. The • Age ≥ 40 only 9% of those met inclusion criteria.
headache is generalized and Also, clinical gestalt again plays a role as
• Neck pain or stiffness the authors suggest not to apply the CDR
rated 10/10. She denies head
• Witnessed loss of consciousness to those who are ultra-high risk with a
trauma, weakness, numbness, pre-test probability for SAH of > 50%.
and tingling in her extremities. • Onset during exertion
The Ottawa SAH Rule was 100%
She denies visual changes, • Thunderclap headache (instantly sensitive but did not lead to reduction of
changes in speech and neck peaking pain) testing vs. current practice. The authors
state that the value of the Ottawa SAH
pain. She has not taken • Limited neck flexion on exam
818
Rule would be to standardize physician surgery. She has no anterior Pulmonary Embolism Rule-
practice in order to avoid the relatively Out Criteria (PERC)
abdominal pain, no dysuria or
high rate of missed sub-arachnoid • Age ≥ 50
hemorrhages. hematuria and no personal or
• Heart rate ≥ 100
family history of gallstones,
Case 5 Discussion
kidney stones, or blood clots. • O2 sat on room air < 95%
By applying the Ottawa SAH Rule, this
She’s never had this pain • Prior history of venous
patient is low risk and does not require
before, has no significant past thromboembolism
further investigation for a SAH.
medical history and her only • Trauma or surgery within 4 weeks
Case 6
medication is birth control pills.
A 19-year-old female presents • Hemoptysis
On exam, her vital signs are
with sharp right flank pain and • Exogenous estrogen
within normal range, she has
shortness of breath that started
normal cardiac and pulmonary • Unilateral leg swelling
suddenly the day prior to
exams, no costovertebral angle The PERC CDR was originally derived
arrival. The pain is worse with
and validated in 2004 and with a
tenderness, no chest wall or
deep inspiration but not related subsequent multi-study center validation
abdominal tenderness and no
to exertion and not relieved in 2008. In the larger validation study, the
leg swelling. rule was only to be applied in those
with ibuprofen. She denies
patients with a pre-test probability of <
anterior chest pain, cough, and Do you need to do any studies to
15%, therefore incorporating clinical
fever. She denies leg pain or evaluate this patient for a pulmonary gestalt prior to using the rule. PERC is a
embolism? one-way rule, as mentioned above, which
swelling and recent travel,
tried to identify patients who are so low-
immobilization, trauma, or risk for pulmonary embolism (PE) as to
819
not require any testing. It does not imply Risk Stratification Tools are normal, and there is no
that testing should be done for patients
Case 7 calf tenderness or swelling.
who do not meet criteria, and it is not
meant for risk stratification, as opposed A 68-year-old male presents How should you proceed with this
to the Wells’ and Geneva scores. with acute onset of shortness patient’s work up for PE?
the ED physician would need to completed his treatment with Previous, objectively diagnosed
PE or DVT
+1.5
820
The Wells’ Criteria for PE is a risk o ff of less than 6 for low risk was studied
Table 20.2 Geneva Score (Revised) for
Pulmonary Embolism stratification score with different point in pregnant patients with a negative
values assigned to different criterion. Its predictive value of 100%.
CRITERIA POINT
CATEGORY VALUE purpose is to identify patients who have a
The original Geneva score included the
Risk factors Age > 65 +1 lower risk for PE in order to potentially
use of chest radiography and an ABG,
Previous DVT or avoid unnecessary testing and the risks
PE
+3 whereas the revised score (rGeneva) uses
and costs associated with it. The criteria
only clinical criteria. A patient with a
Surgery (under have been validated in the ED setting. In
general anesthesia) rGeneva score of 0-3 is considered the
or lower limb +2 the initial three-tier model, a patient with
fracture in past 1 low risk with a < 10% prevalence of PE. A
0-1 points was considered to be in a low-
month score of 4-10 identifies intermediate-risk
risk group (1.3% prevalence of PE in an
Active malignant
+2 patients, and a score of 11+ is high risk
condition ED population) versus patients with a
(>60% prevalence or PE).
Symptoms Unilateral lower moderate score of 1-6 ( 16.2%
+3
limb pain prevalence), and those with a high score The Wells and rGeneva scores have been
Hemoptysis +2 of >6 ( 37.5% prevalence). Subsequent compared and found to have overall
Signs Heart rate < 75 0 studies have been done to apply a s i m i l a r a c c u r a c y. T h e s e P E r i s k
Heart rate 75 - 94 +3 simplified version of the Wells’ Criteria stratification tools are meant to be
Heart rate ≥ 95
and also to use the Wells’ Criteria along applied in those patients with concern for
+5
with D-dimer testing in a dichotomous PE as a diagnosis. If PE is not under
Pain on lower limb
deep venous manner (two-tier model) where a score of consideration, the tools should not be
+4
palpation and
4 or less (“PE Unlikely” group) combined applied. Practically speaking, for many
unilateral edema
with a negative D-dimer would achieve ED physicians, these tools are used to
sufficiently low probability of PE so as not help risk stratify patients to identify those
to pursue further workup. This two-tier who are very low-risk such that no testing
model is supported by the American should be done, low to intermediate risk
College of Physicians (ACEP) Clinical such that D-dimer testing would be a
Guidelines. A two-tier model using a cut-
821
useful diagnostic tool, or high risk such a “solid or hematologic malignant other cardiac risk factors.
that even if a D-dimer were negative, the condition, currently active or considered
His exam in the ED is normal,
post-test probability would remain high cured < 1 year.” Using the dichotomous
enough that further testing should be Wells’ approach, the patient would be and his EKG and initial troponin
pursued. One recent study found that considered “PE Unlikely;” using the are normal.
physician gestalt actually performed rGeneva, the patient would be
better than either the Wells or rGeneva intermediate risk. The ACP Guidelines Does this patient require additional
scores. However, guidelines from the would suggest that a D-dimer should be cardiac workup in the ED or admission
Clinical Practice Committee of the done in this patient, adjusted for age, to to hospital for additional workup? Can
American College of Physicians (ACP) determine the need for possible imaging this patient be safely discharged for
were published in 2015 that outline best to evaluate for PE. outpatient follow-up?
practice advice including advocating that
clinicians should use validated CPRs to Case 8 The HEART Score is used to risk stratify
estimate pre-test probability in patients in A 50-year-old male presents to chest pain patients in the ED to identify
those at risk for major adverse cardiac
whom acute PE is being considered. the ED complaining of chest
events (MACE) within six weeks. With the
Case 7 Discussion pain for two days. His pain is HEART Score, low-risk patients have a
substernal, non-radiating, score of 0-3 and have a less than 2% risk
This patient’s Wells’ score is 4. Although
of MACE at 6 weeks. The HEART Score
subject to ED physician judgment, PE described as a tightness, not
d i ffe r s f ro m t h e T h ro m b o l y s i s i n
could be considered at least equally as related to exertion. He has no Myocardial Infarction (TIMI), and Global
likely as any other diagnosis given the
associated shortness of breath, Registry of Acute Coronary Events
absence of other findings to explain his
nausea or diaphoresis. No (GRACE) scores as those scores measure
shortness of breath (no crackles or
the risk of death for patients with
wheezing on exam, no cough or fever). cough or fever. He’s never had
diagnosed acute coronary syndromes
The patient’s rGeneva score is 6. An this pain before. He has a (ACS) rather than identifying patients who
“active malignant condition” is defined as
history of hypertension but no have cardiac-related chest pain in the first
822
place. Additionally, even with low TIMI ED physician who finds this risk level Case 8 Discussion
scores for those diagnosed with ACS in unacceptable.
This patient’s HEART Score is 3 if the
the ED, there is still a 4.7% risk of a bad
physician considers the history
outcome. This may be of little utility to the
“moderately suspicious.” The patient is at
Table 20.3 HEART Score for Cardiac Events low risk for a major cardiac event in the
next six weeks so that the ED physician
CATEGORY CRITERIA POINT VALUE
could consider outpatient follow-up.
History Highly suspicious +2
Again, however, the risk stratification
Moderately suspicious +1 scores are not prescriptive, however.
Slightly suspicious 0 Decision-making must be done by the
EKG Significant ST depression +2 clinician based on his/her judgment,
Non specific repolarization resources available, and comfort with
+1
disturbance certain levels of risk.
Normal 0
Age ≥ 65 +2 Case 9
45-65 +1
A four-year-old boy presents to
≤ 45 0 the ED with a complaint of sore
Risk Factors (include: hypercholesterolemia, ≥ 3 risk factors or history of throat for one day associated
hypertension, diabetes mellitus, cigarette smoking, atherosclerotic disease +2
positive family history, obesity) with cough and fever. On
1-2 risk factors +1 exam, he is febrile to 38.5
No risk factors known 0 degrees Celsius, has bilateral
≥ 3× normal limit
Troponin +2
tonsillar exudates, and anterior
1-3× normal limit +1
cervical lymphadenopathy.
≤ normal limit 0
823
How should you proceed Antibiotics have been shown to
Table 20.4 Centor Score (Modified) for
Streptococcal Pharyngitis reduce suppurative (peritonsillar abscess,
with the workup for this child cervical lymphadenitis, and mastoiditis)
POINT
for possible strep? CATEGORY CRITERIA
VALUE and non-suppurative (e.g., acute
Age 3-14 rheumatic fever) complications of strep
+1
Options include treating pharyngitis and shorten the duration of
15-44
empirically, doing a rapid point- 0 clinical symptoms as well as reducing
transmission. Rapid antigen detection
of-care strep test, sending a 45 or
-1
older tests have been found to have a
throat culture, or supportive sensitivity between 70 and 90% and a
Exudate or swelling
+1
treatment. on tonsils specificity of ≥95%. Some authors
Tender/swollen recommend rapid antigen detection
The Centor Score is a risk stratification anterior cervical +1 testing (RADT) only for children with high
tool to look at clinical criteria that suggest lymph nodes
clinical scores (using Centor or other
a greater likelihood of strep pharyngitis Fever (T > 38°C, published clinical criteria) or if the results
+1
100.4°F)
that may prompt the ED physician to of the standard throat culture will not be
prescribe antibiotics. It was originally Present
Cough 0 available for more than 48 hours.
designed for use in adults, but a modified Additionally, the presence of particular
Absent
score has been validated for use in +1
clinical criteria may impact the ED
children > 2 years of age and adults that physician’s decision to test and/or treat.
includes age criteria as strep pharyngitis of strep is greater than 50%, and some Studies looking at different clinical
is a more common condition in children. would advocate for empiric antibiotics in prediction scores (including Centor) found
In the absence of any of the criteria at t h i s g r o u p . H o w e v e r, a s a r i s k that the presence of tonsillar
any age group, the risk of strep is less stratification tool, ED physicians can exudates conferred the highest odds of
than 10% (< 2.5% if 15 or older) and adjust their practice according to their having streptococcus infection.
further testing is not necessary. With a interpretation of the risks.
score of 4 or more points, the probability Case 9 Discussion
824
The patient has a Centor Score of 4. diarrhea, fever, or syncope. He Table 20.5 Glasgow-Blatchford Risk
Some clinicians would use this high-risk Score
denies a history of liver or heart
clinical score to justify further testing with
CATEGORY SCORE
an RADT or a throat culture. Others would problems. On exam, he has
BUN in mg/dL
treat empirically, especially given the normal vital signs with an initial
presence of exudates which has a higher 18.2 to 22.4 2
blood pressure of 128/78 in the
specificity than some of the other clinical 22.5 to 28 3
findings. This decision may be based on ED, and his abdomen is non- 28.1 to 70 4
additional factors such availability and tender. His hemoglobin is 13.5, 70.1 or greater 6
processing times of diagnostic testing and BUN is 5. Hemoglobin, men g/dL
and ease of patient follow-up. 12 to 13 1
Does this patient need admission for 10 to 11.9 3
Case 10 further monitoring or evaluation of his 9.9 or less 6
A 30-year-old male presents to upper GI bleed? Hemoglobin, women g/dL
the ED with nausea, vomiting,
Glasgow-Blatchford Risk Score is useful 10 to 12 1
and epigastric discomfort for for predictive of inpatient mortality, blood 9.9 or less 6
one day. He vomited multiple transfusions, re-bleeding, ICU monitoring, Systolic Blood Pressure, mmHg
times, initially non-bloody, then and hospital length of stay. Patients with 100-109 1
a score of zero may be discharged home, 90-99 2
developed some blood in the those with score 2 or higher are usually <90 3
vomit during the last two admitted, and those with score of 10 or
Heartrate >100 peats per minute 1
episodes, which he quantified more are at highest risk for morbidity and
Melena 1
resource utilization. Maximum score is
as a teaspoon in each. He Syncope 2
23.
denies melena or Hepatic Diseases 2
Heart failure 2
hematochezia. He has no
825
Glasgow-Blatchford Risk Score is useful Case 10 Discussion BP is 86/48 which improves
for predictive of inpatient mortality, blood
The patient does not meet any of the to 98/50 with 1L IVF. Her
transfusions, re-bleeding, ICU monitoring,
and hospital length of stay. Patients with
criteria in the GBS and would be hematocrit is 31%, and her
considered low risk. The patient does not
a score of zero may be discharged home, EKG and telemetry monitoring
demonstrate any signs of lower GI
those with score 2 or higher are usually
bleeding and could likely be safely in the ED are normal.
admitted, and those with score of 10 or
discharged home based on this risk
more are at highest risk for morbidity and Is this patient low risk for safe
stratification.
resource utilization. Maximum score is discharge home?
23.
Case 11
San Francisco Syncope Rule
The Glasgow-Blatchford Bleeding Score A 45-year-old woman presents • Congestive heart failure history
(GBS) uses clinical information as well as with syncope immediately prior
some diagnostic testing to risk stratify • Hematocrit < 30%
to arrival. She was feeling
upper GI bleeding patients. It should not
• EKG abnormal (new EKG change from
be used for lower GI bleeding patients or generalized fatigue prior to the
any source, any non-sinus rhythm on
patients in whom the source of GI syncopal episode. She denies
bleeding is unclear. A score of 0 is • EKG or monitoring)
chest pain, palpitations, or
considered low risk. Any score higher
than 0 is high risk for needing a medical shortness of breath. She has • Shortness of breath symptoms
intervention of transfusion, endoscopy, or not had vomiting or diarrhea. • Systolic BP < 90 mmHg at triage
surgery; therefore, the presence of any of She has been taking PO today
the above criteria would be considered The San Francisco Syncope Rule was
high risk. The tool assigns different point
but has a decreased appetite. derived in 2004. In its initial derivation
values to different gradations of the She has no known medical and validation studies, it was found to
h a v e 9 2 % a n d 9 8 % s e n s i t i v i t y,
variables present to a possible highest problems. On exam, her initial
possible score of 29. respectively. Its use has become
826
c o n t r o v e r s i a l , h o w e v e r, d u e t o Case 11 Discussion certainly have the potential to be
inconsistent validation studies where it useful adjuncts for the management of
Although the San Francisco Syncope
has not performed as well. A systematic ED patients with these common
Rule has failed to be consistently
review of the literature from 2011 conditions.
validated for use in identifying all high-
suggested that “the probability of a
risk patients, this patient fails the rule due
serious outcome given a negative score
to her initial SBP being less than 90.
with the San Francisco Syncope Rule References and Further Reading, click
Therefore, this patient would, in any case,
was 5% or lower, and the probability was here
not be considered low-risk, and the ED
2% or lower when the rule was applied
physician might consider additional
only to patients for whom no cause of
monitoring and/or evaluation.
syncope was identified after initial
evaluation in the emergency department.” Ottawa Heart Failure Risk Score,
However, a meta-analysis from 2013
COPD Risk Scale and Canadian TIA
suggests that it only had 87% sensitivity
Risk Score
for serious outcomes according to pooled
results and that there was a broad range These risk stratification tools are
of false-negative rates among the mentioned as they have all completed
included studies (range 0% to 48%). derivation studies and are in various
Although there is clearly no consensus on stages of validation studies. The intent of
use of this tool to safely discharge these tools is to help the clinician develop
patients with syncope home, if they do risk estimates of short-term serious
not meet these criteria, patients who do adverse events in ED patients. Although
have criteria would be considered higher not yet ready for widespread usage, the
risk, possibly warranting observation, ED physician should be aware of these.
admission and/or further diagnostic Additional studies need to be completed
studies. and published to determine the validity
and impact of these scores, but they
827
Section 2
Mnemonics
828
J = inJury (trauma)
APGAR: System to evaluate A = Aggravating and alleviating factors
K = Kidney stones (hypercalciuria) newborn’s condition S = Severity
A = Appearance (color)
C = Character, quality
ABC HELP: Causes of ST P = Pulse (heart rate)
L = Location
Elevation in ECG G = Grimmace (reflex, irritability)
A = Associated
A = AMI
S = Setting
A = Activity (muscle tone)
B = Brugada
T = Timing
R = Respiratory effort
C = CNS Pathologies
H = Hypertrophy (LVH)
APPENDICITIS: RLQ pain ASTHMA: Common
E = benign Early repolarization
differential Medications used to treat
L = LBBB
A = Appendicitis/ Abscess
Asthma
P = Pericarditis P = PID/ Period
A = Albuterol
P = Pancreatitis
S = Steroid
AEIOU TIPS: Causes of E = Ectopic/ Endometriosis
T = Theophylline
altered mental status N = Neoplasia
H = Humidified Oxygen
A = Alcohol
M = Magnesium (MgSO4)
D = Diverticulitis
E = Epilepsy, electrolytes
A = Antileukotrienes
I = Intussusception
I = Infection
C = Crohns Disease/ Cyst (ovarian)
O = Overdose
I = IBD
BATS: Subarachnoid
U = Urea
T = Torsion (ovary)
hemorrhage causes
T = Trauma
B = Berry aneurysm
I = Irritable Bowel
I = Insulin
A = Arteriovenous malformation / Adult
S = Syndrome Stones
P = Psychiatric
polycystic kidney disease
S = Sepsis, shock ASCLAST: Eliciting history of T = Trauma (e.g., being struck with
present illness and exploring baseball bat)
symptoms S = Stroke
829
BE FEVEER: Duke’s Criteria A = Anticoagulate
L = Lactic acidosis
830
A = Ageing (increased body sway, Infarction
haemorrhage)
decreased reaction time)
Ignorance (poor control)
D = Dilated cardiomyopathy
D = Drugs (esp. antihypertensives, Intoxication (alcohol) S = Shock
antipsychotics)
T = Toxicity of digitalis, quinidine
E = Environmental
DEMENTIA: Dementia, some
S = Sensory deficits (eg. visual problems)
common causes DOPE: Acute Deterioration
P = Psychological/ Psychiatric D = Diabetes
in Intubated Patient
(depression)
E = Ethanol
D = Displacement of the tube
A = Acute illness
M = Medication
O = Obstruction of the tube
D = Dementia
E = Environmental (e.g., CO poisoning)
P = Patient (this is the first priority, not the
E = Epilepsy N = Nutritional
machines), Pneumothorax
T = Trauma
E = Equipment failure
DCAP – BTLS: Things to look I = Infection
for in head-to-toe survey for A = Alzheimer’s DOTS: Signs to suspect
trauma fracture
D = Deformity
DEPRESSED ST: Depressed D = Deformity
831
T = Treatment (e.g., pericardiocentesis)
CING-KUF: Diabetic HEADS: Stroke risk
I = Injury (AMI, contusion)
ketoacidosis management factors
O = Osborne waves (hypothermia)
C = Creatinine (check it)/ Catheterize
H = Hypertension/ Hyperlipidemia
N = Non-occlusive vasospasm I = Insulin (5u/hour. Note: sliding scale no E = Elderly
longer recommended in the UK)
A = Atrial fibrillation
FAILURE: CHF causes of N = Nasogastic tube (if patient comatose)
D = Diabetes mellitus/ Drugs (cocaine)
exacerbation G = Glucose (once serum levels drop to S = Smoking/ Sex (male)
F = Forgot medication
12)
A = Arrhythmia/ Anaemia
HEAD HEART VESSELS:
K = K+ (potassium)
I = Ischemia/ Infarction/ Infection
Syncope causes, by system
U = Urea (check it)
L = Lifestyle: taken too much salt
CNS causes include HEAD:
F = Fluids (crytalloids)
U = Upregulation of CO: pregnancy,
hyperthyroidism
H = Hypoxia/ Hypoglycemia
GET SMASHED: Causes of
R = Renal failure
E = Epilepsy
acute pancreatitis
E = Embolism: pulmonary A = Anxiety
G = Gallstones
D = Dysfunctional brain stem
E = Ethanol
FAST HUG: Interventions for T = Trauma
(basivertebral TIA)
critically ill patients in ED S = Steroids
F = Fluid Resuscitation and balance
Cardiac causes are HEART:
M = Mumps
A = Analgesia
H = Heart attack
A = Autoimmune (PAN)
S = Sedation
E = Embolism (PE)
S = Scorpion bites
T = Thromboembolic prophylaxis
A = Aortic obstruction (IHSS, AS or
H = Hyperlipidemia
H = Head-of-bed elevation
myxoma)
E = ERCP
U = stress Ulcer prophylaxis, and
R = Rhythm disturbance
D = Drugs (azathioprine, diuretics)
G = Glucose/glycemic control T = ventricular Tachycardia
Vascular causes are VESSELS:
832
V = Vasovagal
R = Renal tubular acidosis
N = Nitrates
E = Ectopic (reminds one of hypovolemia)
D = Diarrhea
S = Stool Softeners
S = Situational
U = Ureterosigmoidostomy
S = Subclavian steal
P = Pancreatic fistulas and drainage
KUSSMAL: Causes of High
E = ENT (glossopharyngeal neuralgia)
S = Saline (in large amounts) AG Metabolic Acidosis
L = Low systemic vascular resistance (hyperchloremic metabolic acidosis) K = dKA
(Addison’s, diabetic vascular neuropathy)
U = Uremia
S = Sensitive carotid sinüs HOLT: Jugular venous S = Salicylates poisoning
pressure elevation causes S = Sepsis
HEPATICS: Hepatic H = Heart failure
M = Methanol poisoning
encephalopathy, O = Obstruction of venea cava
A = Alcoholic ketoacidosis
precipitating factors L = Lymphatic enlargement – L = Lactic acidosis
H = Hemorrhage in GIT/ Hyperkalemia
supraclavicular
E = Excess protein in diet
T = intra-Thoracic pressure increase LEMON: Difficult
P = Paracentesis
laryngoscopy
A = Acidosis/ Anemia
INFARCTIONS: Myocardial L = Look externally, e.g. short neck, large
833
LOAD: Rapid Sequence D = Diet
Quicktrach, cricothyrodotomy set,
834
A = Alleviating factors
C = Cardiac tamponade
PULSE: MI signs and
B = Before (ever experience this before) H = Hypokalemia/ Hyperkalemia/ symptoms
Hypoxia/ Hypothermia/ Hypovolemia
P = Persistent chest pains
O NAVEL: Endotrachial tube M = Myocardial infarction
U = Upset stomach
deliverable drugs E = Electrolyte derangements
L = Lightheadedness
O = Oxygen
D = Drugs S = Shortness of breath
N = Naloxone
E = Excessive sweating
A = Atropine
PIRATES: Atrial fibrillation
V = Ventolin (albuterol), Vasopressin
causes RATE: Hemolytic-Uremic
E = Epinephrine
P = Pulmonary: PE, COPD
Syndrome components
L = Lidocaine I = Iatrogenic
R = Renal failure
R = Rheumatic heart: mirtral regurgitation
A = Anemia (microangiopathic, hemolytic)
O SHIT: Management of A = Atherosclerotic: MI, CAD
T = Thrombocytopenia
acute severe asthma T = Thyroid: hyperthyroid
E = Encephalopathy (TTP)
O = Oxygen (high dose: >60%)
E = Endocarditis
S = Salbutamol (5mg via oxygen-driven S = Sick sinus syndrome RESS: Principles of
nebuliser)
management in toxicology
H = Hydrocortisone (or prednisolone)
PQRST: Mnemonic for a R = Reduce absorption
I = Ipratropium bromide (if life threatening)
complete pain history E = Enhance elimination
T = Theophylline (or preferably P3 = Positional, palliating, and provoking S = Specific antidote
aminophylline-if life threatening) factors
S = Supportive treatment
Q = Quality
PATCH MED: Pulseless R3 = Region, radiation, referral
RN CHAMPS: Shock types
electrical activity – causes S = Severity
R = Respiratory
P = Pulmonary embolus
T3 = Temporal factors (time and mode of N = Neurogenic
A = Acidosis
onset, progression, previous episodes) C = Cardiogenic
T = Tension pneumothorax
H = Hemorrhagic
835
A = Anaphylactic
SAMPLE: Focused History in R = Radiation distortion
M = Metabolic
Emergency Conditions/ T = Tumor
P = Psychogenic
Trauma
S = Septic S = signs and symptoms
SIMPLE: Criteria to define
A = allergies
simple febrile seizure
RODS: Difficult extraglottic M = medications
S = Seizure of focal type
devices P = pertinent past medical history
I = Intracranial infection
R = Restrictied mouth opening
M = Multiple times a day
L = last oral intake
O = Obstruction upper airway
P = Past history of afebrile seizure
E = events leading up to.
D = Disrupted or distorted upper airway
L = Last longer than 15 minutes
S = Stiff lungs, spine of cervical Scared Lovers Try Positions E = Examination abnormalities
836
C = Cushing’s reflex (raised ICP)
F = Fracture
R = Renal tubular acidosis
A = Aging
E = Elderly
P = Pancreatic fistula
R = Rx (drugs, such as high-dose R = Road trip
atropine)
VOMITING: Vomiting, extra
D = Deep anaesthesia
TV SPARC CUBE: Shock GI differential
I = Ischemic heart disease
signs and symptoms V = Vestibular disturbance/ Vagal (reflex
A = Athletes T = Thirst
pain)
V = Vomiting
O = Opiates
SITTT: Causes of hematuria S = Sweating
M = Migrane/ Metabolic (DKA,
S = Stone
P = Pulse weak
gastroparesis, hypercalcemia)
I = Infection
A = Anxious
I = Infections
T = Trauma
R = Respirations shallow/rapid
T = Toxicity (cytotoxic, digitalis toxicity)
T = Tumor
C = Cool
I = Increased ICP, Ingested alcohol
T = Tuberculosis C = Cyanotic
N = Neurogenic, psychogenic
U = Unconscious
G = Gestation
TOM SCHREPFER: B = BP low
Predisposing Conditions for E = Eyes blank
Pulmonary Embolism References and Further Reading, click
T = Trauma
USED CARP: Causes of here
O = Obesity
Normal Anion Gap Metabolic
M = Malignancy
Acidosis
S = Surgery
U = Ureteroenterostomy
C = Cardiac disease
S = Small bowel fistula
H = Hospitalization
E = Extra chloride
R = Rest (bed-bound)
D = Diarrhea
E = Estrogen, pregnancy, post-partum
C = Carbonic anhydrase inhibitors
P = Past hx
A = Adrenal insufficiency
837
Section 3
Case 1
by Sarah Attwa and Marwan Galal A 20-year-old male presents to your ED with a 5 cm wound
after he fell off his motorbike. On physical exam, the wound
overlays a fractured left tibia but does not show extensive soft
tissue damage nor any signs of periosteal stripping or vascular
injury. Which antibiotic should you give to this patient?
Type II Open fracture, wound >1cm in length without extensive soft tissue damage, flaps, avulsions
Type III Open fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture. This
type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures
that have been open for 8 hours prior to treatment.
Type III A Type III fracture with adequate periosteal coverage of the fractured bone despite extensive soft tissue
laceration or damage
Type III B Type III fracture with extensive soft tissue loss and periosteal stripping and bone damage. Usually
associated with massive contamination. It will often need further soft tissue coverage procedure (i.e.
free or rotational flap).
Type III C Type III fracture associated with arterial injury requiring repair, irrespective of degree of soft tissue injury
838
Application: Gustilo-Anderson Case 2 Image 20.1
classification for open wounds and A 7-year-old boy was brought
antibiotic coverage
by his mother to the ED after a
Interpretation: According to the above heavy object fell on his right
classification, each class should receive
hand earlier the same day. On
the following antibiotics:
physical exam, there is bony
Type I: 1st generation cephalosporin
tenderness, swelling, and
Type II: 1st generation Cephalosporin +/- erythema over his right middle
Gentamycin
finger PIP joint. Distal pulses
Type III: 1st generation Cephalosporin + are intact and no neurological
Gentamycin +/- Penicillin
deficit. You decided to send
Hint: In farm and war wounds, all 3 the patient for imaging. XR is
antibiotics must be given
shown below. What is the
The answer to the above clinical classification of this fracture?
scenario: Type II, Cephazolin +/-
Gentamycin
839
Illustration 20.1 Salter-Harris Class V and I are the least commonly CXR is normal, CBC shows
Classification picked up
WBC of 3600 and urine
Class V carries the worst prognosis dipstick is positive for nitrites
The answer to the above clinical and leukocytes. What is the
scenario: Class II next step in management?
Case 3 SIRS (Systemic Immune
An 85-year-old female was Response Syndrome) Formula
1. Temp > 38 c or < 36 c
brought to the ED by her son
with a 2-day history of fever 2. HR > 90/min
and altered mental status. She 3. RR > 20/min or PaCO2 < 32 mmHg
is known to be diabetic and
4. WBC > 12000 or < 4000
hypertensive. Her vitals are
Application: Any patient with suspected
Temp 38.6 Celsius, BP 85/53,
systemic inflammatory response and can
HR 110/min and RR is 26/min, help guide critical decisions and
Application: This a classification for long
and O2 saturation is 98% on interventions
bone fractures involving epiphyseal
growth plates. room air. On examination, she Interpretation: SIRS is met when the
is alert but confused, and the patient has 2 or more criteria of the above
Hints:
rest of her physical exam is Hints:
Class II fractures are the most common
unremarkable. Random
injuries seen in the ED SIRS + source of infection = Sepsis (16%
glucose level is 8.5 mmol/L, Mortality)
840
Sepsis + more than one organ’s system Temp 37.6 Celsius, BP 100/55, Persistent high SI has been
dysfunction (e.g. Oliguria) = Severe associated with poor outcome
HR 110/min, RR 20/min and
Sepsis (20% Mortality)
O2 Saturation is 99% on room The answer to the above clinical
Severe Sepsis + Hypotension scenario: By applying the above
air. What level of care does this
(unresponsive to fluid resuscitation) = equation, (110/100 = 1.1), this patient has
Septic Shock (69% Mortality) patient require? a high shock index and requires a high
level of care.
The answer to the above clinical Formula
scenario: By applying the above criteria, Case 5
SHOCK INDEX (SI) = HR / SBP
this patient has SIRS + urinary tract
A 72-year-old female presented
infection; therefore, she is in sepsis. She Application: It can be used to identify
needs adequate fluid resuscitation +
with a fever, cough, and
patients needing a higher level of care
Antibiotics, and if still hypotensive, she despite vital signs that may not appear sputum for the last 4 days. She
will be classified as septic shock and will strikingly abnormal. This index is a has a past medical history of
require a higher level of care (e.g., sensitive indicator of left ventricular
DM and hypertension. Her
Vasopressors) and close monitoring. dysfunction and can become elevated
Those patients should be admitted to the following a reduction in left ventricular vitals are: Temp 38.9 Celsius,
ICU. stroke work. HR 110/min, BP 100/45, RR
Case 4 Interpretation:
27/min, and O2 sat 92% on
A 27-year-old female presented room air. On exam, she is alert
Normal SI = 0.5 to 0.7
to the ED with severe and oriented, and chest
If SI > 0.9 was helpful to identify patients
abdominal pain for 1 day. No auscultation reveals crackles
in the ED requiring admission and/or
allergies or significant past intensive care despite apparently stable
over the right lower chest. The
medical history. Her vitals are: vital signs remainder of the physical exam
841
was normal. CXR reveals right Application: Clinical scoring system used cardiac auscultation reveals
for risk stratification and guide
lower lung lobe infiltrate. Labs normal S1-S2 with tachycardia,
management in all adult patients
showed mildly elevated white presenting with evidence of pneumonia no lower limb edema or
cell count with normal renal tenderness. Her left leg is
The answer to the above clinical
function and metabolic panel. scenario: By applying the above tool, this swollen compared to right side.
How would you risk-stratify the patient has a CURB-65 score of 2 (age + 12 lead ECG shows sinus
severity of pneumonia in this diastolic BP). This patient will likely need rhythm with no abnormal
admission for further treatment.
patient? What would be her findings. What is your next step
appropriate disposition? Case 6 in diagnosis?
A 61-year-old female presents
Table 20.7 CURB-65 Application: Wells score is used to
to the ED with leg swelling over calculate pretest probability for all
CATEGORY CRITERIA SCORE
the past 2 days. Her past patients with clinically suspected DVT
C Confusion 1
Recently bedridden for 3 days or more or major surgery within the previous 1 CATEGORY CRITERIA POINT VALUE
12 weeks requiring general or regional anesthesia
C Congestive heart failure 1
Localized tenderness along the distribution of the deep venous system 1
H Hypertension (>140/90 mmHg) 1
Entire leg swollen 1
A Age > 75 years 1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below 1
tibial tuberosity)
D Diabetes Mellitus 1
Pitting edema confined to the symptomatic leg 1
S2 Prior Stroke or TIA 2
Non varicose collateral superficial veins 1
Alternative diagnosis at least as likely as DVT 1 Application: Clinical prediction rule for assessing the risk of
stroke in patients with non-rheumatic Atrial Fibrillation and is used
Case 7 to determine if treatment is required with anticoagulation therapy
or antiplatelet therapy or not.
A 54-year-old male with a past medical history of
peripheral vascular disease comes in with on/off
Table 20.10 CHADS2 Interpretation
palpitations and lightheadedness for the past 2
ANTICOAGULATION
SCORE RISK RECOMMENDATIONS
weeks. His vital signs are normal. On exam, he is THERAPY
and heart sounds are irregularly irregular. The 1 Moderate Oral anticoagulant OR Oral anticoagulant, alternatives are ASA
ASA with Clopidogrel or ASA alone
remainder of his physical exam is unremarkable. 2 or High Oral anticoagulant Oral anticoagulant, alternatives are ASA
His ECG shows Atrial Fibrillation with HR of 96 greater with Clopidogrel or ASA alone
Fever 1
opens his eye to a verbal prompt, moaning and
withdraws from painful stimuli. What’s his GCS
Lab findings Leukocytosis 2 score?
Neutrophil left shift 2
A 18-year-old male involved in a motor vehicle
Application: Used in all cases of clinically suspected acute collision was brought in by EMS with apparent
appendicitis facial and head injuries. On exam, with pinching
his chest, he does not open his eyes nor makes
Table 20.12 Interpretation of Alvarado Score
any sounds but flexes both arms inwards. What’s
SCORE SIGNIFICANCE
4: Spontaneously
Interpretation: Useful objective tool to
3: To verbal command
assess and quantify neurological function
of patients in ED to help guide critical
2: To pain
decisions and interventions (e.g.,
1: No response
Intubation to protect the airway )
4: Flexion withdrawal
Case 11 – GCS score of 5 (this patient
3: Flexion abnormal (decorticate)
needs airway protection)
2: Extension (decerebrate)
1: No response