The chapters are written by nationally and internationally respected clinicians, educators and researchers in emergency medicine. Associate Chief, Division of Emergency Medicine Assistant Professor of Surgery (Emergency Medicine) Stanford University School of Medicine.
Michael Ballester, MD
Emergency Medicine, Associate Director of Emergency Medicine, Cooper Hospital, Robert Wood Johnson Medical School of UMDNJ, Camden, NJ.
List of contributors
Associate Professor Clinical Medicine Program Director Emergency Medicine Residency, University of California San Diego Medical Center, San Diego, CA Gregory W. Associate Professor, The Ohio State University School of Medicine Director Department of Emergency Medicine , Director of Pediatric Education/Quality Improvement, Surveillance Unit, Cleveland Clinic Foundation, Cleveland, Ohio.
Scott Taylor, MD
Jason Thurman, MD
It is true that sequential prose does not accurately reflect the parallel processing necessary to practice effective and efficient emergency medicine. Department of Emergency Medicine Wright State University School of Medicine Editor, Emergency Medicine: An Approach to Clinical Problem Solving.
Acknowledgments
Mahadevan, MD , FACEP , FAAEM
Dedication
Principles of Emergency Medicine
Approach to the emergency patient 3
- Cardiac dysrhythmias 63
- Pain management 131
- Prehospital care and emergency medical services 117
- Traumatic injuries 935. Shock 85
Perhaps the biggest challenge is the spectrum of diseases that EPs must be able to identify. Most importantly, EPs must be comfortable providing detailed, often devastating information in a concise yet comprehensible manner to patients and family members who may have different cultural backgrounds.
1 Approach to the emergency patient
Patient Information (PHI), efforts to maintain patient confidentiality in the ED present an ongoing challenge. Given the pace of the ED environment, it is remarkable that more errors do not occur.
Scope of the problem
The leadership role that EPs have in the ED allows them to demonstrate respect for patient confidentiality and remind others of the importance of upholding this principle. EDs must be fully staffed and always prepared, while never being completely sure of a patient's needs at any given time.
Clinical scope of the problem
This philosophy creates enormous challenges, but also opportunities, unique to the specialty of EM. When care for a particular patient falls outside the scope of EM practice, the EP must ensure that the “right” care is provided.
Anatomic essentials
The psychosocial aspects of each patient should be considered when interpreting presenting complaints and determining the patient's mood, including the appropriate use of consultation.
History
Q is for the quality of pain, as in 'Describe your pain?' or, “Is your pain sharp or dull?”. P stands for prior or past medical history, which may provide a clue to the current condition.
Physical examination
Many emergency departments have a policy of requiring vital signs to be repeated for patients in the waiting room. Orthostatic vital signs (heart rate and blood pressure in supine, sitting and standing positions) are inherently time-consuming, unreliable and non-specific.
Differential diagnosis
This is important so you don't miss critical findings or other clues to the patient's final diagnosis. If this may be relevant to the current problem, expose the patient's skin while examining the area of the body.
Diagnostic testing
For example, if the patient is lying on their back in the gurney, consider examining their abdomen before their lungs. ECGs should be repeated in the ED if patients develop chest pain or if their chest pain resolves, either spontaneously or after intervention.
General treatment principles
ACEP and other organizations have developed a series of consensus clinical policies in an effort to improve patient care and reduce medical errors. Although many EPs feel that these policies could be used against them in litigation, or are an attempt to standardize patient care, these policies were created using research and opinion and are an excellent resource.
Special patients
A discussion of wills and death plans should also be addressed, although this is best done at a designated time in the primary care provider's office. When possible, ED or hospital administrators should be notified of these abuses using established mechanisms.
Disposition
Documentation of this response to therapy is important because it records the patient's emergency management course. Admitting orders written by EPs must clearly convey care to the admitting physician upon the patient's arrival on the floor.
Pearls, pitfalls, and myths
The ideal situation is to schedule a follow-up examination for the patient upon his or her discharge. Tell the patient the name of this control doctor, the date and time of the visit, and the address with directions to the clinic.
The nasopharynx extends from the end of the nasal cavity to the level of the soft palate. The oropharynx, which communicates with the oral cavity and nasopharynx, extends from the soft palate to the tip of the epiglottis.
2 Airway management
The flexible epiglottis, which originates from the hyoid bone and base of the tongue, covers the glottis during swallowing and protects the voice. The valleculais is the space at the base of the tongue formed posteriorly by the epiglottis and anteriorly by the anterior pharynx.
Initial airway assessment
The mentum is the anterior aspect of the mandible and represents the tip of the chin. Identify swelling of the tongue or uvula, bleeding sites, or other visible abnormalities of the oropharynx.
Noninvasive airway management
Correct NPA length is determined by measuring the distance from the tip of the nose to the tragus of the ear. It is equipped with several valves that enable a coordinated flow of air in and out of the patient.
Indications for definitive airway management
The effectiveness of BVM ventilation can be determined by watching the chest rise and fall, feeling resistance in the bag, and monitoring the patient's O2 saturation. In the patient with inaccessible or delayed intravenous (IV) access, administration of ETT is an often overlooked method of medication administration.
Definitive airway management
It is easily remembered as three (of the patient's) fingers in the mouth, three fingers. A CXR should be taken to assess the ETT position (placement depth) and the condition of the patient's lungs.
The difficult airway
The failed airway
Devices and techniques for the difficult or failed
The treatment of the failing airway is determined by whether or not the patient can be supplied with oxygen (Figure 2.16). Fiber optic techniques for endotracheal intubation have proven invaluable in the management of the difficult airway.
Surgical airways
The most important single intervention in the patient with status asthmaticus and respiratory failure is early control of the airways. The cricoid ring is the narrowest part of the pediatric airway; in adults it is the vocal cords.
Introduction
Pathophysiology
The primary survey
3 Cardiopulmonary and cerebral resuscitation
Press the mask between your fingers onto the patient's face to create an airtight seal. Open the patient's mouth by grasping both the tongue and the lower jaw between the thumb and fingers, then lift the mandible.
The secondary survey
If no reversible cause can be determined, the patient should be given epinephrine every 3-5 minutes. Data on the patient's body (wallet, ID bracelet, traumatic injuries, needle marks, wounds, dialysis shunts) can be identified.
Diagnostic studies
Blood gas measurements can also help the physician optimize a patient's ventilation settings if the patient is intubated. If the history, clinical picture and physical examination indicate the possibility of a toxicological cause for the arrest, the patient's serum and urine should be sent for analysis.
Post-resuscitation care
In the patient who is breathing spontaneously, blood gases can help the physician determine whether mechanical ventilation would improve the patient's oxygenation and ventilation. The use of bedside ultrasound in cardiac arrest patients has become more widespread in an attempt to identify any cardiac activity in the pulseless patient.
Termination of efforts
When all Basic Life Support (BLS) or ACLS measures have been reasonably attempted and the likelihood of survival is minimal, resuscitative efforts should be discontinued. VT: ventricular tachycardia; IO: intraosseous; PEA: pulseless electrical activity; TT: Tracheal tube; BLS: Basic Life Support.
Pearls and summary points
The appropriate identification of the rhythm disorder and a good understanding of the underlying disease process are critical for the appropriate short- and long-term management of the patient. Normal cardiac conduction is initiated by the dominant pacemaker of the heart, the sinoatrial (SA) node (Figure 4.1).
4 Cardiac dysrhythmias
Coronary heart disease is the leading cause of death in the US, accounting for 21% of all deaths. In the year 2000, approximately 681,000 Americans died from coronary heart disease, which equates to one death every 60 seconds.
Gurudevan, MD
The normal position of the PMI is the 5th intercostal space in the midclavicular line. Hypomagnesemia can cause QT prolongation and predispose the patient to torsades de pointes.
Management of bradydysrhythmias
AV block is divided into three degrees, based on the characteristics of the ECG and the degree of the block. On the ECG there is a progressive lengthening of the PR interval in successive cardiac cycles until finally a P wave is not conducted ("fall").
Management of tachydysrhythmias
Non-paroxysmal transitional tachycardia Junctional tachycardia occurs when there is increased AV node automation and coexisting AV block. The result is a QRS complex that is a hybrid between the normal narrow complex and the wide complex QRS of the ventricle.
Pearls, pitfall and myths
Shock is a condition in which the oxygen (O2) and metabolic demands of the body are not met by cardiac output. Access to a patient in shock should proceed with the same urgency as a patient suffering from an acute myocardial infarction or cerebrovascular accident.
Classification
Examples include hypertensive emergency with compromised cardiac output, or carbon monoxide intoxication with inability to deliver O2 despite normal hemodynamics.
General approach to the patient in shock
5 Shock
After an initial assessment of preload, fluid or diuretic therapy should be instituted. Alpha-1 (-1) receptors are found in arterial smooth muscle and in the conduction system of the heart.
Pitfalls
These are second-line drugs for the treatment of congestive heart failure and may have an additive effect to dobutamine. Emergency physicians must be trained in the initial assessment and treatment of these patients.
Peaks of death
Falls are the leading cause of non-fatal trauma and the second leading cause of brain injury.
Primary survey
6 Traumatic injuries
Evaluation of the patient's breathing determines how well the patient is oxygenating and ventilating. The patient's heart rate may be elevated due to hypovolemia or secondary to pain and stress.
Secondary survey
A report of this information or a photograph allows an estimate of the amount of kinetic energy delivered to the patient (Figure 6.16). Helmet rating is also important to determine the amount of force distributed to the head.
Additional therapies
Advanced Trauma Life Support (ATLS) suggests that a qualified trauma surgeon and obstetrician should be consulted early in the evaluation of the pregnant trauma patient. The transfer process should be initiated as soon as the need for transfer is identified.
Pearls, pitfalls, and myths
As a general rule, all pregnant women who suffer from trauma of any type should be considered victims of intimate partner violence (IPV). Patients requiring subspecialty care not available at your institution should be considered for transfer.
History of emergency medical services
Prehospital systems
EMS personnel and qualifications
7 Prehospital care and emergency medical services
Additional personnel beyond the EMT-Ps are also frequently used in both air and ground intensive care transport. Nurses who staff intensive care units generally have experience in both acute and critical care settings, with additional experience (pediatric or obstetric) depending on the characteristics of the program's patient population.
EMS response
With the increasing regionalization of specialist medical and surgical services, critical care transport (whether by air or ground) is increasingly recognized as a unique area of expertise. Currently, no consistent national standards exist for critical care transport, but at least one non-governmental accreditation agency (the Commission on Accreditation of Medical Transport Systems) has recognized that the level of care, and not the transport vehicle, should should be a major consideration when evaluating critical care transportation services.
Clinical capabilities of EMS
Most paramedics may perform chest decompression on a patient with suspected tension pneumothorax. All other suspected fractures should be immobilized in a position that provides the greatest transport comfort.
Mass casualty incidents/disaster
Recent data show that well-trained paramedics can provide high-quality care to both adult and pediatric patients in almost all arenas, but such care requires intensive education and frequent review of skills. One very important exception to this rule is that pediatric patients rarely need to be intubated in the field, even in cases of respiratory failure.
Medical direction
Published data show that, in contrast to adults, morbidity and mortality are increased when prehospital care providers attempt to intubate apneic or hypoventilating pediatric patients. A suggested approach to treatment prioritization of victims is that found in the medical emergency triage label system.
Patient transport
The patient in cardiac arrest should be transported directly to the nearest available emergency department, even in cases of trauma. As with victims of severe trauma, significantly burned patients who meet appropriate triage criteria should be transported directly to a designated burn center whenever possible (Table 7.3).
Special considerations in air transport
Analgesia is the 'loss of sensitivity to pain'. In the emergency room, this means reducing pain through therapy. Physicians' inability to treat pain has been documented in both the emergency department and inpatient settings.
8 Pain management
Recognition and acknowledgment of the patient's pain, appropriate treatment, and timely reassessment are essential to managing acute pain in the ED. Poorly treated acute pain can exacerbate the underlying pathophysiology of many diseases and injuries and can lead to the development of chronic pain.
Assessment and
In this study, only 31% of patients with an acute myocardial infarction and persistent chest pain received IV opioids. Lewis and Sasater studied eight EDs and found that only 30% of patients with acute fractures received opioids while in the ED.
This is unlikely to be of benefit in assessing pain in children, but may be helpful in assessing pain in patients whose primary language differs from that of healthcare team members. There are no valid or reliable instruments for assessing pain in patients with significant neurological impairment.
Treatment of pain
Early reassurance that the patient and his/her family and friends will be treated with respect and compassion helps reduce suffering and improve pain. It is also important for the patient to know approximately how long it will take to take the medication, before the medication begins to work, and whether to expect partial or complete relief.
Pharmacologic therapy
Ketorolac is the first non-opioid analgesic available for parenteral use in the US. There is no "maximum" dose of opioid; induction of unwanted side effects usually indicates the limit of the patient's ability to tolerate the drug.
Pearls and pitfalls
Chronic pain patients with non-terminal disease should be under the care of a primary care provider who has a pain management plan. Informed consent and attitudes of general surgeons towards the use of pain relievers in the acute abdomen.
Primary Complaints
- Abdominal pain 145 10. Abnormal behavior 161
- Allergic reactions and anaphylactic syndromes 171
- Altered mental status 179 13. Chest pain 193
- Constipation 211
- Crying and irritability 217
- Diabetes-related emergencies 225 17. Diarrhea 233
- Dizziness and vertigo 241
- Ear pain, nosebleed and throat pain (ENT) 253 20. Extremity trauma 287
- Eye pain, redness and visual loss 313 22. Fever in adults 333
- Fever in children 353
- Gastrointestinal bleeding 365 25. Headache 375
- Hypertensive urgencies and emergencies 393 27. Joint pain 401
- Low back pain 413 29. Pelvic pain 427
- Shortness of breath in adults 485 34. Shortness of breath in children 503
- Toxicologic emergencies 531
- Vaginal bleeding 555 39. Vomiting 569
- Weakness 581
- Urinary-related complaints 543
Evaluating the patient with acute abdominal pain is one of the most challenging aspects of emergency medicine. Abdominal pain is the presenting complaint in approximately 10% of emergency department (ED) patients.
9 Abdominal pain
V. Mahadevan, MD
However, the rectal examination still remains a necessary part of the evaluation of patients with abdominal pain. Abdominal pain can be caused by extra-abdominal causes, such as pharyngitis, pneumonia and MI.
Abdominal pain Diagnostic testing
Several factors make the diagnosis and management of abdominal pain in elderly patients difficult. This highlights the importance of considering surgical disease (and consulting a surgeon) in most elderly patients with abdominal pain.
10 Abnormal behavior
Before taking the history, the safety of the patient and staff must be ensured. While in the room, the examiner should always stand between the patient and the door.
11 Allergic reactions and anaphylactic syndromes
Finally, the inciting antigen (if known) should be well documented in the patient's medical record, especially if the antigen is a medication or latex. The distinction can be difficult to make, but can be critical to the ultimate well-being of the patient.
12 Altered mental status
AMS is a change in a patient's level of cognitive ability (related to knowledge), appearance, emotional mood, and speech and thought patterns. Level of consciousness relates to one's level of awareness and response to his or her surroundings.
