• Acute Care
    • 1

      Acute Respiratory Failure

      By Raghu Seethala, MD; R Eleanor Anderson, MD; Tony Joseph, MD; Calvin A Brown III, MD
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      Acute Respiratory Failure

      • RAGHU SEETHALA, MDAttending Physician, Emergency Department and Surgical Intensive Care Unit, Brigham and Women’s Hospital, Instructor of Emergency Medicine, Emergency Medicine, Harvard Medical School, Boston, MA
      • R ELEANOR ANDERSON, MDResident Physician, Harvard Affiliated Emergency Medicine Residency Program, Brigham and Women’s Hospital, Boston, MA
      • TONY JOSEPH, MDResident Physician, Harvard Affiliated Emergency Medicine Residency Program, Brigham and Women’s Hospital, Boston, MA
      • CALVIN A BROWN III, MDAttending Physician, Department of Emergency Medicine, Assistant Professor of Medicine (Emergency Medicine), Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

      Acute respiratory failure (ARF) is the most common reason for patients to be admitted to a critical care setting, and occurs when oxygenation and/or ventilation begin to fail. Improved use of advanced therapies to optimize care such as supplemental oxygen, noninvasive positive pressure ventilation, and mechanical ventilation have shown a decline in ARF-related mortality. This review covers pathophysiology, stabilization and assessment, diagnosis and treatment, sedation, analgesia, and neuromuscular blockade, and disposition and outcomes. Figures show an oxygen-hemoglobin dissociation curve demonstrating the relationship between oxygen saturation and partial pressure of oxygen, low-flow nasal cannula, nonrebreather face mask with a one-way exhalation valve and bag reservoir, high-flow nasal cannula including air-oxygen blender setup, Venturi mask with various color adapters, bag-valve-mask apparatus with oxygen reservoir, one-way inspiratory valve, and self-inflating bag, extrapolated desaturation time for different clinical scenarios, lung ultrasonograms demonstrating a normal appearing lung versus a diagnosis of interstitial edema, an apical four-chamber view of the heart showing a significantly enlarged right ventricle, and mortality for various conditions causing respiratory failure. Tables list common clinical conditions causing hypoxemia and hypercapnia, estimates of maximum fraction of inspired oxygen with various oxygen delivery systems, initial ventilator settings, a tiered approach to refractory hypoxemia in acute respiratory distress syndrome (ARDS), common analgesia and sedation regimens, the Richmond Agitation-Sedation Scale, and causes of ARDS.

       

      This review contains 11 highly rendered figures, 8 tables, and 81 references

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    • 2

      Approach to the Patient With Shock

      By David C Mackenzie, MD, CM
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      Approach to the Patient With Shock

      • DAVID C MACKENZIE, MD, CMDirector of Emergency Ultrasound, Maine Medicine Medical Center, Portland ME, Assistant Professor of Emergency Medicine, Tufts University School of Medicine, Boston, MA

      There are four main categories of shock: hypovolemic, distributive, cardiogenic, and obstructive. Although the main end point (i.e., inadequate delivery of oxygenated blood to the body’s tissues and organs) of each of these categories of shock is the same, the pathophysiologic mechanisms differ. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with shock. Figures show the Frank-Starling relationship illustrating changes in distributive and cardiogenic shock, the FAST examination, lung ultrasonography in pulmonary edema, pericardial effusion, apical four-chamber view of the heart with right ventricular enlargement, and a parasternal short-axis view of the heart. Tables list representative historical information associated with specific categories of shock; point-of-care ultrasound applications for the evaluation of shock; criteria for severe sepsis and septic shock; vasopressor dosages, mechanisms of action, clinical effects, and indications; anaphylaxis diagnostic criteria; and causes of cardiogenic shock.

      This review contains 6 highly rendered figures, 6 tables, and 32 references.

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    • 3

      Acute Care: Pain Management

      By Claudia Ranniger, MD, PhD
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      Acute Care: Pain Management

      • CLAUDIA RANNIGER, MD, PHDDirector, Simulation Center, George Washington University CLASS Center, George Washington, University Hospital, Washington, DC

      Pain is a chief complaint in more than 50% of emergency department (ED) visits. Injury accounts for approximately one-third of presentations associated with pain; other common diagnoses include neck and back pain, minor infections, abdominal pain, and headache. In the ED, pain is underdiagnosed and undertreated, and existing pain management practices in the ED are inconsistent.  Inadequate pain management is common, and pain remains unchanged or worsens during the ED visit for more than 40% of patients.  Patient satisfaction improves when expectations for pain control are met. This review covers the pathophysiology of pain and the practice of pain management. Figures show the approach to pain management in the ED, an example of a numerical and visual analog scale pain rating scale, field block of the pinna, ultrasound probe and hand position for ultrasound-guided regional anesthesia, regional anesthesia of the face, innervation of the hand and fingers, regional anesthesia of the median, radial and ulnar nerves, innervation of the foot, ultrasound-guided regional anesthesia of the posterior tibialis nerve, regional anesthesia of the sural nerve, and method of regional anesthesia of the dorsal foot. Tables list local anesthetics and anesthetic combinations, common nonnarcotic pain relievers, commonly used parenteral opioids for acute pain, commonly prescribed oral opioid-containing pain medications, principles of pain assessment in the ED, and advantages and disadvantages of in- and out-of-plane approaches to ultrasound-guided nerve block.

      This review contains 13 highly rendered figures, 6 tables, and 105 references

      Key words: Acute pain, Pain management, Oligoanalgesia, Pain assessment, Inadequate pain management, Acute pain management, Pain management in the emergency department, Pain in the ED, Pain presentation

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    • 4

      Procedural Sedation

      By David A. Meguerdichian, MD, FACEP; Eva Tovar Hirashima, MD, MPH; Christian Arbelaez, MD, MPH, FACEP
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      Procedural Sedation

      • DAVID A. MEGUERDICHIAN, MD, FACEPAssistant Medical Director for Emergency Medicine/GME, STRATUS Center for Medical Simulation, Attending Physician, Department of Emergency Medicine, Brigham and Women’s Hospital, Instructor of Emergency Medicine, Harvard Medical School, Boston, MA
      • EVA TOVAR HIRASHIMA, MD, MPHClinical Instructor of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
      • CHRISTIAN ARBELAEZ, MD, MPH, FACEPAssistant Residency Director, Harvard Affiliated Emergency Medicine Residency, Attending Physician, Department of Emergency Medicine, Brigham and Women’s Hospital, Assistant Professor of Emergency Medicine, Harvard Medical School, Boston, MA

      Procedural sedation and analgesia (PSA) is defined as the technique of administering a sedative or dissociative agent, usually along with an analgesic, to induce a controlled state that allows the patient to tolerate painful procedures while maintaining adequate spontaneous cardiorespiratory function. PSA reduces physiologic and psychological stress in the patient while also increasing the likelihood that the procedure will be successful. This review provides an overview of PSA and discusses in detail its pathophysiology and use in practice. Figures show the sedation continuum, a procedural sedation checklist, the Mallampati classification, components of the capnogram, ventilation forms during procedural sedation, and procedural sedation aftercare instructions. Tables list indications for procedural sedation and analgesia based on procedure type; drugs and pharmacokinetics of common agents used in PSA; opioid medications and their dose equivalences, time of onset, duration of action, and common side effects; a focused history and physical examination for patients undergoing procedural sedation and analgesia; American Society of Anesthesiologists physical status classification and likely risk of adverse sedation events for each class; pneumonics for the evaluation of the difficult airway; factors to consider for the risk of aspiration during PSA; the SOAPME acronym for procedural sedation; suggested monitoring for procedural sedation pre- and postprocedure; and selection of PSA drugs based on indications for the procedure.

      This review contains 6 highly rendered figures, 10 tables, and 34 references.

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    • 5

      Shock: Pathophysiology and Management

      By Hamid Shokoohi, MD, MPH, RDMS, RDCS; Paige Armstrong, MD, MHS
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      Shock: Pathophysiology and Management

      • HAMID SHOKOOHI, MD, MPH, RDMS, RDCSAssociate Professor of Emergency Medicine, Director, Emergency Ultrasound Fellowship, Department of
      • PAIGE ARMSTRONG, MD, MHSChief Resident, Department of Emergency Medicine, George Washington University Medical Center, Washington, DC

      Shock is a serious clinical condition in which tissue perfusion is inadequate to meet oxygen demand, resulting in tissue hypoxia. Shock is categorized based on the primary process leading to hemodynamic instability. There are five main classifications: cardiogenic, distributive, hypovolemic, obstructive, and dissociative. Regardless of etiology, the diagnosis and initial care of patients with shock must be prompt and directed towards reversing the tissue ischemia and preventing its consequences. Often initial evaluation, diagnosis, and resuscitation occur simultaneously. The first goal is to accurately identify the etiologic cause and initiate therapy before there is irreversible damage to end vital organs.

      This review focuses on the pathophysiology and management of shock and addresses a number of new developments that have profoundly altered the treatment paradigms.  A number of protocols have been developed in the arena of shock resuscitation. Focused ultrasonography is recommended for the prompt recognition of complicating physiology in patients with hypotension and shock, especially in unstable patients. Tables outline classification systems for different types of shock as well as appropriate first and second line vasopressors indicated in each.

      Key words:  Hypovolemic shock, cardiogenic shock, obstructive shock, distributive shock, dissociative shock, point-of-care ultrasonography, cardiac ultrasonography, vasopressors

      This review contains 5 highly rendered figures, 6 tables, and 62 references.

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    • 6

      Airway Management in the Emergency Department

      By Bryan Wilson, MD; Garrett S. Pacheco, MD
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      Airway Management in the Emergency Department

      • BRYAN WILSON, MDDepartments of Emergency Medicine & Pediatrics University of Arizona College of Medicine, Banner University Medical Center Tucson, Tucson, AZ
      • GARRETT S. PACHECO, MDAssistant Professor, Departments of Emergency Medicine and Pediatrics, University of Arizona, Tucson, AZ

      Emergency airway management has evolved tremendously since the onset of the specialty’s origin. Over the years, the importance of first-pass success and approach to the difficult airway were the primary challenges faced by emergency physicians. With the advent of video laryngoscopy, the rates of first-pass success continue to increase, and the effect of the anatomically difficult airway has begun to lessen. With advances in tools for airway management, the challenges have shifted to approaching optimal preoxygenation and correction of physiologic disturbances prior to any intubation attempt. This review discusses traditional rapid sequence intubation and advances in the field of emergency airway management.

       This review contains 5 figures, 6 tables and 74 references

      Key words: difficult airway, emergency airway management, preoxygenation, surgical airway

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    • 7

      Acute Respiratory Failure and ­mechanical Ventilation

      By Lawrence A. DeLuca, Jr, EdD, MD
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      Acute Respiratory Failure and ­mechanical Ventilation

      • LAWRENCE A. DELUCA, JR, EDD, MDAssociate Professor of Emergency Medicine, University of Arizona/Banner University Medical Center, Department of Emergency Medicine, Tucson AZ

      Patients with acute respiratory failure present to the emergency department (ED) on a regular basis, and emergency physicians (EPs) are expected to be skilled in endotracheal intubation. Historically, although a significant portion of emergency medicine residency training focuses on airway management, extended management of the ventilated patient has received relatively short shrift. Recent data indicate that not only is endotracheal intubation one of the most commonly performed ED procedures, but also that in the initial hours of care, it is also often the EP rather than the intensivist who provides the bulk of critical care to the patient. It is therefore critical that EPs are skilled in ongoing management of the ventilated patient in the early hours as inappropriate management of the ventilator or sedation/analgesia can have a significant impact on complications such as ventilator-induced lung injury, ventilator-associated pneumonia (VAP), ventilator weaning, and delirium. This review outlines basic strategies for the physiologic management of respiratory failure patients to reduce periintubation complications and discuss ventilation strategies, appropriate use of analgesia/sedation, and prevention of secondary complications such as VAP and delirium. Basic troubleshooting of common ventilator problems is also reviewed. Although it is not expected that the EP will replace the intensivist, the goal of this review is to optimize patient management early in the ED stay, to facilitate the transition between the ED and the intensive care unit, and to reduce preventable complications by optimizing the care of ventilated patients in the ED.

      This review contains 9 figures, 4 tables and 46 references

      Key words: acute respiratory distress syndrome, analgesia, chronic obstructive pulmonary disease, delirium, hypercapnia, hyperventilation, hypoxia, patient-ventilator dyssynchrony, pulmonary edema, respiratory failure, sedation, ventilator-associated pneumonia

       

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    • 8

      Cardiac Arrest and Resuscitation

      By Patrick Hughes, MD; Oren Mechanic, MD, MPH; Shamai A. Grossman, MD, MS
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      Cardiac Arrest and Resuscitation

      • PATRICK HUGHES, MDHarvard Affiliated Emergency Medicine Residency Program, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Resident
      • OREN MECHANIC, MD, MPHHarvard Medical School, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Attending Physician
      • SHAMAI A. GROSSMAN, MD, MSAssociate Professor of Emergency Medicine, Harvard Medical School, Vice Chair for Health Care Quality, Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA

      The ultimate goal of cardiac resuscitation is full neurologic recovery; however, the probability of achieving this goal deteriorates rapidly with each minute of cardiac arrest. The most essential steps are rapid recognition of cardiac arrest, early high-quality chest compressions with minimal interruptions, and early defibrillation. Additional key components include effective leadership and followership, appropriate airway management, and effectual investigation for possible reversible causes of the arrest. This review discusses the role of and evidence for using pharmacologic agents. Additional discussion evaluates the use of ultrasonography and end-tidal CO2 in cardiac arrest resuscitation. Lastly, this review discusses cardiac arrest in special circumstances, such as patients who are pregnant, have left ventricular assist devices, or are subjects of trauma.

      This review contains 6 figures, 3 tables and 101 references

      Key words: advanced cardiovascular life support, antidysrhythmics, asystole, cardiac arrest, basic life support, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, pulseless electrical activity, resuscitation, ventricular fibrillation, ventricular tachycardia

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    • 9

      Postresuscitation Management and Outcomes

      By Patrick Hughes, MD; Oren Mechanic, MD, MPH; Shamai A. Grossman, MD, MS
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      Postresuscitation Management and Outcomes

      • PATRICK HUGHES, MDHarvard Affiliated Emergency Medicine Residency Program, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Resident
      • OREN MECHANIC, MD, MPHHarvard Medical School, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Attending Physician
      • SHAMAI A. GROSSMAN, MD, MSAssociate Professor of Emergency Medicine, Harvard Medical School, Vice Chair for Health Care Quality, Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA

      Most patients who achieve return of spontaneous circulation (ROSC) do not survive to hospital discharge. Focus on postarrest care is critical to maximize outcomes. In the post-ROSC phase, patients are frequently hemodynamically unstable, electrophysiologically vulnerable, and in need of airway management and/or ventilatory support. While focusing on further stabilizing the patient, attention should also be placed on identifying the etiology of arrest and minimizing postischemic injury to the brain and other organs. Goal-directed therapy can provide optimal care and outcomes. Neurologic prognostication should wait until 72 hours after ROSC or return to normothermia. If a patient remains is recognized as brain dead, tissue and organ donation should be considered. Debriefing after cardiopulmonary resuscitation improves objective measures in future resuscitation and allows a chance for closure after a stressful event.

      This review contains 4 figures, 4 tables and 42 references

      Key words: cardiac arrest, postarrest care, post–cardiac arrest syndrome, postresuscitation management, target temperature management, therapeutic hypothermia

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  • Trauma
    • 1

      Trauma Resuscitation

      By Joaquim M. Havens, MD; Ali S. Raja, MD, MBA, MPH
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      Trauma Resuscitation

      • JOAQUIM M. HAVENS, MDInstructor in Surgery, Harvard Medical School, Associate Surgeon, Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA
      • ALI S. RAJA, MD, MBA, MPHAssistant Professor of Medicine, Harvard Medical School, Vice Chairman, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

      Although patients with recently sustained traumatic injuries may present at any health care setting, this review focuses on resuscitation, stabilization, and management of the trauma patient in the emergency department. Patients with potentially severe traumatic injury often present to local, community hospitals and may require transfer to a trauma center after evaluation. Nevertheless, as long as it does not delay transfer unnecessarily, the initial evaluation can be undertaken in any setting. This review discusses assessment and stabilization, including triage and preparation, trauma team management, bedside evaluation, and supportive care and empirical therapy; diagnosis, including secondary evaluation and management, laboratory testing, and additional imaging following the secondary evaluation; treatment and disposition; and outcomes. Tables describe advanced trauma life support primary evaluation, the Glasgow Coma Scale, National Emergency X-Radiography Utilization Study low-risk criteria, criteria for a positive diagnostic peritoneal lavage, bedside airway tools and rescue airway devices, and difficult airway predictors. Figures include an illustration showing immobilization of the cervical spine, a computed tomographic scan of an open book pelvic fracture, left-sided traumatic hemothorax, focused abdominal sonography for trauma examination, and the appropriate intercostal spaces of needle insertion.

      This review contains 5 highly rendered figures, 6 tables, and 115 references.

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    • 2

      Trauma: Head and Facial Trauma

      By Christopher R. Tainter, MD, RDMS; Raghu Seethala, MD
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      Trauma: Head and Facial Trauma

      • CHRISTOPHER R. TAINTER, MD, RDMSAssistant Clinical Professor, Department of Emergency Medicine, Department of Anesthesia, Division of Critical Care, University of California, San Diego, San Diego, CA
      • RAGHU SEETHALA, MDAttending Physician, Emergency Department and Surgical Intensive Care Unit, Brigham and Women’s Hospital, Instructor of Emergency Medicine, Emergency Medicine, Harvard Medical School, Boston, MA

      Head and facial trauma includes a wide variety of heterogeneous injuries that vary according to cause, severity, management, and outcomes. These injuries are classified as head injuries (the scalp, skull, and brain) and facial injuries (to the eyes, bony structures, nose, mouth, teeth, tongue, and glands and the accompanying nerves, muscles, and vasculature). This review covers the epidemiology, anatomy, assessment and stabilization, diagnosis, treatment and disposition, and outcomes for traumatic brain injury (TBI), scalp and cranial vault trauma, ocular trauma, and facial trauma. Figures show computed tomographic scans showing a large left frontal lobe intraparenchymal hemorrhage, a traumatic subarachnoid hemorrhage, a subdural hematoma, a right occipital epidural hematoma, and a left orbital floor “blowout” fracture; an illustration of the brain herniation syndromes; the anatomy of the globe; and the Le Fort classification scheme of midface fractures. Tables list the Glasgow Coma Scale, clinical decision aids for computed tomography after mild TBI, the PECARN clinical decision rule for children with mild TBI, the graduated return to play protocol, and anticoagulant and antiplatelet agent reversal.

      This review contains 8 highly rendered figures, 5 tables, and 75 references.

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    • 3

      Penetrating Neck Trauma

      By Adam R. Kellogg, MD, FACEP; B. Witkind Davis, DO, MPH, MS
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      Penetrating Neck Trauma

      • ADAM R. KELLOGG, MD, FACEP
      • B. WITKIND DAVIS, DO, MPH, MS

      Penetrating neck injuries are approximately 1% of all traumatic injuries in the US, yet the case fatality rate approaches 10%. All emergency physicians need to be able to expediently differentiate those requiring emergent interventions from those with less serious injuries. Initial management of penetrating neck injuries focuses on identification of patients requiring early airway management or emergent surgical evaluation. Due to bleeding, anatomic distortion, hemodynamic instability, or potential airway violation patients with penetrating neck trauma should be presumed to have difficult to manage airways. The emergency physician must be prepared to perform cricothyrotomy, and even tracheostomy, should orotracheal intubation attempts fail. Diagnosis of injury in the stable patient with evidence of violation of the platysma has moved away from the traditional zone based approach and now focuses on structured physical exam and the use of MDCTA. Further diagnostic testing may be required dependent on the results of the MDCTA and should be at the direction of a surgeon.

       

      Keywords:

      Penetrating Neck Trauma, Laryngotracheal Trauma, Carotid Artery Injury, Airway Management, Cricothyrotomy, Surgical Airway, CT Angiography

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    • 4

      Spine and Spinal Cord Injury

      By Miguel Arribas, MD; Michael A. Cole, MD
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      Spine and Spinal Cord Injury

      • MIGUEL ARRIBAS, MDEmergency Medicine Resident, Department of Emergency Medicine, Michigan Medicine, University of Michigan
      • MICHAEL A. COLE, MDAssistant Professor, Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, University of Michigan

      Spinal injury has the potential to dramatically change a patient’s life. Prompt diagnosis, appropriate supportive medical care, early transfer to a spinal injury center and, if necessary, surgical intervention within 24 hours are essential to optimizing outcomes.  Clinical decision rules aid in determining the need for imaging. When needed, non-contrast enhanced CT is the initial imaging test of choice with MRI being used in patients with neurologic findings, significant pathology on CT, and/or high suspicion for injury. CT or MRI with intravenous contrast is preferred in penetrating trauma. Radiographs are of limited utility in evaluating spinal injury in adults. Classification of spinal injury based on appearance on imaging and neurologic exam is important for surgical management decisions. Cervical injury may lead to respiratory distress requiring early intubation. Hypotension is most often a result of hemorrhage from concomitant traumatic injuries to other organ systems. Crystalloid, blood products, atropine and norepinephrine should be used as needed to avoid systolic BP< 90 mm Hg or heart rate< 60 BPM and maintain a MAP of 85-90 mm Hg. Steroid administration within the first 8 hours of significant spinal injury is controversial and the decision to administer steroids should be made through consultation with patient, family and spinal specialist.

      The review contains 8 figures, 2 videos, 13 tables, and 59 references.

      Keywords: blunt trauma, neurologic assessment, penetrating trauma, spinal anatomy, spinal cord injury, spinal injury, steroid use, vertebrae, vertebral anatomy, vertebral injury

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    • 5

      Thoracic Trauma

      By William E. Baker, MD; Ron Medzon, MD
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      Thoracic Trauma

      • WILLIAM E. BAKER, MDAssistant Professor, Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
      • RON MEDZON, MDAssociate Professor, Emergency Medicine Director, Solomont Center for Simulation and Nursing Education, Boston Medical Center, Boston University School of Medicine, Boston, MA

      More than 85% of blunt and penetrating trauma to the thorax results in injury to the lungs or ribs. Among civilians, blunt trauma is the most common mechanism, while penetrating trauma is the most common among military sectors. This review describes the assessment and stabilization, diagnosis, treatment and disposition, and outcomes of thoracic trauma. Videos shows the “lung point” sign on M-mode and two-dimensional ultrasonography, and a transthoracic echocardiogram clip of pericardial clot and tamponade due to a gunshot wound. Figures show a sonogram showing the “lung point sign”, a chest x-ray and computed tomographic scan demonstrating right-sided hemothorax in a patient with a right chest stab wound, and a three-dimensional computed tomographic scan and chest x-ray of a blunt trauma patient with displaced fractures of the left lateral sixth to ninth ribs. Tables list types of injuries, NEXUS chest decision instrument imaging criteria, level 2 evidence-based recommendations for the management of pulmonary contusion and flail chest by the Eastern Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma practice guidelines for managing issues with pulmonary contusion and flail chest, and the Vancouver simplified and University of Washington grading systems for blunt aortic injury.

      This review contains 2 videos, 4 highly rendered figures, 5 tables, and 89 references.

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    • 6

      Trauma to the Abdomen and Pelvis

      By Zahir Basrai, MD; Timothy Jang, MD; Manuel Celedon , MD
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      Trauma to the Abdomen and Pelvis

      • ZAHIR BASRAI, MDAttending Physician, Department of Emergency Medicine, Veterans Affairs Medical Center, West Los Angeles, Clinical Instructor, David Geffen School of Medicine at UCLA
      • TIMOTHY JANG, MDAttending Physician, Department of Emergency Medicine, Veterans Affairs Medical Center, West Los Angeles, Clinical Instructor, David Geffen School of Medicine at UCLA
      • MANUEL CELEDON , MD

      Abdominal trauma accounts for approximately 12% of all trauma. The evaluation of abdominal trauma is difficult as the patient may have concomitant distracting injuries or alteration of mental status. As a result, a systematic approach to abdominal trauma is needed to ensure that life threatening injuries are not missed. The evaluation and management of abdominal trauma is directed by the Western and Eastern Trauma Association guidelines.Trauma to the abdomen is divided into two main categories, penetrating and blunt. The initial steps in management of both types are determined by the hemodynamic stability of the patient. Unstable patients with either pattern of injury are emergently taken to the operating room (OR) for exploration. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is being used at select trauma centers in unstable patients with abdominal trauma that are unresponsive to standard trauma resuscitation. For hemodynamically stable patient with penetrating trauma, recent data on selective non-operative management has shown promising outcomes. Patients with tenuous hemodynamics and blunt abdominal trauma are resuscitated with blood transfusions while being worked up by a Focused Assessment with Sonography for Trauma (FAST) exam or deep peritoneal lavage (DPL). If the patient stabilizes further work up with labs and imaging is performed. Patients that remain tenuous should be taken to the OR. Hemodynamically stable patients with blunt trauma and evidence of peritonitis on exam can be evaluated with labs and imaging to assess for organ injury. Non- tender patients can be evaluated with labs and serial abdominal exams. The American Association for the Surgery of Trauma (AAST) organ injury scales are used to guide the definitive management of patients with intraabdominal injury. The Young-Burgess Classification System can be used to characterize pelvic fractures and to guide stabilization and definitive management. Tables demonstrate the AAST Injury Scales for the different abdominal organs. Images demonstrate the FAST exam and CT findings for different abdominal organs.

       

      This review contains 14 figures, 6 tables and 48 references

      Key Words: Abdominal Trauma, Penetrating Trauma, Blunt Trauma, FAST exam, Liver Trauma, Splenic Trauma, Intestinal Trauma, Pancreatic Trauma, Diaphragmatic Trauma, Aortic Trauma, Pelvic Fracture, Deep peritoneal lavage, DPL, Focused Assessment with Sonography for Trauma, REBOA, Resuscitative Endovascular Balloon Occlusion of the Aorta

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    • 7

      Genitourinary Trauma

      By Daniel Lakoff, MD; Adam D. Hill, MD
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      Genitourinary Trauma

      • DANIEL LAKOFF, MDAssistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai & Elmhurst Hospital Center, New York, NY
      • ADAM D. HILL, MDAssistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai & Elmhurst Hospital Center, New York, NY

      Injury to the urogenital tract from blunt or penetrating trauma comprises 10% of injuries sustained from trauma with renal injuries comprising the majority of those cases at 1-5 % of all trauma, followed by bladder injuries. Worldwide variations in trauma mechanisms exist, with blunt trauma causing the majority of renal trauma in the United States. Careful attention to the mechanism, anatomic location, and specific physical and radiologic findings can aid in the diagnosis and appropriate management to optimize patient outcomes. Unless trauma is overtly obvious on a physical examination, imaging is required for diagnosis and staging purposes. Owing to the complexity of the urogenital tract, there is a great deal of variation in management, ranging from a conservative approach in most renal injuries to the need for operative intervention with intraperitoneal bladder rupture. This review discusses common practice and provides more recent up-to-date guidelines pertaining to the clinical history, examination findings, and imaging modalities, along with the diagnosis and management of injuries to the genitourinary system.

      Keywords: Genitourinary Trauma, Renal Trauma, Ureter Trauma, Bladder Trauma, Urethral Trauma, External Genitalia Trauma

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    • 8

      Extremity Trauma: Nonaxial Skeleton Fractures, Sprains, Dislocations

      By David A. Meguerdichian, MD, FACEP; John Eicken, MD
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      Extremity Trauma: Nonaxial Skeleton Fractures, Sprains, Dislocations

      • DAVID A. MEGUERDICHIAN, MD, FACEPAssistant Medical Director for Emergency Medicine/GME, STRATUS Center for Medical Simulation, Attending Physician, Department of Emergency Medicine, Brigham and Women’s Hospital, Instructor of Emergency Medicine, Harvard Medical School, Boston, MA
      • JOHN EICKEN, MDDepartment of Emergency Medicine, Brigham and Women’s Hospital, Instructor, Harvard Medical School, Boston, MA

      Orthopedic extremity injuries may require emergent orthopedic consultation, but are typically managed by the acute care provider. Initial management for all fractures should focus on providing immediate analgesia and ensuring adequate blood flow distal to the fracture. This review summarizes the assessment and stabilization, diagnosis, treatment and disposition, and outcomes for fractures, dislocations, and sprains. Figures include illustrations of fracture types, carpal bones and their articlulation in the wrist, bones of the hand, the anatomy of the hip demonstrating the areas where hip fractures occur, the Weber classification, the Bohler angle, and fractures of the proximal fifth metatarsal; a bedside sonogram of a fracture of the distal radius; and 10 radiographs showing various fractures and dislocations. Tables list the Gustilo classification of open fractures; common terms used to accurately describe fractures; components of the Ottawa Knee Rules and the Ottawa Ankle/Foot Rules; Schatzker classification system of tibial plateau fractures; common fractures of the hand and foot, respectively, with their associated treatment, splint, and recommended follow-up; normal anatomic alignments that should be assessed on radiographic evaluation of a possible Lisfranc injury; common splints and the associated fractures they are used to treat; AC joint injuries graded according to the severity of injury to the joint structures; and the four stages of worsening lunate instablity.

      This review contains 18 highly rendered figures, 11 tables, and 98 references.

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    • 9

      Extremity Trauma: Foreign Bodies and Vascular Injury

      By David A. Meguerdichian, MD, FACEP; John Eicken, MD
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      Extremity Trauma: Foreign Bodies and Vascular Injury

      • DAVID A. MEGUERDICHIAN, MD, FACEPAssistant Medical Director for Emergency Medicine/GME, STRATUS Center for Medical Simulation, Attending Physician, Department of Emergency Medicine, Brigham and Women’s Hospital, Instructor of Emergency Medicine, Harvard Medical School, Boston, MA
      • JOHN EICKEN, MDDepartment of Emergency Medicine, Brigham and Women’s Hospital, Instructor, Harvard Medical School, Boston, MA

      It is important for physicians to be mindful of the possibility of a foreign body in the context of extremity trauma. Patients with foreign bodies may not suspect their presence, and a significant proportion of foreign bodies are missed by the initial treating physician. Trauma injuries to the peripheral vasculature can be divided into blunt and penetrating trauma, and can also be classified as occlusive or nonocclusive injuries. This review details the assessment and stabilization, diagnosis, treatment and disposition, and outcomes for patients with foreign body and vascular injuries. Figures show beside ultrasonography using a linear ray probe that demonstrates a foreign body wood splinter in soft tissue, the major arteries of the upper and lower extremities, and measurement of the ankle-brachial index in an injured limb with suspected vascular injury. Tables list supplies needed to perform bedside ultrasound-guided foreign body removal, steps to remove a foreign body under ultrasound guidance, hard and soft signs of arterial injuries, and high-risk orthopedic injuries and their commonly associated vascular injury.

      This review contains 3 highly rendered figures, 4 tables, and 51 references.

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    • 10

      Wound Management

      By Jennifer Starling, MD, FAWM; Jay Lemery, MD, FACEP, FAWM
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      Wound Management

      • JENNIFER STARLING, MD, FAWMAdjoint Assistant Professor of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
      • JAY LEMERY, MD, FACEP, FAWMAssociate Professor of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO

      The primary purpose of wound management is to create an optimal environment for the body to form an aesthetically pleasing and functional scar. The majority of wounds are treated with primary closure (ie, closure at the time of presentation). This review discusses the essential steps of laceration management, including patient and wound assessment, tissue preparation, decontamination and débridement, techniques of skin closure, and wound aftercare. This is presented as assessment and stabilization, treatment and disposition, and outcomes of wound management. Figures include illustrations of the anatomy of the skin and an ear field block; illustrations of multiple techniques (simple suture, running suture, horizontal and vertical mattress, deep dermal suture, and tissue adhesive); and photographs showing examples of the stapling technique and the tissue adhesive combined with surgical tape technique. Tables list tetanus prophylaxis recommendations, summaries of the commonly used local anesthetics, suture characteristics, wounds recommended for specialist consultation, and suture removal times based on the anatomic site.

      This review contains 9 highly rendered figures, 5 tables, and 149 references.

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    • 11

      Traumatic Brain Injury

      By Pierre Borczuk, MD, FACEP
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      Traumatic Brain Injury

      • PIERRE BORCZUK, MD, FACEPAssociate Physician in Emergency Medicine, Massachusetts General Hospital, Assistant Professor in Emergency Medicine, Harvard Medical School, Boston, MA.

      The emergency department (ED) clinician needs to be prepared to manage patients of all ages with traumatic brain injury (TBI). This review outlines key historical and physical examination findings on initial trauma evaluation and treatment of the severely head injured patient with a herniation syndrome. The most common lesions seen on cranial computed tomographic (CT) scanning are discussed. Since the most important decision in managing patients with milder forms of TBI is whether to perform brain imaging, the review includes an in-depth discussion of the history and evolution of CT decision rules, including the most commonly used rule in children. Given the aging population and increased use of anticoagulants, it is imperative to understand the current evidence available to best treat these patients. Finally, we may all be required to assess sport-related concussions in the ED or on the field.

      This review contains 6 figures, 5 tables, and 32 references.

      Key words: traumatic brain injury, concussion, subdural hematoma, subarachnoid hemorrhage, Canadian head CT rules, PECARN, mannitol, hypertonic saline

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    • 12

      TEST CME TOOL

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      TEST CME TOOL

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    • 13

      Focused Assessment With Sonography for Trauma

      By David Barounis, MD ; Elise Hart, MD
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      Focused Assessment With Sonography for Trauma

      • DAVID BAROUNIS, MD Attending Physician, Departments of Emergency Medicine and Critical Care Medicine, Advocate Christ Medical Center, Oak Lawn, IL
      • ELISE HART, MDPostgraduate Year 3, Emergency Medicine Residency Program, Advocate Christ Medical Center, Oak Lawn, IL

      The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients.

      Key words: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

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  • Cardiovascular
    • 1

      Aortic Aneurysm

      By Christine E Lee, MD, MPH; Leily Naraghi, MD; Beatrice Hoffmann, MD, PhD, RDMS
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      Aortic Aneurysm

      • CHRISTINE E LEE, MD, MPHClinical Instructor, Harvard Medical School, Ultrasound Faculty, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
      • LEILY NARAGHI, MDEmergency Medicine Physician and Emergency Ultrasound Fellow, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, United States
      • BEATRICE HOFFMANN, MD, PHD, RDMSAssociate Professor Harvard Medical School, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.

      Aortic diseases are relatively rare but are associated with high morbidity and mortality. Emergency physicians (EPs) should consider aortic disease in all patients with pain in the torso, particularly those with other diverse or seemingly unconnected complaints. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with abdominal aortic aneurysms (AAAs), thoracic aortic aneurysms (TAAs), and aortic dissection. Figures show a transverse image of an AAAs with a transmural hematoma, a three-dimensional computed tomographic angiogram (CTA) rendering of a thoracic aneurysm associated with a bicuspid aortic valve in the typical ascending aortic location, a chest x-ray film demonstrating prominent and blurred aortic knob due to TAA, acute aortic dissection subtypes, an electrocardiogram and transesophageal echocardiography of a patient with acute ascending aortic dissection, magnetic resonance images of a patient with dissection of the proximal descending aorta, CT representations of a type A dissection involving a dilated ascending aorta and a type B dissection involving the descending thoracic aorta, and a decision algorithm for evaluation and treatment of a suspected aortic dissection. Tables list normal aortic dimensions by CTA and echocardiography, average annual rate of expansion and rupture of AAA based on current diameter, and the etiology of TAA.

      This review contains 3 figures, 3 tables, 4 videos and 66 references.

      Key words: AAA, aorta, aortic dissection, ascending aortic dissection, descending aortic dissection, intimal tear, intramural hematoma, thoracic aortic aneurysm

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    • 2

      Approach to the Patient Presenting With Chest Pain

      By Elizabeth Temin, MD, MPH
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      Approach to the Patient Presenting With Chest Pain

      • ELIZABETH TEMIN, MD, MPHInstructor, Harvard Medical School, Massachusetts General Hospital, Boston, MA

      Caring for the emergency department patient with chest pain represents an important challenge to the emergency physician. Chest pain is the second most common presentation among all emergency department patients, accounting for approximately 6 million visits per year in the United States. Chest pain may represent a benign condition or a time-critical life threat; symptom overlap between benign and serious conditions can make an accurate chest pain diagnosis challenging. This review covers the pathophysiology, assessment, stabilization, diagnosis and treatment, and disposition and outcomes of chest pain. The figure shows an algorithm outlining the approach to the patient with chest pain. Tables list critical and noncritical diagnoses in patients presenting with chest pain: history, physical examination, and bedside testing; risk factors or associations for acute coronary syndrome, pulmonary embolism, and aortic dissection; characteristics of the chest pain story to diagnose acute coronary syndrome; ABCDEs of resuscitation for patients with unstable vital signs; critical and noncritical diagnoses in patients presenting with chest pain: history, diagnosis, and treatment; prevalence of pulmonary embolism in patients classified as low or high probability for this diagnosis by Wells score, modified Geneva score, and gestalt; commonly recognized pitfalls in the workup and diagnosis of chest pain in the emergency department; critical diagnoses in patients presenting with chest pain: history, disposition, and outcome; and summary of current recommendations.

      This review contains 1 highly rendered figure, 11 tables, and 54 references.

      Key words: acute coronary syndrome, acute myocardial infarction, anginal pain, aortic dissection, cardiac-related pain, chest pain, coronary artery disease, non–ST segment elevation myocardial infarction, pulmonary embolism, ST segment elevation myocardial infarction

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    • 3

      St-segment Elevation Myocardial Infarction

      By Andra L. Blomkalns, MD
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      St-segment Elevation Myocardial Infarction

      • ANDRA L. BLOMKALNS, MDProfessor of Emergency Medicine, University of Texas Southwestern, Dallas, TX

      ST-segment myocardial infarction (STEMI) needs to be recognized and differentiated  as quickly as possible from other causes of acute coronary syndrome (unstable angina and non-ST segment elevation myocardial infarction), as rapid intervention is necessary to salvage myocardium and improve morbidity and mortality. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of patients with STEMI. Figures show electrocardiographic changes in STEMI and the corresponding territory of myocardium, cardiac biomarker release following acute myocardial infarction over time, lower mortality and reduced infarct size among survivors of myocardial infarction treated most rapidly, a schematic of reperfusion strategies, multivariate-adjusted relationship between door-to-balloon time and in-hospital mortality, and the Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI. Tables list signs that can accompany serum biochemical markers of myocardial necrosis for diagnosis of myocardial infarction, the Sgarbossa criteria, differential diagnosis of ST segment elevation, contraindications for administering thrombolytic agents, thrombolytic therapy recommendations, major recommendations for antithrombotic therapy in patients with STEMI treated with primary percutaneous coronary intervention, major recommendations for antithrombotic therapy in patients with STEMI treated with thrombolysis, and the Killip classification of acute myocardial infarction and mortality.

      This review contains 6 highly rendered figures, 8 tables, and 110 references.

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    • 4

      Unstable Angina and Non-st Segment Elevation Acute Coronary Syndrome

      By Edward Ullman, MD
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      Unstable Angina and Non-st Segment Elevation Acute Coronary Syndrome

      • EDWARD ULLMAN, MD

      Unstable angina and non-ST-segment acute coronary syndrome represent a frequent and serious presentation to the emergency department.  While most patients present with chest discomfort, atypical presentations warrant that clinicians maintain a high index of suspicion. This review summarizes the present nomenclature, definitions, and pathophysiology for this high morbidity disease process. The rapid acquisition of an electrocardiogram and serial cardiac troponins are mainstays of diagnosis.  Also outlined is an approach for initial assessment, high-risk ECG findings, risk stratification, biomarker strategies, and subsequent stabilization.  Once diagnosed, treatment options for these patients aim to halt continued ischemia and resultant necrosis. These therapies may include agents such as supplemental oxygen, nitrates, anti-platelet agents, beta blockers, anti-coagulation, anti-thrombin and statin therapies in appropriate settings. Caution should be exercised when dosing high-risk patients for bleeding such as those who are elderly or who weigh less than 60kg. Emergent angiography is reserved for patients who develop hemodynamic instability, cardiogenic shock, pulmonary edema, persistent angina refractory to medical therapy, and sustained arrhythmia.

       

      Keywords: acute coronary syndrome, unstable angina, myocardial infarction, troponin, electrocardiogram

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    • 5

      Management of Acute Heart Failure

      By Inna Leybell, MD; Liliya Abrukin, MD
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      Management of Acute Heart Failure

      • INNA LEYBELL, MDAssistant Professor, Department of Emergency Medicine, NYU Langone Medical Center/Bellevue Hospital, New York, NY
      • LILIYA ABRUKIN, MDChief Resident, Department of Emergency Medicine, NYU Langone Medical Center/Bellevue Hospital, New York, NY

      Acute heart failure (AHF) is a heterogeneous syndrome characterized by patients who present with signs and symptoms of heart failure (HF) in need of urgent or emergent therapy. Although dyspnea is the most common presentation, AHF is accompanied by a variety of signs and symptoms. AHF primarily afflicts the elderly; these patients typically have numerous comorbid conditions, both cardiovascular and noncardiovascular. Although signs and symptoms are similar in nearly all patients with AHF, the precipitant of acute decompensation, cardiac structure and function, and etiology of HF, as well as other comorbid conditions, vary considerably. This review covers the epidemiology, pathophysiology, diagnosis, treatment, and disposition of patients who present to the emergency department with nonacute coronary syndrome AHF.

      This review contains 5 highly rendered figures, 2 videos, 4 tables, and 82 references.

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    • 6

      Bradyarrhythmias

      By Sally Graglia, MD; Gary Green, MD
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      Bradyarrhythmias

      • SALLY GRAGLIA, MDResident Physician, UCSF Medical Center, San Francisco, CA
      • GARY GREEN, MDAssociate Physician, UCSF Medical Center, San Francisco, CA, Associate Physician, Kaiser Permanente East Bay, Oakland, CA

      Bradyarrhythmias can present as an incidental electrocardiographic (ECG) finding or a life-threatening condition requiring immediate intervention. They are caused by sinus node disease or atrioventricular block. This review covers pathophysiology, stabilization and assessment, diagnosis and treatment options, and disposition and outcomes for patients with bradycardia. Figures in the review demonstrate characteristic ECG tracings. Tables list classifications of sinus node dysfunction as well as of sinoatrial and atrioventricular blocks, presenting symptoms, important information to elicit on history taking, various causes of bradycardia, and specific interventions for toxicologic etiologies.

      Key words: atrioventricular block, atropine, bradyarrhythmia, bradycardia, first-degree atrioventricular block, second-degree atrioventricular block, sinoatrial block, sinus bradycardia, sinus node disease, tachycardia-bradycardia syndrome, third-degree atrioventricular block

      This review contains 9 highly rendered figures, 7 tables, and 92 references.

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    • 7

      Wide Complex Tachycardia

      By Tareq Al-Salamah, MD, MPH; Laura J. Bontempo, MD, MEd
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      Wide Complex Tachycardia

      • TAREQ AL-SALAMAH, MD, MPHEmergency Medicine Resident, Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD
      • LAURA J. BONTEMPO, MD, MEDAssistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD

      Wide-complex tachycardias (WCTs) should always alert the emergency physician to a potentially immediate or rapidly developing, life-threatening scenario. The approach to these patients should follow general emergency medicine principles. The review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of WCT. Figures show a basic electrocardiogram (ECG) tracing, an ambulatory monitoring strip of a patient with recurrent presyncope showing repetitive monomorphic ventricular tachycardia, a 12-lead ECG of a rapid wide QRS tachycardia due to an antidromic atrioventricular reciprocating tachycardia in a patient with Wolff-Parkinson-White (WPW) syndrome, an example of pacemaker-mediated tachycardia, ventricular tachycardia occurring in the context of QT prolongation consistent with torsades de pointes, a 12-lead ECG in a patient with WPW syndrome showing a rapid, irregular ventricular rate and wide QRS complexes of atrial fibrillation with a short refractory period, an ECG representative of tricyclic antidepressant overdose, and an algorithm for identifying patients with systolic heart failure and left ventricular ejection fraction less than or equal to 35% who are candidates for an implantable cardioverter-defibrillator. Tables list causes of regular WCT, causes of prolonged QT interval, common medications with potential QT prolongation activity, pharmacologic treatment options for stable patients with WCT, Kindwall and colleagues’ criteria for ventricular tachycardia, Brugada and colleagues’ criteria for ventricular tachycardia, Vereckei and colleagues’ aVr algorithm for the diagnosis of ventricular tachycardia, and a comparison of self-reported sensitivities, specificities, and test accuracies of the algorithms presented by Kindwall, Brugada, and Vereckei and their colleagues.

       

      Key words: prolonged QT interval, supraventricular tachycardia, ventricular tachycardia, wide-complex tachycardias

       

      This review contains 8 highly rendered figures, 8 tables, and 59 references.

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    • 8

      Atrial Fibrillation

      By Michael Logan, MD; Kelly Williamson, MD; William J. Brady, MD
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      Atrial Fibrillation

      • MICHAEL LOGAN, MDResident Physician, Advocate Christ Medical Center, Oak Lawn, IL
      • KELLY WILLIAMSON, MDAttending Physician, Advocate Christ Medical Center, Oak Lawn, IL
      • WILLIAM J. BRADY, MDProfessor, Emergency Medicine and Medicine, Department of Emergency Medicine, University of Virginia, Charlottesville, VA

      Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by chaotic atrial electrical activity.  It is associated with heart failure, stroke, and reduced quality of life. AF is frequently recurrent and refractory to treatment. These facts underscore the importance of recognizing this arrhythmia even in its asymptomatic form. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of AF. Figures show AF, atrial flutter, and AF with preexcitation on a 12-lead electrocardiogram, rate control agent selection recommendations, and a decision-making algorithm for oral anticoagulation therapy. Tables list etiologies and risk factors for AF, American Heart Association/American College of Cardiology/Heart Rhythm Society classification of AF, some of the clinical consequences of AF, diagnostic evaluation for AF, antiarrhythmic drugs for conversion of AF, drugs used for acute rate control of AF, CHA2DS2-VASc score calculation, CHA2DS2-VASc  adjusted stroke rate and treatment guidelines, scoring system to assess the risk of bleeding with oral anticoagulation: HAS-BLED (hypertension, abnormal renal/liver function, history of stroke, bleeding history or predisposition, labile international normalized ratio, elderly [65 years], drugs/alcohol concomitant), and HAS-BLED scores with proportion of patients from the Euro Heart Survey in each category and associated major bleeding risk.

       

      This review contains 5 highly rendered figures, 10 tables, and 69 references

      Key words: Atrial fibrillation; Supraventricular tachycardia; Irregular heart beat; Cardioversion; Nonvalvular atrial fibrillation; Paroxysmal atrial fibrillation; Rate control; CHA2DS2-VASc scoring system; Rhythm control

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    • 9

      Supraventricular Tachycardia

      By Annalee M Baker, MD
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      Supraventricular Tachycardia

      • ANNALEE M BAKER, MDAttending Physician and Clinical Instructor, Ronald O. Perelman Department of Medicine, NYU Langone Medical Center, Bellevue Hospital, New York, NY

      Supraventricular tachycardia (SVT) is a category of arrhythmias that originate at or above the atrioventricular node. These are typically narrow complex QRS arrhythmias, without discernible P waves, with a regular rhythm and rapid rate. SVT is relatively common, occurring in 2.25 cases per 1,000 persons. Therefore, understanding the pathophysiology and method of treatment of SVT is an important skill for the emergency medicine physician to master. Therapeutic interventions include vagal maneuvers or pharmacologic agents, such as adenosine or calcium channel blockers, for the stable patient and synchronized cardioversion for the unstable patient. Stable patients with minimal comorbidities whose sinus rhythm is converted back in the emergency department can be safely discharged with a close follow-up by a cardiologist. However, admission is often required for the patient who presents with unstable SVT or has multiple comorbidities and requires further work-up.

       

      This review contains 10 figures, 1 table, and 47 references.

      Keywords: ablation, adenosine, cardioversion, supraventricular tachycardia, valsalva maneuver, Wolff-Parkinson-White syndrome

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    • 10

      Syncope

      By Ryan M Kring, MD; Shamai A. Grossman, MD, MS
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      Syncope

      • RYAN M KRING, MDChief Resident in Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Beth Israel Deaconess Medical Center, Boston, MA
      • SHAMAI A. GROSSMAN, MD, MSAssociate Professor of Emergency Medicine, Harvard Medical School, Vice Chair for Health Care Quality, Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA

      Syncope is a common presenting complaint in the emergency department, accounting for approximately 1 to 3% of presentations and up to 6% of admissions. Syncope is properly defined as a brief loss of consciousness and postural tone followed by spontaneous and complete recovery. Often syncope must be distinguished from other etiologies of transient loss of consciousness, such as seizures and hypoglycemia. Comprehension of the pathogenesis, clinical presentation, and prognosis of the varied causes of syncope is essential if emergency physicians are to succeed in identifying patients at risk for adverse events while also reducing unnecessary syncope admissions. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of syncope. Figures show heart block, prolonged QTc and torsades de pointes, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, and Brugada syndrome. Tables list etiologies of syncope, important historical elements, “red flags”: clinical cues for life-threatening diagnoses, syncope clinical decision rules and scores, and risk stratification criteria in a randomized controlled trial of syncope observation.

       

      Key words: cardiac syncope, orthostasis, presyncope, syncope, transient loss of consciousness

       

      This review contains 6 highly rendered figures, 5 tables, and 71 references.

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    • 11

      Pacemaker Therapy

      By Keith A. Marill, MD
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      Pacemaker Therapy

      • KEITH A. MARILL, MDDepartment of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA

      The number of permanent pacemakers implanted per year increased by 55.6% between 1993 and 2009, and is continuing to rise. Accordingly, the number of patients treated in the emergency department who have permanent pacemakers is increasing, and it is important for physicians in the emergency department to be familiar with the operation and potential complications of these devices. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with pacemakers presenting to the emergency department. Figures show examples of dual chamber pulse generators from four major pacemaker manufacturers, VVI pacing with a lower rate limit of 60 beats per minute,  DDD pacing with a lower rate limit of 60 beats per minute and an upper rate limit of 120 beats per minute, a 12-lead electrocardiogram with bifascicular block, a proprietary algorithm (Managed Ventricular Pacing, Medtronic Inc.) aimed at reducing ventricular pacing, and an example of a pacemaker pocket infection. Tables list North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group generic five-position code for antibradycardia pacing, and Levels of Evidence and Society Guideline Recommendations for Selected Pacing Indications.

      This review contains 6 highly rendered figures, 2 tables, and 28 references.

      Key Words: Single-chamber pacing (VVI), Dual-chamber pacing (DDD), Cardiac resynchronization therapy, Sinus node dysfunction, Chronotropic incompetence, Complete Heart Block, Bifasicular Block, Mode Switching, Electromagnetic interference

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    • 12

      Venous Thromboembolism

      By David W. Schoenfeld , MD, MPH
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      Venous Thromboembolism

      • DAVID W. SCHOENFELD , MD, MPH

      Venous thromboembolism (VTE) encompasses both deep vein thrombosis (the development of clots in the large veins of the extremities, with the deposition of clotting factors, platelets, and red blood cells) and pulmonary embolism (which occurs when a portion of a clot dislodges, travels through the right heart, and embeds in the pulmonary vasculature). Risk factors for VTE include recent surgery, extremity trauma, age, obesity, smoking, cancer, antiphospholipid antibody syndrome, and inherited risk factors, such as factor V Leiden. This review details the epidemiology and risk factors, pathophysiology, stabilization and assessment, supportive care and empirical therapy, diagnosis, treatment, and outcomes of patients with venous thromboembolism. Figures show the pathophysiology of right heart failure in acute pulmonary embolism; a venous sonogram showing a large acute deep vein thrombosis in a dilated, noncompressible right common femoral vein in cross section; and a computed tomographic pulmonary angiography demonstrating intraluminal filling defects caused by pulmonary embolism in the lobar artery of the left lower lobe and the main artery of the right lung in a patient with chest deformity. Tables list risk factors for VTE, the Wells score, the revised Geneva score for PE, and pulmonary embolism rule-out criteria.

      This review contains 3 highly rendered figures, 4 tables, and 61 references.

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    • 13

      Pericardial Diseases

      By Akinyi Ragwar, MD; Jeffrey Siegelman, MD, FACEP
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      Pericardial Diseases

      • AKINYI RAGWAR, MDResident Physician, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
      • JEFFREY SIEGELMAN, MD, FACEPAssistant Professor, Assistant Residency Director, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA

      Diseases of the pericardium represent a wide range of clinical syndromes that vary substantially in severity, from a benign pericardial effusion to fatal constrictive pericarditis or hemopericardium. Acute pericarditis is the most common pericardial disease, with viral and idiopathic as the most frequent etiologies. Typically, acute pericarditis can be managed as an outpatient with dual-agent therapy consisting of aspirin or nonsteroidal anti-inflammatory drug plus colchicine and rarely requires admission. Pericardial effusions are fluid collections in the pericardial cavity. They are a common incidental finding, can be associated with other systemic disease, and at their extreme, cause life-threatening cardiac tamponade. Cardiac tamponade exists on a spectrum with patients who are quasi stable to those where cardiovascular collapse and death are imminent. Cardiac tamponade may be temporized with fluid boluses, but treatment is through pericardiocentesis and occasional surgical intervention. Constrictive pericarditis is progressive process with poor prognosis in which the pericardium becomes rigid and causes diastolic dysfunction, leading to heart failure. Once the diagnosis is made, definitive management is surgical but carries a high operative risk.

      This review contains 7 highly rendered figures, 5 videos, 3 tables, and 42 references.

      Key Words: cardiac tamponade, constrictive pericarditis, effusive-constrictive pericarditis, pericardial effusion, pericarditis, pericardiocentesis

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    • 14

      Hypertensive Crises

      By Jennifer L Martindale, MD; Daniel Zeccola, MD
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      Hypertensive Crises

      • JENNIFER L MARTINDALE, MDHarvard Affiliated Emergency Medicine Residency Program, Brigham and Women’s Hospital, Boston, MA
      • DANIEL ZECCOLA, MDSUNY Downstate Medical Center/Kings County Hospital Emergency Medicine Residency Program, Brooklyn, NY

      Hypertension is the most common chronic medical condition, affecting more than 1 billion people worldwide. When acute hypertension causes end-organ damage, this is termed a hypertensive emergency. Hypertension can result in a variety of life-threatening clinical scenarios, including aortic dissection, intracerebral hemorrhage, renal dysfunction, pulmonary edema, acute coronary syndrome, and eclampsia. These require aggressive management, whereas asymptomatic hypertension can be managed on an outpatient basis. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition of patients with hypertensive crises, including a discussion of the various pharmacologic agents available to the emergency physician. Figures show the types of hypertensive emergency, clinical manifestations, and pharmacologic treatment. 

      Key words: acute coronary syndrome, aortic dissection, asymptomatic hypertension, eclampsia, hypertension, hypertensive crisis, hypertensive encephalopathy, stroke

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    • 15

      Valvular Emergencies

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      Valvular Emergencies

      Accurate and timely diagnosis of acquired valvular heart disease in symptomatic patients is critical. The prevalence of valvular disease and prostheses continues to increase within our aging worldwide population. Although the epidemiology, microbiology, and clinical presentation of infective endocarditis (IE) have changed significantly, it continues to be associated with increased morbidity and mortality. The diagnosis of IE should be considered in at-risk patients presenting with fever, patients with a new regurgitant murmur, patients with sepsis without a clear source of infection, or patients with febrile illness associated with congestive heart failure or an unexplained embolic event. Hematologic, infectious, and mechanical complications in patients with prosthetic valves should be considered. This review delineates how to recognize and manage native, left-sided (aortic and mitral) valvular emergencies in the acute care setting. Patients with acute valvular regurgitation are often in distress; the therapeutic approach is based on afterload reduction and urgent surgical intervention. Chronic valvular pathology becomes more clinically evident when patients develop altered cardiac filling pressures as a consequence of cardiac remodeling; indications for definitive surgical intervention are based on symptoms and echocardiographic measures of severity.

      This review contains 3 figures, 2 tables, and 29 references.

      Key words: aortic valve insufficiency, aortic valve stenosis, endocarditis, heart valve prosthesis, heart valves, mitral valve insufficiency, transcatheter aortic valve replacement

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    • 16

      Aortic Dissection

      By Christine E Lee, MD, MPH; Leily Naraghi, MD; Beatrice Hoffmann, MD, PhD, RDMS
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      Aortic Dissection

      • CHRISTINE E LEE, MD, MPHClinical Instructor, Harvard Medical School, Ultrasound Faculty, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
      • LEILY NARAGHI, MDEmergency Medicine Physician and Emergency Ultrasound Fellow, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, United States
      • BEATRICE HOFFMANN, MD, PHD, RDMSAssociate Professor Harvard Medical School, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States.

      Aortic dissections are associated with high morbidity and mortality and thus are important diagnoses to consider, as delaying diagnosis can have drastic consequences. Emergency physicians should consider dissection in patients with the classic presentation of tearing chest and/or back pain but should also be aware that its presentation can be varied based on the location of the dissection. This review summarizes the pathophysiology, presentation, stabilization and assessment, diagnosis, treatment, disposition, and outcomes for patients with aortic dissection.


      This review contains 5 figures, 1 video, and 77 references.

      Key Words: aortic dissection, ascending aortic dissection, descending aortic dissection, intimal tear, intramural hematoma

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  • Pulmonary Emergencies
    • 1

      Approach to the Patient With Respiratory Symptoms

      By David Silvestri, MD, MBA; Calvin Huang, MD, MPH
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      Approach to the Patient With Respiratory Symptoms

      • DAVID SILVESTRI, MD, MBAHarvard Affiliated Residency in Emergency Medicine, Brigham and Women’s Hospital/Massachusetts General Hospital, Boston, MA
      • CALVIN HUANG, MD, MPHAttending Physician, Division of Emergency Ultrasound, Department of Emergency Medicine Massachusetts General Hospital, Boston, MA

      Respiratory complaints are among the most common symptoms encountered by emergency physicians (EPs). Collectively, acute and chronic respiratory diseases account for 11.1% of all mortality and 8.8% of all disability-adjusted life-years lost worldwide. Acute respiratory infections are the single greatest contributor to the overall global burden of disease. Chronic respiratory conditions, including asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and occupational lung disease, affect an estimated 1 billion people. Many of these chronic conditions present as acute and life-threatening exacerbations in emergency care settings. Respiratory complaints are not specific to pulmonary pathology. Indeed, cardiovascular, neurologic, musculoskeletal, and even gastrointestinal and endocrine diseases can all manifest principally with respiratory symptoms. Moreover, primary conditions of the lung need not present with respiratory symptoms and may instead be heralded only by nonspecific symptomatology, including weakness or confusion. The EP’s approach must be systematic, rooted in a firm grasp of relevant respiratory pathophysiology, with a rapid and yet comprehensive approach to stabilization, diagnosis, and treatment. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of respiratory diseases in the emergency department. Figures show an illustration of the respiratory system and the relation of oxygen saturation, partial pressure, and minute ventilation. The table lists clinical indications for microbiological testing in suspected community-acquired pneumonia.
       

      Key words: asthma, chronic obstructive pulmonary disease, dyspnea, expiratory wheeze, respiratory symptoms

      This review contains 2 highly rendered figures, 1 table, and 98 references.

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    • 2

      Chronic Obstructive Pulmonary Disease

      By Regan H. Marsh, MD, MPH
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      Chronic Obstructive Pulmonary Disease

      • REGAN H. MARSH, MD, MPHInstructor, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

      Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction that is not fully reversible. The airflow obstruction is usually progressive and associated with an inflammatory response of the lungs to noxious particles and gases, often from smoking. COPD is the third leading cause of death in the United States, with both its prevalence and mortality continuing to increase. It has also become one of the leading causes of death and disability worldwide. COPD is estimated to affect more than 5% of the total population in the United States; approximately 5 million adults have emphysema and another 10 million have chronic bronchitis. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of COPD. Figures show spirometry test results in a normal patient and a patient with severe COPD, stages of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the pathogenesis of emphysema from smoking, pathologic lesions in small airways in a patient with COPD, the acinar structure of normal lungs compared with that of lungs in patients with centriacinar (centrilobular) emphysema or panacinar (panlobular) emphysema, and electrocardiogram demonstrating findings consistent with P pulmonale and right heart strain due to advanced COPD. Tables list pathogenic mechanisms of COPD, pathophysiology of a COPD exacerbation, bacterial pathogens in acute COPD exacerbations, key historical features of COPD, differential diagnosis of patients presenting with possible COPD, criteria for hospitalization as indicated by GOLD guidelines, and indications for ICU admission.

      This review contains 6 highly rendered figures, 7 tables, and 124 references

      Key words: Chronic obstructive pulmonary disease; COPD; Emphysema; Chronic bronchitis; Acute exacerbation of COPD; AECOPD; Airway disease

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    • 3

      Asthma

      By Kohei Hasegawa, MD, MPH; Haitham Nsour, MBBS; Anne E. Dixon, MA, BMBCH
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      Asthma

      • KOHEI HASEGAWA, MD, MPHAssistant Professor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
      • HAITHAM NSOUR, MBBSAssistant Professor, Department of Medicine, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT
      • ANNE E. DIXON, MA, BMBCHProfessor, Department of Medicine, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT

      Asthma is one of the most common diseases in developed nations. A pathognomonic feature of asthma is episodic aggravations of the disease; these exacerbations can be life-threatening and contribute to a significant proportion of the public health burden of asthma. In the emergency department, successful management of asthma exacerbations requires early recognition and intervention before they become severe and potentially fatal. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for asthma. Figures show the management of asthma exacerbations in the emergency department and hospital and an asthma discharge plan at the emergency department. Tables list current asthma prevalence among selected demographic groups in the United States, risk factors for fatal asthma exacerbations, differential diagnosis of asthma exacerbations, dosages of drugs for asthma exacerbations, and the latest asthma management guidelines, among others.

      This review contains 2 figures,10 tables, and 64 references.

      Keywords: asthma, asthma education, asthma exacerbation, biologics, emergency department, follow-up asthma care, guidelines, inhaled corticosteroids, medication adherence, quality of care

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    • 4

      Pneumonia and Other Pulmonary Infections

      By Karen D. Serrano, MD ; Scott A. Fruhan, MD, MBA
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      Pneumonia and Other Pulmonary Infections

      • KAREN D. SERRANO, MD Clinical Assistant Professor, Department of Emergency Medicine University of North Carolina, Chapel Hill
      • SCOTT A. FRUHAN, MD, MBAClinical Instructor, Department of Emergency Medicine University of California, San Francisco

      Pulmonary infections span a wide spectrum, ranging from self-limited to life threatening.  Pneumonia refers to infection of lung parenchyma, specifically the alveolar or gas-exchanging portions of the lung. Taken together, pneumonia and influenza rank as the sixth leading cause of death in the United States and the leading infectious cause of death in the United States and the world. Tuberculosis (TB) is a bacterial disease caused by Mycobacterium tuberculosis. TB, historically a leading cause of death worldwide, remains an enormous global public health epidemic in much of the developing world. Rates of coinfection with HIV are high, and HIV increases the morbidity and mortality associated with TB. This review details the pathophysiology, epidemiology, clinical presentation, and treatment of pulmonary infection, including pneumonia, empyema, pulmonary abscess, and tuberculosis (TB). Figures show chest radiographs of reactivation pulmonary tuberculosis, HIV-infected patients with proven culture-confirmed tuberculosis, prominent hilar adenopathy with clear lung fields, and bilateral interstitial changes; and treatment of drug-susceptible pulmonary tuberculosis. Tables list major causes of pulmonary infection, host defence mechanisms against pulmonary infection, initial empirical antibiotic therapy in patients with suspected community-acquired pneumonia, initial antibiotic therapy for community-acquired pneumonia in outpatients, initial antibiotic therapy for community-acquired pneumonia in patients who require hospitalization, antibiotic choices for aspiration pneumonia, pneumonia severity index scoring, and mortality by pneumonia severity index point score.

      This review contains 2 highly rendered figures, 8 tables, and 87 references
       

      Key words: Pulmonary infections; Pneumonia; Tuberculosis; Lung infection; Mycobacteria; Community-acquired pneumonia; Health care-associated pneumonia; Aspiration pneumonia; Empyema; Legionnaires disease

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  • Gastrointestinal Diseases
    • 1

      Approach to the Patient With Abdominal Pain

      By Dana Sajed, MD
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      Approach to the Patient With Abdominal Pain

      • DANA SAJED, MDDirector of Ultrasound Education, Continuing Medical Education Director, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA

      Abdominal pain is the most common presenting complaint in the emergency department (ED), accounting for nearly 8% of ED visits. Although many chronic conditions may cause pain in the abdomen, acute abdominal pain, defined as undiagnosed pain present for less than 1 week, is of greatest concern to the emergency practitioner. For many reasons, acute abdominal pain is often diagnostically challenging. Abdominal pain may be due to numerous causes, including gastrointestinal, genitourinary, cardiovascular, pulmonary, and other sources. Symptoms may fluctuate or change in nature, and the quality of pain can be difficult for the patient to describe. Physical examination findings, although important, are variable and can even be misleading. Despite being such a common presenting complaint, misdiagnosis is not uncommon and results in a high percentage of medicolegal actions in both and adult and pediatric populations.

      Key words: abdominal computed tomography, abdominal pain, abdominal ultrasonography, pain management, point-of-care ultrasonography

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    • 2

      Diseases of the Stomach

      By Tara C. Sheets, MD, FACEP; Moath Amro, MD
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      Diseases of the Stomach

      • TARA C. SHEETS, MD, FACEPBaylor College of Medicine, Assistant Professor, Section of Emergency Medicine Department of Medicine
      • MOATH AMRO, MDBaylor College of Medicine, Emergency Medicine Resident, Section of Emergency Medicine Department of Medicine

      There are multiple diseases of the stomach and esophagus that will lead a patient to seek emergent care, including peptic ulcer disease (PUD), esophagitis, dysphagia, esophageal foreign bodies, and gastroesophageal reflux disease (GERD). Hemorrhage and perforation are major emergencies in peptic ulcer disease and esophageal disease requiring early recognition with immediate resuscitative efforts to stabilize. This review covers the risk factors, pathophysiology, assessment and stabilization, diagnosis and treatment, and disposition and outcomes for patients with diseases of the stomach and esophagus. Figures show illustrations of esophageal anatomy, an algorithm for the evaluation of dysphagia, the pathogenesis of peptic ulcers, and radiographs demonstrating an esophageal button battery and pneumoperitoneum caused by a perforated ulcer. Tables list some common causes of esophageal stricture and pill-induced esophagitis, differential diagnosis of peptic ulcer disease and commonly used regimens to eradicate Helicobacter pylori infection.

      Key Words: Peptic ulcer disease, esophagitis, dysphagia, esophageal foreign body, GERD, H. Pylori, button battery

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    • 3

      Anorectal Disorders

      By Megan Fix, MD; Steven Glerum, MD
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      Anorectal Disorders

      • MEGAN FIX, MDAssociate Residency Director, Division of Emergency Medicine, University of Utah, Salt Lake City, UT
      • STEVEN GLERUM, MDResident Physician, Division of Emergency Medicine, University of Utah, Salt Lake City, UT

      Anorectal disorders can generate considerable patient discomfort and disability. Although mortality due to such complaints is very low, it is important for the clinician to maintain a high index of suspicion for systemic illness caused by an anorectal source. A detailed history and physical examination should be performed, and the need for imaging or procedures should be assessed. This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with anorectal disorders. Figures show the important structures of the anal canal; differences in the anatomy of the origin of internal and external hemorrhoid venous supplies; depictions of a typical anodermal linear tear; Foley catheter–assisted rectal foreign body removal technique; and pertinent anatomy related to a prolapsed rectum through the anus; and types and locations of anorectal abscesses and fistulas. Tables list common painful and painless anorectal disorders; key differences in anal canal structures above and below the pectinate line; anal symptoms mistakenly attributed to hemorrhoids; internal hemorrhoidal grading, description, and recommended treatment; Rome III criteria for the diagnosis of constipation; and a summary of anorectal conditions.

      This review contains 6 highly rendered figures, 6 tables, and 80 references.

      Keywords: functional constipation; PEG; abdominal radiographs; pediatric constipation

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    • 4

      Appendicitis

      By James Creswell Simpson, MD; Sarah Sebbag, MD, CM, CCFP(EM)
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      Appendicitis

      • JAMES CRESWELL SIMPSON, MDResident Physician, Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
      • SARAH SEBBAG, MD, CM, CCFP(EM)Director, Emergency Ultrasound, Ochsner Health System, Department of Emergency Medicine, New Orleans, LA

      Appendicitis is defined as inflammation of the vermiform appendix. It is the most common abdominal surgical emergency and occurs at an annual rate of approximately one in 10,000 in the United States. The lifetime risk of appendicitis is about 9% for males and 7% for females; approximately 80% of cases occur before 45 years of age. Appendicitis rarely occurs in infants; it increases in frequency between 2 and 4 years of age and reaches a peak between the ages of 10 and 19 years. However, clinicians must maintain a high index of suspicion in patients of all age groups. This review covers the pathophysiology, stabilization and assessment, and diagnosis and treatment of complicated and uncomplicated appendicitis. The disposition and outcomes are also reviewed. Figures show an image of appendicitis on a bedside sonogram, and a computed tomographic image of appendicitis. Tables list likelihood ratios of signs and symptoms of appendicitis, the sonographic appearance of appendicitis, the Alvarado scoring system, and the differential diagnosis of appendicitis.

       

      Key words: appendicitis, obstructed appendiceal lumen, rebound abdomen, right lower quadrant pain, ruptured appendix

       

      This review contains 2 highly rendered figures, 4 tables, and 33 references.

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    • 5

      Acute Pancreatitis

      By Jason Ahn, MD, MPA; Calvin K. Huang, MD, MPH
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      Acute Pancreatitis

      • JASON AHN, MD, MPAResident, Emergency Medicine, Harvard Medical School, Boston, MA
      • CALVIN K. HUANG, MD, MPHInstructor of Emergency Medicine, Harvard Medical School, Boston, MA

      Pancreatitis is a leading differential diagnosis in patients presenting with abdominal pain.  Although there are multiple initial inciting factors, the end result is the inappropriate activation of pancreatic enzymes leading to localized, and sometimes systemic, inflammation.  The severity of pancreatitis as a disease can range from mild pain to shock and hypotension.  This review covers the initial treatment and stabilization of patients with this disease as well as the mainstay of diagnosis including lab testing and imaging.  Disease severity scoring systems including the revised Atlanta Criteria, APACHE II score, SIRS criteria, BISAP score, and Ranson criteria, followed by treatment and disposition stratified by disease severity, are discussed.  Figures display pertinent findings of the imaging modalities including fluoroscopy, ultrasound, and computed tomography.  Tables list the major causes of pancreatitis, differential diagnosis, and non-pancreatic causes of amylase and lipase elevation.

       

      Key words: pancreatitis, abdominal pain, shock, gallstones, ultrasound, lipase, amylase

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    • 6

      Bowel Obstruction

      By Andrew S. Liteplo, MD, FACEP
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      Bowel Obstruction

      • ANDREW S. LITEPLO, MD, FACEPEmergency Ultrasound Fellowship Director, Massachusetts General Hospital, Assistant Professor, Harvard Medical School, Boston, MA

      Small bowel obstruction can be a surgical emergency, and may be the ultimate diagnosis in 2 to 15% of patients presenting to the emergency department with abdominal pain. Bowel obstruction can be either mechanical (caused by extrinsic compression, twisting of the bowel, or intrinsic obstruction) or functional (caused by an impaired ability of the bowel to propel contents distally). The most common cause of small bowel obstruction in the developed world is postoperative adhesions. This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and outcomes for patients with bowel obstruction. Figures show sonograms of small bowel obstruction, pneumatosis, and an abdominal wall hernia; and a computed tomographic scan of small bowel obstruction. Videos show ultrasonography of fluid-filled, dilated loops of bowel with decreased peristalsis; pendulous peristalsis; a ventral hernia with protruding bowel; normal peristalsis; and absent peristalsis in ileus. Tables list the differential diagnosis for small bowel obstruction, and a summary of performance of imaging modalities in diagnosing small bowel obstruction.

      This review contains 4 highly rendered figures, 5 videos, 2 tables, and 26 references.

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    • 7

      Diverticulitis and Colitis

      By Joshua Rempell, MD, MPH
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      Diverticulitis and Colitis

      • JOSHUA REMPELL, MD, MPH

      Diverticulitis and colitis (which may be broadly grouped into inflammatory, infectious, and ischemic categories) are commonly encountered in the emergency department, and patients’ conditions can range from mild to severe. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment, dispositions and outcomes of diverticulitis and colitis. Figures include a computed tomographic scan showing diverticulitis, a bedside sonogram of a patient with diverticulitis, an ultrasound showing bowel wall thickening, a plain abdominal film showing grossly dilated small and large bowel (as seen in toxic megacolon in a patient with inflammatory bowel disease), a computed tomographic image of a patient presenting with known Crohn disease showing thickening of the distal ileum and a small abscess formation, and a computed tomographic image of a patient with ischemic colitis showing air in the small bowel. Tables list the Hinchey classification and the modified Hinchey classification showing stages of diverticulitis, differential diagnosis of left lower quadrant pain, empirical coverage for diverticulitis, indications for surgical treatment for acute diverticulitis, and differential diagnosis of colitis.

      This review contains 6 highly rendered figures, 5 tables, and 105 references.

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    • 8

      Gallstones and Biliary Tract Emergencies

      By Luis F. Lobon, MD, MS, FACEP; Michael Billington, MD
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      Gallstones and Biliary Tract Emergencies

      • LUIS F. LOBON, MD, MS, FACEPChief Emergency Medicine, Brigham & Women’s Faulkner Hospital, Vice Chair Community Emergency Medicine Brigham & Women’s Health Care, Instructor Emergency Medicine Harvard Medical School, Boston, Massachusetts
      • MICHAEL BILLINGTON, MDHarvard Affiliated Emergency Residency - PAY 3, Brigham & Women’s Hospital, Massachusetts General Hospital, Harvard Medical School, Bos-ton, Massachusetts

      Patients with diseases of the biliary tract (which includes the hepatic bili canaliculi, hepatic bile ducts, common bile duct, and gallbladder) typically present with symptoms that include abdominal pain, nausea, vomiting, and jaundice. This review covers the pathophysiology, assessment and stabilization, diagnosis and treatment, and disposition and outcomes for common biliary tract emergencies (cholelithiasis, acute cholecystitis, choledocholithiasis, and ascending cholangitis). Special considerations for less frequently encountered disease processes are also mentioned. Figures show ultrasonograms of gallstones, gallstones in the neck of the bladder, a longitudinal view of gallbladder thickness without clear evidence of gallstones and a wall measurement of 4.3 mm highly sensitive for acute cholecystitis, a transverse view of gallbladder wall thickness, and gallstones and increased gallbladder thickness. Tables list the epidemiology of biliary tract disease, summary of laboratory and radiographic tools in acute biliary disease, ultrasonography evidence of acute cholecystitis, and common bile duct sizes.

      This review contains 5 highly rendered figures, 4 tables, and 34 references.

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    • 9

      Review of Inflammatory Bowel Disease

      By Joshua Guttman, MD, FRCPC; Frederick Davis, DO, MPH, FACOEP
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      Review of Inflammatory Bowel Disease

      • JOSHUA GUTTMAN, MD, FRCPCAssistant Professor of Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, NY
      • FREDERICK DAVIS, DO, MPH, FACOEPAssistant Professor of Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, NY

      Inflammatory bowel disease (IBD) is an inflammatory condition of the gastrointestinal (GI) tract made up of ulcerative colitis (UC) and Crohn disease (CD). These diseases are differentiated based on the location in the GI tract and findings on colonoscopy and biopsy. Management in the emergency department is similar for these two conditions. Patients presenting with exacerbations of known IBD should be classified according to severity and managed accordingly. Mild to moderate disease will require only a limited workup consisting of testing for anemia and electrolyte abnormalities. These patients may be discharged with a 5-aminosalicylic acid (5-ASA) agent, or if the condition is refractory to 5-ASA, then with oral budesonide. Severe or fulminant disease will need intravenous hydration, intravenous corticosteroids, computed tomography (CT) to assess for intestinal complications, and admission to the hospital. Patients with abscesses, colitis, or ileitis on CT will need antibiotics. Additionally, patients should be evaluated for both intestinal complications, such as strictures and fistulas, and extraintestinal manifestations, the majority of which are dermatologic and ophthalmologic. Patients with fulminant complications, toxic megacolon and intestinal perforation, should receive intravenous antibiotics, hydration, and immediate surgical consultation. Patients presenting with signs and symptoms of IBD but without a known diagnosis should receive supportive therapy. If discharged, they should be referred to a gastroenterologist for colonoscopy to make an appropriate diagnosis and to initiate therapy.

       

      Key words: Inflammatory bowel disease (IBD), gastrointestinal (GI) tract, ulcerative colitis (UC), Crohn disease (CD), colonoscopy, fulminant complications

       

      This review contains highly rendered 5 figures, 5 tables, and 30 references.

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    • 10

      Hernias in the Emergency Department

      By Daniel Berhanu, MD; Ciara J. Barclay-Buchanan, MD, FACEP; Mary C. Westergaard, MD, FACEP
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      Hernias in the Emergency Department

      • DANIEL BERHANU, MDResident Physician, Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • CIARA J. BARCLAY-BUCHANAN, MD, FACEPAssociate Residency Program Director, Assistant Professor (Clinical Health Sciences), Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • MARY C. WESTERGAARD, MD, FACEPResidency Program Director, Assistant Professor (Clinical Health Sciences), Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Hernia is defined as an abnormal protrusion of an organ or tissue through a pathologic defect in its surrounding wall. Overall, hernia is common and is generally believed to be a benign condition associated with some morbidity, although it is not thought to be associated with significant mortality. Between 2001 and 2010, 2.3 million inpatient abdominal hernia repairs were performed in the United States, of which 567,000 were performed emergently. In some cases, a hernia can be a deadly condition. In 2002, hernia was listed as the cause of death for 1,595 US citizens. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of hernia. Figures show anatomic locations of the various abdominal wall, groin, lumbar, and pelvic floor hernias; a direct inguinal hernia; an indirect inguinal hernia; point-of-care sonograms showing a ventral wall hernia and an abdominal wall hernia; and the differential diagnosis of an abdominal mass based on anatomic location. Tables list risk factors for the development of inguinal hernia, sex-based differences in inguinal hernia development, risk factors for the development of incisional hernia, factors to consider when assessing the patient for a hernia, and factors associated with the highest rates of incarceration in patients with groin hernia.
       

      Key words: emergent hernia, hernia incarceration, incisional hernia, inguinal hernia, strangulated hernia

      This review contains 6 highly rendered figures, 5 tables, and 66 references.

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    • 11

      Constipation in the Emergency Department

      By Jamie Santistevan, MD; Ciara J. Barclay-Buchanan, MD, FACEP; Mary C. Westergaard, MD, FACEP
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      Constipation in the Emergency Department

      • JAMIE SANTISTEVAN, MDResident Physician, Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • CIARA J. BARCLAY-BUCHANAN, MD, FACEPAssociate Residency Program Director, Assistant Professor (Clinical Health Sciences), Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • MARY C. WESTERGAARD, MD, FACEPResidency Program Director, Assistant Professor (Clinical Health Sciences), Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Constipation can be classified as either primary constipation or secondary constipation. Constipation can be distressing to patients and can lead to serious complications, including bowel obstruction, perforation, volvulus, and proctitis. Emergency physicians should be aware of the evaluation, diagnosis, and management of patients presenting with the chief complaint of constipation. This review covers the risk factors, pathophysiology, assessment, diagnosis and treatment, and disposition and outcomes for patients presenting to the emergency department with constipation. Figures show radiographic and schematic images of several diagnoses which may present with the chief complaint of constipation. Tables list the primary and secondary causes of constipation, the criteria for the diagnosis of irritable bowel syndrome, and the mechanism of action of common medications used to treat constipation.

      This review contains 6 highly rendered figures, 5 tables, and 66 references.

      Key words:  bowel obstruction, constipation, 

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    • 12

      Mesenteric Ischemia

      By Ugo A. Ezenkwele, MD, MPH
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      Mesenteric Ischemia

      • UGO A. EZENKWELE, MD, MPHChief, Emergency Department, Mount Sinai Queens, Associate Professor, Department of Emergency Medicine, Icahn Mount Sinai School of Medicine, New York, NY

      Acute mesenteric ischemia is interruption of intestinal blood flow by embolism, thrombosis, or a low-flow state. Bowel infarction is the end result of a process initiated by mediator release and inflammation. On clinical assessment, the early hallmark is severe abdominal pain but minimal physical findings. The abdomen remains soft, with little or no tenderness. Mild tachycardia may be present. Early diagnosis is difficult, but selective mesenteric angiography and computed tomographic angiography have the most sensitivity; other imaging studies and serum markers can show abnormalities but lack sensitivity and specificity early in the course of the disease, when diagnosis is most critical. Treatment is by embolectomy, anticoagulation, revascularization of viable segments, or resection; sometimes vasodilator therapy is successful. If diagnosis and treatment take place before infarction occurs, mortality is low; after intestinal infarction, mortality approaches 30 to 70%. For this reason, in the emergency department, clinical diagnosis should supersede diagnostic tests, which may delay treatment.

      Key words: acute mesenteric ischemia; bowel necrosis; chronic mesenteric ischemia; mesenteric occlusive disease; mesenteric venous thrombosis; nonocclusive mesenteric ischemia; postprandial abdominal pain; superior mesenteric artery thromboembolism

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    • 13

      Complications Following Bariatric Surgery

      By David A Harris, M.D; Eric G. Sheu, M.D., D.Phil.
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      Complications Following Bariatric Surgery

      • DAVID A HARRIS, M.DGeneral Surgery Resident, Harvard Medical School, Brigham and Women’s Hospital
      • ERIC G. SHEU, M.D., D.PHIL.Associate Surgeon, Department of Surgery, Brigham and Women’s Hospital, Instructor of surgery, Harvard Medical School

      Bariatric surgery has proven to be the most effective and durable treatment for obesity and obesity-related diseases. As such, the number of bariatric procedures performed has dramatically increased over the past several decades. Although multiple bariatric procedures have been performed, the sleeve gastrectomy, Roux-en-Y[H1]  gastric bypass, and gastric band have been by far the most common operations in the United States in the last decade. Given the prevalence of bariatric surgery and increased push to short-track postoperative hospital stays, emergency department (ED) visits are common in this patient cohort. This review covers the pathophysiology, diagnosis, and treatment of complications that ED providers are likely to see in patients after bariatric surgery. Although many complications are shared between all bariatric procedures, there are unique surgery-specific complications. To address the needs of these patients, providers must understand the surgery that their patients have had and how the postoperative timing and nature of their complaints inform the likely etiology of their presentation.

      This review contains 6 figures, 4 tables, and 83 references.

      Key words: anastomotic leak, bariatric surgery, cholelithiasis, complications, dehydration, dumping syndrome, gastric banding, gastrogastric fistula, internal hernia, malnutrition, mesenteric vein thrombosis, Roux-en-Y gastric bypass, sleeve gastrectomy, stricture, ulcer, vitamin deficiency

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    • 14

      Hepatic Disorders

      By Andrew Goldsmith, MD, MBA
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      Hepatic Disorders

      • ANDREW GOLDSMITH, MD, MBAHarvard-affiliated emergency medicine resident at Massachusetts General Hospital, Boston, MA.

      Hepatic disorders are characterized by a variety of etiologies that can present to the emergency department (ED) as acute, chronic, or acute on chronic liver disease. Unfortunately, a large number of these complex disorders can progress to cirrhosis, a progressive and severe clinical condition associated with high morbidity and mortality. Primary prevention, measures include vaccine prophylaxis and abstaining from alcohol. Unfortunately, liver disease can lead to a wide spectrum of clinical manifestations that are in need of urgent and/or emergent therapy mainly attributable to hepatic insufficiency and portal hypertension. Major complications of portal hypertension include ascites, gastrointestinal variceal bleeding, hepatic encephalopathy, renal failure, and bacterial infections. This review covers the epidemiology, pathophysiology, diagnosis, treatment, and disposition of patients who present to the ED with liver disease.

      This review contains 3 figures, 4 tables, and 59 references.

      Key words: abdominal pain, ascites, cirrhosis, encephalopathy, hepatic abscess, hepatic liver transplant, hepatitis, hepatorenal syndrome, spontaneous bacterial peritonitis

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    • 15

      Diarrheal Illness

      By Jeremy S Faust, MD, MS, MA
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      Diarrheal Illness

      • JEREMY S FAUST, MD, MS, MABrigham & Women’s Hospital/Brigham Faulkner Hospital Department of Emergency Medicine, Clinical Instructor, Harvard Medical School, Boston, MA

      Diarrhea, qualitatively defined as an increase in stool frequency and liquid content, is a frequent complaint in patients presenting to emergency departments. Although most cases are uncomplicated viral infections, the most frequent causes of dangerous underlying entities are often not viral. In uncomplicated cases, laboratory testing for metabolic derangements is not required unless there are signs of moderate to severe dehydration or the patient has particular risks, such as chronic kidney disease. Secondary infections associated with antibiotic use (C difficile–associated diarrhea), other significant nosocomial exposures, recent international travel history, the presence of a nonintact immune system (HIV/AIDS, cancer/chemotherapy), and exposure to high-risk environments (including zoonotic exposures, outbreak-prone environments such as day care facilities) increase the likelihood of a bacterial or other infectious cause requiring either microbiologic testing or empirical antimicrobial treatments. Diarrhea is often present as a feature of clinically significant noninfectious conditions, including complications of inflammatory bowel diseases (Crohn disease and ulcerative colitis), overdoses, and withdrawal syndromes. In such cases, after hemodynamic stability has been ensured, advanced workup and treatment are guided by the underlying condition and antecedent risks, not the presence of diarrhea per se. Oral rehydration is the first step in management for mild dehydration caused by uncomplicated diarrhea. Intravenous fluids may be necessary in moderate to severe dehydration and in cases of electrolyte derangement requiring resuscitation where fluid choice and rate are paramount, as well as in patients who cannot tolerate oral intake. In cases of suspected bacteria-caused diarrhea, antibiotics, most often fluoroquinolones, reduce both the severity and duration of illness. In patients safe for home management, antidiarrheal agents such as loperamide may be used in uncomplicated and resolving cases. Probiotics appear safe in most cases and impart a small but clinically detectable decrease in the duration and severity of illness. Although there have been fears of bacterial outbreaks following natural disasters, improvements in local and global health efforts have led to decreases in cholera outbreaks, and typical viral causes of diarrhea are generally the most common causes.

       This review contains 4 figures, 5 tables and 32 references

      Key words: Clostridium difficile, diarrhea, infectious diseases, inflammatory bowel diseases, medication side effects, overdose syndromes, sepsis, traveler’s diarrhea, zoonotic infections 

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    • 16

      Hepatitis B Virus

      By April Wall, MD; Ming V. Lin, MD
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      Hepatitis B Virus

      • APRIL WALL, MDResident, Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA
      • MING V. LIN, MDInstructor of Medicine, Harvard Medical School, Associated Physician, Division of, Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA

      Chronic hepatitis B virus (HBV) infection is a major health burden worldwide, with approximately 257 million people with chronic infection. HBV is a small partially double-stranded DNA virus that replicates within the nucleus of the hepatocyte and commonly leads to chronic infection. Chronic HBV infection can cause cirrhosis, hepatocellular carcinoma, and extrahepatic manifestations such as glomerulonephritis or vasculitis. The latter is due to deposition of circulating immune complex in the different tissues. The natural history of HBV infection can be conceptualized as a spectrum encompassing different phases, including immune tolerance, immune clearance, inactive carrier, and reactivation and resolution. The diagnosis of the different phases of chronic HBV infection relies on various HBV serologies, liver enzyme levels, and histology findings. There are currently eight therapies approved for the treatment of HBV. Tenofovir alafenamide was the most recently approved therapy with a better side effect profile compared with tenofovir disoproxil fumarate. With the recent advances in the basic research in hepatitis B, new treatment options may become available in the near-future.

       

      This review contains 9 figures, 8 tables and 78 references

      Key words: cirrhosis, entecavir, Hepadnaviridae, hepatitis B virus, hepatocellular carcinoma, precore mutation, tenofovir

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    • 17

      Viral Hepatitis A

      By Kenrad E Nelson, MD; Brittany L Kmush, PhD
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      Viral Hepatitis A

      • KENRAD E NELSON, MDProfessor, Department of Epidemiology and Department of International Health, Johns Hopkins University, Baltimore, MD
      • BRITTANY L KMUSH, PHDAssistant Professor, Department of Public Health, Food, Studies and Nutrition, Falk College of Sport and Human Dynamics, Syracuse University, Syracuse, NY

      Epidemics of infectious jaundice have been reported throughout recorded history. However, the proof that many of these outbreaks and individual cases of acute hepatitis were caused by a viral infection, the hepatitis A virus (HAV), did not appear until the 1960s. After the transmission of infection to marmosets and humans, the epidemiologic and virologic characteristics that differed between hepatitis A and hepatitis B virus infections were defined more clearly. After the development and licensure of hepatitis A vaccines in the 1990s, it became possible to implement an effective prevention program involving routine immunization of young children in the United States and several other Western countries. However, despite the dramatic efficacy of the childhood immunization program in reducing the incidence of acute hepatitis from HAV in the population, older children and adults remained susceptible. Significant morbidity continues to occur in the United States among international travelers, injection drug users, persons with underlying liver disease, and other high-risk populations. Since HAV is a global pathogen, the prevention of increasing morbidity from hepatitis A attributable to the incidence of clinically more severe disease increases in countries transitioning from high to intermediate or low endemic status is a major public health challenge. In this review, we discuss the epidemiology, virology, clinical characteristics, and prevention of hepatitis A infections.

       

      This review contains 8 figures, 2 tables and 88 references

      Key words: epidemiology, global impact, hepatitis A vaccine, hepatitis A virus, prevention, reservoirs, risk factors, treatment

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    • 18

      Gastrointestinal Bleeding

      By Romeo Fairley, MD; Truman J. Milling Jr, MD
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      Gastrointestinal Bleeding

      • ROMEO FAIRLEY, MDResident, University of Texas, Austin Emergency Medicine Residency Program, Austin, TX
      • TRUMAN J. MILLING JR, MDDeputy Director of Clinical Research, Department of Emergency Medicine, University of Texas, Dell Medical School, Austin, TX

      Gastrointestinal bleeding occurs when a pathologic process such as ulceration, inflammation, or neoplasia leads to erosion of a blood vessel. Bleeding can occur in the upper gastrointestinal tract (50%) or the lower gastrointestinal tract (40%) or may be obscure (10%), meaning that no definitive source is identified. Gastrointestinal bleeding is common, with major bleeding leading to 1 million hospitalizations every year in the United States. This review details the pathophysiology of gastrointestinal bleeding and the stabilization and assessment, diagnosis, treatment, and disposition and outcomes of patients with gastrointestinal bleeding. Situations requiring special consideration are also discussed. Figures show how gastrointestinal bleeding occurs when a pathologic process causes erosion of the mucosa and exposes a submucosal blood vessel; an ulcer with a raised, red, variceal spot; a Mallory-Weiss tear; the formation of varices; vascular ectasia; treatment of esophageal varices with balloon tamponade; and a wireless capsule. Tables list the major causes of gastrointestinal bleeding, terms relating to gastrointestinal bleeding and their definitions, Blatchford score, substances that interfere with occult blood testing, clinical factors differentiating gastrointestinal bleeding placed in descending order of likelihood ratio, and a summary of American College of Radiology recommendations for angiography in nonvariceal gastrointestinal bleeding.

      This review contains 7 figures, 10 tables, and 102 references.

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  • Neurology
    • 1

      Dizziness

      By Joshua N. Goldstein, MD, PhD
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      Dizziness

      • JOSHUA N. GOLDSTEIN, MD, PHDAssociate Professor, Harvard Medical School, Director, Center for Neurologic Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA

      Dizziness is a relatively common condition in the emergency setting. Patient descriptions of their symptoms can be vague and inconsistent. This review highlights the most important aspects of the history and physical examination that can help differentiate among different causes of dizziness. In addition, it covers the pathophysiology of inner ear disease, including diagrams of vestibular anatomy. For the history, it is critical to capture dizziness, duration, triggers for dizziness, and associated symptoms. For the physical examination, a focused neurologic assessment is important, including balance, coordination, as well as an oculomotor assessment. For treatment of benign positional vertigo, various canalith repositioning maneuvers are described and diagrams shown. For vestibular neuritis, treatment options including vestibular rehabilitation and steroids are discussed. Finally, medical options for symptomatic therapy are listed. 

      Key words: Dizziness, benign positional vertigo, canalith repositioning maneuver, vestibular disorders.

      This review contains 7 highly rendered figures, 7 tables, and 40 references.

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    • 2

      Acute Lower Back Pain

      By John W. Martel, MD, PhD; Caitlin Hynes, MD
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      Acute Lower Back Pain

      • JOHN W. MARTEL, MD, PHDAssistant Professor, Department of Emergency Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME
      • CAITLIN HYNES, MDResident Physician, Department of Emergency Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME

      Lower back pain is common, with up to 8% of the adult population in the United States reporting at least one episode of acute back pain within the last year. This is associated with considerable burden to the health care system. The majority of patients who experience back pain have no clear etiology for their symptoms; although symptoms tend to improve within 4 to 6 weeks, they also tend to recur. This review covers the pathophysiology, diagnosis and treatment, and disposition and outcomes of acute lower back pain. Figures show magnetic resonance images of L4/L5 disk herniation, spinal neoplasm, and epidural abscess; schematics of cauda equina syndrome associated with central disk herniation and disk herniation causing unilateral radicular symptoms due to nerve root compression; and dermatomal symptoms associated with L4-S1 nerve root compromise. Tables list red flag signs and symptoms of acute back pain, emergent causes of acute back pain, Waddell signs suggestive of nonorganic back pain, neurologic examination findings associated with L1-S1 nerve roots, pros and cons of treatment options for musculoskeletal and radicular back pain, and indications for surgery for patients with spinal epidural abscess and vertebral osteomyelitis.

      This review contains 5 highly rendered figures, 6 tables, and 98 references.

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    • 3

      Acute Ischemic Stroke and Transient Ischemic Attack

      By Lauren M. Nentwich, MD
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      Acute Ischemic Stroke and Transient Ischemic Attack

      • LAUREN M. NENTWICH, MDAssistant Professor, Department of Emergency Medicine, Boston University School of Medicine, Boston, MA

      Stroke is a sudden neurologic deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including either ischemia (87%) or hemorrhage (13%). Specifically, acute ischemic stroke (AIS) is an episode of neurologic dysfunction caused by focal cerebral, spinal, or retinal infarction, where infarction is defined as pathologic, imaging, clinical, or other objective evidence of focal ischemic cell death and injury in a defined vascular distribution. Conversely, a transient ischemic attack (TIA) is defined as a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. A TIA is not a separate entity from AIS, but rather both AIS and TIA are on the spectrum of serious conditions caused by CNS ischemia. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and  disposition and outcomes of AIS and TIA. Figures show potential sources of cardioembolism, cerebrovascular anatomy and common sites of atherosclerosis, early computed tomographic (CT) findings in AIS and noncontrast head CT scan of a right putamenal intracerebral hemorrhage, magnetic resonance image (MRI) showing perfusion-diffusion mismatch in AIS, and intra-arterial thrombolysis for AIS. Tables list clinical features of the major cerebrovascular occlusive syndromes, ABCD score, time goals in the emergency department evaluation of patients presenting with suspected AIS, differential diagnosis of AIS (i.e., stroke mimics), National Institutes of Health stroke scale, multimodal CT in AIS, multimodal MRI in AIS, and indications and contraindications for intravenous recombinant tissue plasminogen activator treatment in AIS.

      Key words: acute ischemic stroke, atheroembolism, cardioembolism, stroke, transient ischemic attack

       

      This review contains 5 highly rendered figures, 8 tables, and 100 references.

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    • 4

      Subarachnoid Hemorrhage

      By Imoigele P Aisiku, MD, MBA
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      Subarachnoid Hemorrhage

      • IMOIGELE P AISIKU, MD, MBAAssistant Professor, Chief Division of Emergency Critical Care, Department of Emergency Medicine, Harvard University, Brigham and Women’s Hospital

      Subarachnoid hemorrhage (SAH) represents a small portion of cerebrovascular disease but a disproportionally large percentage of the morbidity and mortality. The overall prognosis depends on the volume of the initial bleeding, rebleeding, and the degree of delayed cerebral ischemia. The presence of cardiac manifestations and neurogenic pulmonary edema at the initial presentation indicates a higher degree of severity and systemic complications. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of SAH. Figures show common saccular aneurysm locations, a noncontrast head computed tomographic scan of an SAH, an angiogram and surgical clipping of a broad-based anterior communicating aneurysm, and a three-dimensional reconstruction angiogram of a complex anterior communicating aneurysm with additional imaging of endoscopic stent-assisted coiling of the same aneurysm. Tables list the natural history of unruptured aneurysms and the annual risk of rupture, common clinical features and syndromes related to aneurysm location, the World Federation of Neurologic Surgeons grading system, the Hunt and Hess grading systems, and the Fisher scale.

      This review contains 4 highly rendered figures, 5 tables, and 144 references.

      Key words: aneurysm rupture, cerebral aneurysm, cerebral vasospasm, Fisher scale, Glasgow Coma Scale assessment, Hunt and Hess grading criteria, subarachnoid hemorrhage, World Federation of Neurologic Surgeons grading scale 

      Key Advances

      1. CT angiography is an emerging technology that has the diagnostic advantage of being non-invasive.  The diagnostic accuracy of CTA varies widely and when compared to the standard digital subtraction angiography (DSA) the sensitivity and specificity range from 77% to 100% and 87%-100% respectively.
      2. The 2012 AHA guidelines and the 2011 Neurocritical care society (NCS) consensus guidelinesrecommend that from the time of symptom onset to securing of the aneurysm, the blood pressure be controlled with a titratable agent with a goal systolic blood pressure of less than 160mmHg or a MAP of less than 110mmHg.
      3. Cardiac abnormalities are common following acute SAH.  Subendocardial ischemia may result from autonomic stimulation from the brain and circulating catecholamine surge, resulting in an abnormal ECG in 50% to 100% of patients with SAH in the acute phase depending on severity.
      4. The International Subarachnoid Aneurysm Trial ISATwas a landmark study that looked at aSAH repair comparing surgical clipping with endoscopic coiling and demonstrated a mortality benefit with coiling in the right patient population.


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    • 5

      Seizure

      By Robert Silbergleit, MD
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      Seizure

      • ROBERT SILBERGLEIT, MDProfessor, Neurological Emergencies Research, Department of Emergency Medicine, Ann Arbor, MI

      A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event in both children and adults. Epilepsy, a chronic disorder of the brain characterized by recurrent unprovoked seizures, is far less common. Patients who present to the emergency department with seizures vary considerably in underlying etiology, symptoms, and prognosis. Optimal care of the seizure patient in the emergency department requires differentiating those who need little intervention from those requiring intensive resuscitation. This review presents the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of seizure. Figures show the progression of selected neuronal pathophysiologic mechanisms involved over time during and after status epilepticus, tongue bite from seizure, a general emergency department management strategy for patients with seizure presentations, an electroencephalogram of a patient who experienced convulsive syncope after placement of an intravenous line, and staged treatment of status epilepticus. Tables list key elements of the initial emergency department management of status epilepticus, third-line medications for treatment of seizures, and the Status Epilepticus Severity Score (STESS).

      Key words: acute seizure, convulsion, epilepsy, seizure, status epilepticus

      This review contains 5 highly rendered figures, 3 tables, and 54 references.

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    • 6

      Delirium in the Emergency Department: Diagnosis, Evaluation, and Management

      By Maura Kennedy, MD, MPH
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      Delirium in the Emergency Department: Diagnosis, Evaluation, and Management

      • MAURA KENNEDY, MD, MPHDivision Chief, Geriatric Emergency Medicine, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor of Emergency Medicine, Harvard Medical School, Boston, MA

      Delirium, an acute confusional state characterized by disturbances in attention, cognition, and arousal, is present in 7 to 10% of older emergency department (ED) patients, underdiagnosed in the ED setting, and associated with increased short-term mortality. Delirium is typically precipitated by a physiologic stressor, such as an acute medical illness, a new medication, or a change in environment. The keys to the care and management of delirious patients are timely diagnosis of delirium and identification and treatment of the precipitating cause. The medical evaluation should include a formal delirium assessment that includes tests of attention and targeted diagnostic tests to identify the underlying etiology, such as infection, metabolic derangement, neurologic emergencies, new medications, and/or toxidromes. Pharmacologic treatment of delirium should be limited to patients who are severely agitated and at risk for substantial harm to self and/or others and patients with delirium secondary to alcohol withdrawal. Typical and atypical psychotics at low doses are first line for use in severely agitated patients. Benzodiazepines may worsen delirium and should be reserved for treatment of patients with delirium secondary to alcohol withdrawal or if sedation is required for critical imaging and/or procedures. ED physicians should also be conscious of and strive to minimize iatrogenic precipitants of delirium.

       

      This review contains 2 figures, 10 tables and 53 references

      Key words: aged, agitation, arousal attention, confusion, delirium, delirium/diagnosis, delirium/etiology, delirium/therapy, dementia complications, geriatrics, risk factors

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    • 7

      Coma and Disorders of Consciousness

      By Nicole M Dubosh, MD; Jonathan A. Edlow, MD, FACEP
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      Coma and Disorders of Consciousness

      • NICOLE M DUBOSH, MD
      • JONATHAN A. EDLOW, MD, FACEPVice-Chairman of Emergency Medicine, Beth Israel Deaconess Medical Center, Professor of Medicine and Emergency Medicine, Harvard Medical School, Boston, MA

      There are many causes of disorders of consciousness, including toxic/metabolic, infectious, and traumatic disorders, as well as other causes that may be more difficult to diagnose. Following stabilization, a thorough history taking involving discussion with family members, witnesses, friends, or police can often help disclose the likely cause of coma, although the resulting information may be limited. In the emergency department, physicians should be extremely cautious about making an early prognosis or diagnosis of brain death because all relevant information may not yet be available. This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, prognosis, and disposition and outcomes for coma and disorders of consciousness. Figures show anatomic structures and dorsal and ventral pathways involved with the maintenance of consciousness, the Full Outline of Unresponsiveness (FOUR) scale, and the spectrum of pupil abnormalities and causes. Tables list the Glasgow Coma Scale, blood gas abnormalities due to toxins, and a computed tomography checklist for comatose patients. 

      This review contains 3 figures, 5 tables, and 62 references.

      Keywords: coma, altered level of consciousness, reticular activating system, basilar artery stroke, posterior circulation stroke, stupor, brain herniation, brainstem compression, non-convulsive status epilepticus


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    • 8

      Headache

      By Benjamin W Friedman, MD, MS
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      Headache

      • BENJAMIN W FRIEDMAN, MD, MSProfessor of Emergency Medicine, Department of Emergency Medicine,Albert Einstein College of Medicine, Montefi ore Medical Center, Bronx, NY

      Headaches are one of the most common complaints of patients seen by emergency physicians. They can be classified as primary headaches, which have no identifiable underlying cause, and secondary headaches, which are classified according to their cause. The majority of headaches are benign in origin, and most patients with headache can be treated successfully in the emergency department and discharged home; however, some have potentially life-threatening causes, and consideration of a broad differential diagnosis for all patients is essential. This review covers the primary headache disorders, pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes. The figure shows areas of the brain sensitive to pain. Tables review differential diagnosis of headache, International Headache Society primary headache criteria, clinical characteristics of secondary headaches, high-risk clinical characteristics among patients with a headache peaking in intensity within 1 hour, drugs associated with headache, and parenteral treatment of acute migraine.

      This review contains 1 figure, 9 tables, and 58 references.


      Key words: migraine, calcitonin gene related peptide, greater occipital nerve block, venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, Ottawa, subarachnoid, cluster headache, trigeminal autonomic cephalalgias, post-traumatic headache

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    • 9

      Intracerebral Hemorrhage

      By Natalie P. Kreitzer, MD; Opeolu Adeoye, MD, MS
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      Intracerebral Hemorrhage

      • NATALIE P. KREITZER, MDNeurocritical Care Fellow in Training, Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH
      • OPEOLU ADEOYE, MD, MSAssociate Professor of Emergency Medicine and Neurocritical Care, University of Cincinnati, Cincinnati, OH

      Intracerebral hemorrhage can be classified as either secondary (due to trauma, vascular malformations, aneurysms, tumors, or hemorrhagic transformation of ischemic stroke) or primary (without a clear secondary cause). Intracerebral hemorrhage is a neurologic emergency, and leads to significant death and disability each year; care should be expedited and emergency departments should be equipped to appropriately care for and manage these patients. This review covers the risk factors, natural history, pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with intracerebral hemorrhage. Figures show head computed tomographic scans demonstrating a left basal ganglia intracerebral hemorrhage, and an algorithm of management of intracerebral hemorrhage in the emergency department. Tables list some common causes of intracerebral hemorrhage, Boston criteria for diagnosis of cerebral amyloid angiopathy, mechanism of action of common anticoagulants, and suggested reversal agents.


      This review contains 2 figures, 6 tables, and 59 references.

      Key words: Intracerebral hemorrhage; intracranial hemorrhage; intraparenchymal hemorrhage; hemorrhagic stroke; hypertensive hemorrhage; spontaneous intracerebral hemorrhage; ICH; cerebral bleeds


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    • 10

      Principles of Neurologic Ethics

      By Matthew S. Siket, MD; Jay M. Baruch, MD
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      Principles of Neurologic Ethics

      • MATTHEW S. SIKET, MDAssistant Professor, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
      • JAY M. BARUCH, MDAssociate Professor, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI

      Neuroethics refers to the branch of applied bioethics pertaining to the neurosciences and emerging technologies that impact our ability to understand or enhance a human mind. In the setting of emergency medicine, the clinician will encounter neuroethical dilemmas pertaining to the acutely brain injured or impaired; similar to other ethical decisions encountered in emergency medicine, such neuroethical dilemmas are often complicated by insufficient information regarding the patient’s wishes and preferences and a short time frame in which to obtain this information. This review examines the basis of neuroethics in emergency medicine; neuroethical inquiry; the neuroscience of ethics and intuition; issues regarding autonomy, informed consent, paternalism, and persuasion; shared decision making; situations in which decision-making capacity is in question; beneficence/nonmaleficence; incidental findings and their implications; risk predictions; and issues of justice. The figure shows the use of tissue plasminogen activator (t-PA) for cerebral ischemia within 3 hours of onset and changes in outcome due to treatment. Tables list common ethical theories, virtues/values of an acute care provider, components of informed consent discussion unique to t-PA in acute ischemic stroke, models of the physician-patient relationship, eight ways to promote effective shared decision making, components of capacity assessment, and emergency department assessment of futility.

      This review contains 1 figure, 9 tables, and 90 references.

      Keywords: Ethics, autonomy, shared decision-making, moral dilemmas, framing, decision-making capacity, beneficence and nonmaleficence

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  • Toxicology
    • 1

      General Approach to the Poisoned Patient

      By Emily Gordon, MD; Steven B Bird, MD
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      General Approach to the Poisoned Patient

      • EMILY GORDON, MDInstructor of Emergency Medicine, University of Massachusetts Medical School, Worcester MA
      • STEVEN B BIRD, MD Professor of Emergency Medicine, University of Massachusetts Medical School, Worcester MA

      Poisoning and ingestions constitute an increasing amount of morbidity and mortality nationwide. According to the American Association of Poison Control Centers (AAPCC), 2.2 million exposures were reported in 2013, and ingestions are currently the leading cause of injury-related death in the United States. Exposures include intentional overdose or suicide attempts, accidental overdose in drug abusers or children, and work-related injuries or acts of terrorism. According to the AAPCC, 50% of exposures are in children less than 5 years old and 80% of exposures are unintentional. When it comes to the unstable undifferentiated and possibly poisoned patient, one must take a stepwise approach similar to that for any critically ill patient, This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of poisoning. Figures show The Full Outline of Unresponsiveness (FOUR) scale, a patient with methemoglobinemia, a hand with scaling due to mercury poisoning, an electrocardiogram with examples of QT prolongation and QRS widening, and an electrocardiogram of bidirectional ventricular tachycardia, pathognomonic of digitalis glycoside poisoning. Tables list a stepwise approach to a potentially poisoned patient, a general approach to the poisoned patient,  heart rate, toxidromes, anticholinergic toxidrome, cholinergic toxidrome, Glasgow Coma Scale, toxins and associated odors, electrocardiogram findings, causes of anion-gap metabolic acidosis, and antidotes.

       

      This review contains 5 highly rendered figures, 11 tables, and 23 references

       

      Key words: Poison ingestion, Accidental poisoning, Toxidrome, Accidental overdose

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    • 2

      Nonopioid Analgesics

      By Sean Rhyee, MD, MPH; Katherine Boyle, MD
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      Nonopioid Analgesics

      • SEAN RHYEE, MD, MPHAssistant Professor of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
      • KATHERINE BOYLE, MDInstructor in Emergency Medicine, University of Massachusetts Medical School, Worcester, MA

      Acetaminophen is the most common toxic ingestion in the United States, causing 400 deaths per year. Poisoning occurs both intentionally and unintentionally, with suicidal intent, overuse for treatment of pain, and ingestion of multiple medications containing acetaminophen all contributing. Aspirin poisoning remains a concern even though its popularity as an analgesic and antipyretic has decreased over time. Among nonaspirin nonsteroidal antiinflammatory drugs (NSAIDs), ibuprofen and naproxen are the most commonly encountered in overdose, likely due to their easy availability as over-the-counter medications. This review covers the principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcomes related to acetaminophen, aspirin, and ibuprofen and other NSAIDs. Tables describe N-acetylcysteine dosing, King’s College criteria for acetaminophen-induced liver failure, and indications for hemodialysis in aspirin poisoning. Figures include a pie chart showing acetaminophen metabolization, the Rumack-Matthew nomogram, and a graph showing frequency of hepatotoxicity in patients receiving N-acetylcysteine.

      This review contains 3 highly rendered figures, 3 tables, and 97 references.

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    • 3

      Drugs of Abuse

      By Matthew D Zuckerman , MD; Kavita Babu, MD, FACEP, FACMT
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      Drugs of Abuse

      • MATTHEW D ZUCKERMAN , MDAssistant Professor, Department of Emergency Medicine, Medical Toxicology, University of Colorado Anschutz Medical Campus, Aurora, CO
      • KAVITA BABU, MD, FACEP, FACMTFellowship Director, Division of Medical Toxicology, Associate Professor, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA

      The term “drugs of abuse” lacks a formal medical definition. Historically, discussions of drugs of abuse focused on “street drugs”; however, the adverse effects of the nonmedical use of prescription medications, such as opiates, benzodiazepines, and therapeutic amphetamines, are increasingly seen. The purpose of this review is to aid the clinician in identifying and treating a broad representation of drugs of abuse, which may include those illicitly produced in laboratories (e.g., methamphetamine), diverted pharmaceuticals (oxycodone), and herbal products (marijuana). This review covers stimulants, hallucinogens, cannabinoids, and sedative-hypnotics. Figures show substances ranked according to weighted harm score on a normalized scale from 0 being no harm to 100 being extreme harm to self and others, a treatment algorithm for sympathomimetic toxicity, a treatment algorithm for sedative-hypnotic overdose, and a treatment algorithm for opioid overdose. Tables list commonly abused sympathomimetic agents, modern novel drugs of abuse, commonly abused sedative-hypnotic agents, commonly abused opiates, and pitfalls of the drug screen.

       

      This review contains 4 highly rendered figures, 5 tables, and 89 references

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    • 4

      Psychoactive Medications

      By Kavita M Babu, MD; Mark J Neavyn, MD
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      Psychoactive Medications

      • KAVITA M BABU, MDFellowship Director, Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
      • MARK J NEAVYN, MDDirector of Medical Toxicology, Department of Emergency Medicine, Hartford Hospital, Hartford, CT

      Psychoactive medications are defined as medications that affect the central nervous system neurotransmitter pathways with the intention to modulate mood or consciousness. This broad category of medications includes sedative-hypnotic agents such as benzodiazepines and barbiturates, antidepressants, neuroleptics, and mood stabilizers. The principal source of exposure for these medications is through prescription drug use and misuse. This review discusses the principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcomes related to sedative-hypnotics, antidepressants, neuroleptics, and lithium. Tables include common benzodiazepine and barbiturate compounds, dosing instructions for multidose activated charcoal, flumazenil dosing recommendations, commonly available tricyclic and atypical (noncyclic) antidepressants, dosing recommendations for sodium bicarbonate in serum alkalinization, benzodiazepine dosing recommendations in serotonin syndrome, dosing recommendations for cyproheptadine, signs and symptoms that differentiate  neuroleptic malignant syndrome from serotonin syndrome, and indications for renal replacement therapy based on lithium concentration and clinical setting. Figures show action potentials in the His-Purkinje syndrome, an electrocardiogram tracing demonstrating a terminal R wave, and a QT interval nomogram.

      This review contains 2 highly rendered figures, 9 tables, and 101 references.

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    • 5

      Cardiovascular Medications

      By Stephanie Carreiro, MD; Jeanine Ward, MD, PhD
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      Cardiovascular Medications

      • STEPHANIE CARREIRO, MDFellow, Clinical Instructor, Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
      • JEANINE WARD, MD, PHDAssistant Professor, Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA

      Multiple classes of xenobiotics have the potential to influence the function of the cardiovascular system. When evaluating the hemodynamic consequences of any toxic exposure and initiating treatment of such abnormalities, the clinician must consider the mechanism by which the toxin exerts its effect. This review focuses on diagnosis and management of toxicity related to common classes of antiarrhythmic drugs and the centrally acting hypertensives. Beta blockers, calcium channel blockers, cardiac glycosides, sodium channel and potassium channel blockers, and clonidine and centrally acting alpha2 agonists are described in relation to principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcome. Tables include classes of antiarrhythmics, various beta-blocker properties, standard dosing regimen for hyperinsulinemia/euglycemia, calcium channel blockers, botanical and animal sources of cardiac glycosides, P-glycoprotein inhibitors, and various alpha agonists. Figures show the mechanisms for beta-receptor activation, hyperinsulinemia/euglycemia, and cardiac glycosides. An electrocardiogram demonstrating digitalis effect is also provided.

      This review contains 4 highly rendered figures, 7 tables, and 126 references.

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    • 6

      Cholinergic Toxicity

      By Steven B Bird, MD, FACEP, FACMT
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      Cholinergic Toxicity

      • STEVEN B BIRD, MD, FACEP, FACMTAssociate Professor of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School, Worcester, MA

      Cholinergic drugs exert their functions by inhibiting acetylcholinesterase, the enzyme responsible for hydrolyzing acetylcholine and ending neuronal or neuromuscular neurotransmission. These compounds are used in clinical medicine to treat various disorders, as pesticides, and as weapons of mass destruction. This review describes the drugs that affect the cholinergic system and discusses stabilization, diagnosis and definitive therapy, principles and controversies of definitive care, and disposition and outcomes for these agents. Figures show acetylcholinesterase hydrolysis of acetylcholine, neurotransmission in the nervous system, the mechanism of inhibition of acetylcholinesterase by an organophosphorus (OP) compound, and the general chemical structure of thion OP and oxon OP agents and carbamates. Tables list OP pesticides associated with OP-induced delayed neuropathy, the effects of cholinesterase inhibition, the symptoms of cholinergic poisoning according to severity, and a treatment algorithm for acetylcholinesterase poisoning.

      This review contains 4 highly rendered figures, 4 tables, and 85 references.

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    • 7

      Anticholinergic Toxicity

      By Jeffrey T Lai, MD; Kavita M Babu, MD
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      Anticholinergic Toxicity

      • JEFFREY T LAI, MDResident Physician, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
      • KAVITA M BABU, MDAssociate Professor, Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA

      Anticholinergic compounds oppose the action of the endogenous neurotransmitter acetylcholine at its target receptors and are found in over-the-counter and prescription medication, natural products, and plants. Anticholinergic medications, such as atropine and scopolamine, are used for the treatment of a wide range of conditions, including bradycardia, motion sickness, and insomnia. Antihistaminergic medications, such as diphenhydramine, also possess anticholinergic activity and are used in the treatment of seasonal allergies, common cold symptoms, and allergic reactions. Other medications, such as antidepressants (especially the older tricyclic class), antipsychotics, muscle relaxants, and anticonvulsants, can act as anticholinergic agents or produce anticholinergic side effects. Toxicity can result from therapeutic misadventure, intentional overdose, recreational use, and pediatric exposures. This review covers the principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcomes. Figures show the anticholinergic toxidrome, look-alike structures, and electrocardiographic changes in tricyclic antidepressant overdose. Tables list medications with anticholinergic activity and selected botanicals that cause anticholinergic toxicity.

      Key words: anticholinergic overdose, anticholinergic toxicity, anticholinergic toxidrome, physostigmine, tricyclic antidepressant toxicity

      This review contains 3 highly rendered figures, 2 tables, and 49 references.

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    • 8

      Caustics

      By Kavita Babu, MD, FACEP, FACMT; Lynn A Farrugia, MD
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      Caustics

      • KAVITA BABU, MD, FACEP, FACMTFellowship Director, Division of Medical Toxicology, Associate Professor, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
      • LYNN A FARRUGIA, MDEmergency Medicine Residency Program, University of Massachusetts Medical School, Worcester, MA

      A caustic is any substance capable of causing full-thickness damage on contact with healthy, intact tissue. Caustic agents are generally classified by pH as acids or bases. Irritants are those substances that do not produce true breakdown of tissue but cause discomfort and inflammation, such as vomiting, burning eyes, or coughing. This review covers caustic and irritant agents, dermal caustic exposure, caustic inhalation and pulmonary irritants, caustic ingestion, and ocular caustic exposure, along with special consideration of hydrofluoric acid, including hydrofluoric acid and dermal exposure, hydrofluoric acid ingestion, hydrofluoric acid inhalation, ocular hydrofluoric acid exposure, and systematic hydrofluoric acid toxicity. Figures show classification of burns; chemical burns; an autopsy specimen of the tongue, epiglottis, and esophagus after caustic ingestion; and an autopsy specimen of the stomach after caustic ingestion. Tables list common caustic and irritant agents, household products containing caustic and irritant agents, agents for which water or saline irrigation is not recommended, indications for endoscopy after caustic ingestion, ocular chemical burn management, and common chemicals and products containing fluoride.

      Key words: caustic eye injury, caustic ingestion, caustic injury, chemical burn, hydrofluoric acid, pulmonary irritants 

      This review contains 5 highly rendered figures, 6 tables, and 53 references.

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    • 9

      Hydrocarbons

      By Jarrett M. Burns, DO, FACEP
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      Hydrocarbons

      • JARRETT M. BURNS, DO, FACEPAssistant Professor, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA

      Hydrocarbons (HCs) are organic compounds that contain primarily hydrogen and carbon atoms. Although most HC exposures occur in occupational settings dealing with various solvents, they can be found in products in every household. Therefore, the risk of exposure in everyday life is high. This review discusses the toxicokinetics, pathophysiology, common clinical presentation, and management of HCs. The three major classes of HCs (aliphatic, aromatic, and halogenated) are closely examined. An in-depth look is taken at commonly encountered HCs with unique toxicologic characteristics. The principles of toxicity, immediate stabilization, diagnosis, definitive management, disposition, and outcomes of these specific HCs are defined. Tables describe HCs commonly found in the household, toxic metabolites and viscosities of common HCs, and target organs of the toxic effects of common alihepatic, halogenated, and aromatic HCs both early and late after exposure. Figures show the structure of the various HCs described in the review.

      This review contains 13 highly rendered figures, 6 tables, and 116 references.

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    • 10

      Alcohols

      By Mark J Neavyn, MD; Steven B Bird, MD, FACEP, FACMT
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      Alcohols

      • MARK J NEAVYN, MDDirector of Medical Toxicology, Department of Emergency Medicine, Hartford Hospital, Hartford, CT
      • STEVEN B BIRD, MD, FACEP, FACMTAssociate Professor of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School, Worcester, MA

      Although alcohols share a common metabolic pathway, the toxicity of each is unique. This review discusses the common toxic alcohols, including ethanol, isopropanol, methanol, and ethylene glycol, and summarizes the principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcome for each. A special consideration is also given to diethylene glycol due to its historical significance as a contaminant of multiple different drugs. Figures show type B lactic acidosis; the Mellanby effect; the role of thiamine in aerobic metabolism; the metabolism of isopropanol, methanol, formate, and ethylene glycol; and the relationship between the osmol gap and the anion gap over time. Tables list treatment recommendations for Wernicke encephalopathy, alcoholic ketoacidosis, and alcohol withdrawal; the Clinical Institute Withdrawal Assessment–Alcohol Revised (CIWA-Ar); dosing recommendations for fomepizole and ethanol; serum alkalization; and indications for hemodialysis in ethylene glycol poisoning.

      This review contains 8 highly rendered figures, 8 tables, and 68 references.

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    • 11

      Heavy Metals

      By Jennifer L. Carey, MD; Edward W. Boyer, MD, PhD
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      Heavy Metals

      • JENNIFER L. CAREY, MDDepartment of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA
      • EDWARD W. BOYER, MD, PHDProfessor of Emergency Medicine, University of Massachusetts Medical School; Chief, Division of Medical Toxicology, UMass-Memorial Medical Center; Lecturer in Pediatrics, Harvard Medical School

      Heavy metal poisoning may be acute, subacute, or chronic, and it is important for the emergency physician to recognize poisonings that are acutely life threatening. Nearly all parts of the human body are affected by heavy metals, including the cardiovascular, gastrointestinal, renal, hematologic and nervous systems. In many heavy metal poisonings, chelation therapy is the standard of care. This review details the principles of toxicity, immediate stabilization, diagnosis and definitive therapy, and disposition and outcomes for patients who have been exposed to arsenic, chromium, cobalt, lead, mercury, and thallium. Figures show the skin manifestations of chronic arsenic toxicity and treatment algorithms for lead exposure and thallium poisoning. Tables list the clinical manifestations of arsenic poisoning, the side effects of common chelators, systemic manifestations of lead toxicity in adults, routes of exposure and clinical manifestations of mercury poisoning, and symptoms following acute thallium overdose.

      This review contains 3 highly rendered figures, 5 tables, and 92 references.

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    • 12

      Toxic Gases

      By Stephanie T Weiss, MD, PhD; Kathryn W Weibrecht, MD
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      Toxic Gases

      • STEPHANIE T WEISS, MD, PHDAssociate Director, Emergency Medicine, Morton Hospital and Medical Center, Taunton, MA
      • KATHRYN W WEIBRECHT, MDAssociate Director, Emergency Medicine, Morton Hospital, Taunton, MA

      This review looks at the potential causes, diagnoses, and possible treatments for three asphyxiant gases: carbon monoxide, hydrogen cyanide, and hydrogen sulfide. Exposure to these gases can lead to central nervous system depression, unconsciousness, and death due to tissue hypoxia. These gases are among the most common causes of fatalities related to toxic gas poisoning, with carbon monoxide responsible for 36% and hydrogen sulfide 7.7%. It is necessary to remove victims affected by poisoning immediately from the source of the toxic gas, administer oxygen, and assess their stability. As symptoms of these gases can differ widely, ranging from broad and unspecific to highly morbid, and may require different levels of care, the correct diagnosis should also rely on inferences from the patient history and the context of the admission, including evidence of fire and chemical reactions. Normobaric oxygen and hyperbaric oxygen are the two main treatments for carbon monoxide, although studies have been inconclusive in regards to the effectiveness of hyperbaric oxygen. The Cyanokit (containing hydroxocobalamin) is considered to be more effective for hydrogen cyanide when compared with the Cyanide Antidote Kit due to the former’s low toxicity and high effectiveness. Hydrogen sulfide is often used as a suicide agent, the mortality of which is close to 100%. Figures show the mechanisms by which the asphyxiant gases carry out their negative effects on the human body. Tables show the half-life of carboxyhemoglobin with oxygen therapy and a comparison between the Cyanide Antidote Kit and the Cyanokit. 

      This review contains 3 highly rendered figures, 2 tables, and 43 references. 


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    • 13

      Toxic Plants and Mushrooms

      By Marie King, MD, PhD; Richard Church, MD
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      Toxic Plants and Mushrooms

      • MARIE KING, MD, PHDEmergency Physician, Harrington Hospital, Southbridge, MA
      • RICHARD CHURCH, MDAssistant Professor, Emergency Medicine and Toxicology, University of Massachusetts, Worcester, MA

      Many species of plants and mushrooms exist that, when consumed, can induce poisoning in individuals, causing a range of side effects. As the toxins do not always correspond to an antidote, it is important to have the ability to identify each harmful species to determine the appropriate treatment. This review gives an overview of some of the more prevalent toxic plants and mushrooms, detailing their principles of toxicity, recommendations for immediate stabilization, keys to proper diagnosis and definitive therapy, and patient disposition and outcomes. Figures show photographs of the various toxic plants and mushrooms featured. Tables show a list of toxic species for both plants and mushrooms, including their common names, the toxins contained within, their effects, and the corresponding antidote (if any).

      This review contains 16 highly rendered figures, 2 tables, and 44 references.

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    • 14

      Venomous Bites and Stings

      By J Patrick Walker, MD, FACS
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      Venomous Bites and Stings

      • J PATRICK WALKER, MD, FACSChief of Surgery, ETMC, Crockett, TX, Houston County Surgical Associates, Crockett, TX

      Approximately 8000 persons are bitten by venomous snakes in the US each year.  Mortality is low (4 to 6/yr), but morbidity can be significant, treatment costly. Overuse of surgery and antivenom is common. Simply cutting the wound with attempted aspiration is not indicated. Fasciotomy should only be used for patients with elevated compartment pressures. CroFab is a highly effective (but expensive) treatment useful for serious envenomation. Antivenom should be used in patients with life-threatening symptoms (hypotension, clinical coagulopathy) or rapid advancement of local signs, and to reduce compartment pressures to avoid fasciotomy. The most significant morbidity from insect envenomation is secondary to anaphylaxis. A bite from the black widow spider can induce abdominal cramping and pain that can mimics an acute abdomen. Brown recluse envenomation can produce tissue necrosis and long-term complications. Most events are seen rarely by the average physician; this review can be a useful guide in management. 

      Key words: antivenom, copperhead bite, CroFab, insect bite, rattlesnake bite, snakebite, water moccasin bite

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  • Environment
    • 1

      Thermal Injuries

      By Tatiana Havryliuk, MD; Ryan Paterson, MD
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      Thermal Injuries

      • TATIANA HAVRYLIUK, MDEmergency Physician, Mount Sinai St. Luke-Roosevelt Hospital Center, New York, NY
      • RYAN PATERSON, MDEmergency Physician, Kaiser Permanente, Denver, CO

      In the United States, an estimated 450,000 patients with burns are treated in medical facilities annually. On assessment of burn patients, Advanced Trauma Life Support protocols should be followed because these patients often suffer from concomitant trauma; chemical exposure and airway compromise should also be considered in the initial assessment. Mortality from burn injuries increases with the patient’s age, the extent of the burn, and the presence of inhalation injury. This review covers the epidemiology, pathophysiology, assessment and stabilization, diagnosis, treatment and disposition, and outcomes of patients with burn injuries. Figures show the structure of the skin, and photographs of partial-thickness and full-thickness burns. Tables list burn classification by depth, indications for intubation, American Burn Association 2010 guidelines for calculating IV fluid resuscitation, indications for escharotomy in patients with circumferential trunk and extremity burns, and indications for burn center referral.

      This review contains 3 highly rendered figures, 5 tables, and 33 references.

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    • 2

      Frostbite and Hypothermia

      By Jeffrey I. Schneider, MD, FACEP, FAAEM
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      Frostbite and Hypothermia

      • JEFFREY I. SCHNEIDER, MD, FACEP, FAAEMResidency Program Director, Department of Emergency Medicine, Boston Medical Center, Assistant Professor, Boston University School of Medicine, Boston, MA

      Frostbite and hypothermia are becoming increasingly common as the popularity of extreme and outdoor sports rises and the homeless population increases. Advanced age is also associated with an increased risk of frostbite and hypothermia; thus, their incidence will likely continue to increase as the population ages. Frostbite occurs when there is sufficient heat loss to produce ice crystals within either superficial or deep flesh. Hypothermia is defined as an involuntary drop in body temperature to below 35°C, but a useful functional definition is a decrease in temperature that results in an inability of the body to maintain its natural functions. This review details the assessment and stabilization, diagnosis, and treatment and disposition for frostbite and hypothermia. Figures show factors that may predispose individuals to developing frostbite, long-term consequences of severe frostbite, and an approach for pleural cavity lavage. Tables list factors that increase the risk of frostbite, degrees of frostbite, three phases of frostbite, and staging of hypothermia.

      This review contains 3 highly rendered figures, 4 tables, and 71 references.

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    • 3

      Heat Injury

      By Renee N. Salas, MD, MS; N. Stuart Harris, MD, MFA
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      Heat Injury

      • RENEE N. SALAS, MD, MSDivision of Wilderness Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
      • N. STUART HARRIS, MD, MFAChief, Division of Wilderness Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Associate Professor, Harvard Medical School, Boston, MA

      Heat injuries present on a spectrum from mild (eg, miliaria rubra) to severe and life-threatening (heat stroke). The two main classifications of heat injury are exertional, which affects mainly young to middle-age individuals undergoing physical activity in hot environments, and classic, which typically affects young children and the elderly and results from an inability to dissipate heat. This review details the assessment and stabilization, diagnosis, treatments, disposition, and outcomes for patients with heat injury. Figures show the four mechanisms of passive heat transfer, physiologic responses to heat, the spectrum of heat injuries, risk factors for exertional versus classic heat stroke, a clinical algorithm to provide guidance in the diagnosis and management of heat stroke, the general pattern of organ dysfunction, and two evidence-based methods of rapid cooling for patients with heat stroke. Tables list factors affecting the efficiency of the mechanisms of passive heat transfer; minor to moderate heat injuries; exertional versus classic heat stroke; predisposing medical conditions, medications, and drugs for heat stroke; systemic inflammatory response criteria; key historical questions and physical examination items for heat stroke and differential diagnosis; signs, symptoms, and spectrum of pathology in heat stroke; comparison of pathology in exertional versus classic heat stroke; differential diagnosis for heat stroke; comparison of methods of cooling heat stroke patients; mortality data for heat stroke; and biologic variable prognostic indicators of mortality.

      This review contains 7 highly rendered figures, 14 tables, and 193 references.

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    • 4

      Radiation Injury

      By Maryann Mazer-Amirshahi, PharmD, MD, MPH
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      Radiation Injury

      • MARYANN MAZER-AMIRSHAHI, PHARMD, MD, MPHAssistant Professor of Emergency Medicine, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC

      Since the development of x-rays in the late 19th century, radiation has increasingly been used for diagnostic imaging and various industrial purposes. The human health consequences of radiation exposure can range from minor asymptomatic exposures to the development of potentially fatal acute radiation sickness depending on the characteristics of the exposure. This review provides an overview of radiation injury, including historical perspective and principles of toxicity; assessment and stabilization (bedside evaluation, supportive care, and empirical therapy); diagnosis (estimation of radiation dose, laboratory assessment, biodosimetry and bioassays, smoke inhalation, and psychiatric sequelae); treatment and disposition (hematologic acute radiation illness, countermeasures and antidotes, gastrointestinal symptoms, fluid and electrolyte management, surgical intervention, local radiation injury, psychiatric treatment, radiation exposure during pregnancy, palliative care, and disposition); and outcomes (carcinogenesis, noncancer effects). Tables include the characteristic of common radioactive isotopes, common radiation dose equations and conversions, prescribing information for colony-stimulating factors, recommended antimicrobial prophylaxis and treatment regimens, and radioisotope decorporation or blocking agents. Figures show types of ionizing radiation, comparison of radiation contamination and exposure, patterns of early lymphocyte response based on radiation dose, the relationship between time to onset of vomiting and radiation dose, and a sample body chart for documentation of radiation contamination.

      This review contains 5 highly rendered figures, 5 tables, and 82 references.

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    • 5

      Lightning and Electrical Injury

      By Christopher Davis, MD; Tracey A. Cushing, MD, MPH, FACEP
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      Lightning and Electrical Injury

      • CHRISTOPHER DAVIS, MDAssistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
      • TRACEY A. CUSHING, MD, MPH, FACEPAssistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, Staff Physician, Denver Health Medical Center, Denver, CO

      There are multiple types of electrical injuries, which vary according to the type of electricity (alternating current or direct current) and the mechanism of contact. Electrical injuries caused by contact with alternating current are generally considered to be more dangerous than those caused by contact with direct current; unfortunately, alternating current is more commonly encountered in the household setting. Lightning injuries are rare in the United States but are much more common in developing countries due to a lack of access to infrastructure and more agrarian economies. This review includes an overview, assessment and stabilization, diagnosis, treatment and disposition, and outcomes for each of these types of injury. Figures show lightning fatalities by state from 2004 to 2013 and an electrical burn in a toddler, with entry and exit points. Tables list body tissue resistance, classification of lightning injuries, and common presentations of lightning victims based on injury severity.

      This review contains 2 highly rendered figures, 3 tables, and 82 references.

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    • 6

      Drowning and Near Drowning

      By Emily S Miller, MD
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      Drowning and Near Drowning

      • EMILY S MILLER, MDInstructor in Emergency Medicine Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA

      The most recently updated definition of drowning is “the process of experiencing respiratory impairment from submersion/immersion in liquid.” The primary insult in these patients is asphyxia, and the resulting hypoxia, hypercarbia, and acidosis will progress until cardiac arrest, multiple organ dysfunction, and death. The patient’s prognosis will depend on where the drowning process was interrupted on this continuum. This review includes an overview of the epidemiology, risk factors, pathophysiology, assessment and stabilization, diagnosis, treatment and disposition, and outcomes of drowning. Figures show how nonambulatory infants and toddlers may drown after pulling up on the edge of a toilet, leaning over, and falling head first into the toilet bowl and an algorithm for the approach to the drowning patient. Tables list risk factors for drowning, indications for intubation, prognostic factors for death or survival with severe neurologic sequelae, and key preventive measures.

      This review contains 2 highly rendered figures, 4 tables, and 73 references.

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    • 7

      Dysbarism

      By Kris Lehnhardt, MD, FRCPC (EM), FACEP
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      Dysbarism

      • KRIS LEHNHARDT, MD, FRCPC (EM), FACEPAssistant Professor, Department of Emergency Medicine, George Washington University, Washington, DC

      Dysbarism is defined as any medical condition that arises as a result of changes in ambient pressure. This review describes dysbarism with a focus on the undersea environment. Conditions discussed in this review include middle and inner ear barotrauma, pulmonary barotrauma, immersion pulmonary edema, decompression illness, and gas toxicities. For each, assessment and stabilization, treatment and disposition, and outcomes are presented. Figures show the AQUARIUS habitat for saturation diving; the anatomy of the external, middle, and inner ear; the Teed classification; the paranasal sinuses; and an example of a recompression chamber. Tables list the types of diving, gas laws relevant to diving, units of underwater pressure, compositions of typical breathing gas mixtures, decompression illness risk factors, symptoms of decompression illness (in order of frequency), signs and symptoms of decompression illness based on body system, maximum recommended depth to reduce the risk of central nervous system oxygen toxicity for various breathing gas mixtures, and progression of nitrogen narcosis symptoms with increasing depth.

      This review contains 5 highly rendered figures, 9 tables, and 120 references.

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    • 8

      High Altitude Illness

      By N. Stuart Harris, MD, MFA, FACEP, FRCP Edin.
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      High Altitude Illness

      • N. STUART HARRIS, MD, MFA, FACEP, FRCP EDIN.Chief, Division of Wilderness Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Assistant Professor of Surgery, Harvard Medical School, Boston, MA

      High-altitude illnesses include acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). Gradual ascent provides the optimal means of avoiding high-altitude illness; thus, public education regarding gradual ascent plays an important role in reducing the morbidity and mortality of serious altitude illness. This review summarizes the primary types of acute altitude sickness, acclimatization to high altitude, assessment and stabilization, diagnosis, treatment and disposition, prophylaxis, and outcomes for patients with high-altitude illness. Figures show physiologic changes leading to acclimatization to high altitude, HAPE physiology, the ‘bar-code sign’ indicating the presence of pneumothorax, the ‘waves on a beach’ sign indicating the absence of pneumothorax, images of lungs with and without edema on ultrasonography, a chest x-ray of HAPE, and a photograph of a portable hyperbaric treatment bag. Tables list rules to avoid serious altitude illness; initial assessment of the new patient with potential high-altitude illness; differential diagnosis, diagnostic criteria, and treatments for AMS, HACE, and HAPE; the Lake Louise score for establishing AMS severity; and prophylaxis for cerebral forms of altitude illness. Videos show the use of a high-frequency linear array probe to assess pneumothorax.

      This review contains 8 highly rendered figures, 14 tables, 3 videos, and 68 references.

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  • Allergy and Immunology
    • 1

      Hypersensitivity Reactions and Anaphylaxis

      By Kristopher K. Ford, MD; Timothy M. Loftus, MD; Joseph J. Moellman, MD
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      Hypersensitivity Reactions and Anaphylaxis

      • KRISTOPHER K. FORD, MDEmergency Medicine Resident, Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH
      • TIMOTHY M. LOFTUS, MDEmergency Medicine Resident, Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH
      • JOSEPH J. MOELLMAN, MDAssociate Professor of Emergency Medicine, Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH

      Allergic reactions vary in intensity from mild rash or allergic rhinitis to devastating anaphylactic shock. Anaphylaxis, often underrecognized and undertreated, can be a life-threatening syndrome leading to multiorgan dysfunction. This review covers the etiology, pathophysiology, and treatment of severe allergic reactions and anaphylaxis. It is precipitated by exposure to particular allergens—commonly food, medications, insect stings, and environmental exposures—in a previously sensitized individual. Symptoms develop from an IgE-mediated immune response leading to degranulation of mast cells and basophils and the release of preformed mediators, lipid-derived metabolites, and inflammatory cytokines. First-line treatment for anaphylaxis involves epinephrine. Secondary treatments are antihistamines and corticosteroids. Further treatments for patients refractory to standard therapies involve vasopressor agents, nebulized albuterol, and glucagon. Frequency and duration of biphasic reactions are variable, limiting the development of consensus guidelines for monitoring of anaphylactic reactions.

      Figures show the immune activity and inflammatory pathways in allergic responses, mast cell degranulation, and a depiction of common organs involved and corresponding clinical manifestations. Tables list the criteria for diagnosis of anaphylaxis, classification of hypersensitivity reactions, common clinical manifestations, and etiology and mediators of anaphylaxis.
       

      Key words: allergy, anaphylaxis, antihistamine, corticosteroid, epinephrine, mast cells

      This review contains 4 highly rendered figures, 9 tables, and 41 references.

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    • 2

      Drug Allergies

      By Natalie P. Kreitzer, MD; Edmond A. Hooker, MD, DrPH
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      Drug Allergies

      • NATALIE P. KREITZER, MDNeurocritical Care Fellow in Training, Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH
      • EDMOND A. HOOKER, MD, DRPHAssistant Professor, Residency Research Director, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH

      Adverse drug reactions (ADRs) are very common, causing approximately 2% of emergency department visits. It is estimated that approximately one-half of these ADRs are preventable. Although most ADRs and allergic reactions are minor, some may be severe, and the emergency physician's first priority should be the identification of anaphylactic or life-threatening reactions. This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of ADRs and drug allergies. Figures show the Gell and Coombs system, the four basic immunologic mechanisms for drug reactions, drugs as haptens and prohaptens, chemical structure of different β-lactam antibiotics, and management of the patient with possible drug allergy. Tables list the types of adverse drug reactions, drugs frequently implicated in allergic reactions in the emergency department, classification of allergic reactions, pretreatment protocol for radiocontrast allergy, and important parts of a history and physical examination of a patient with a suspected or confirmed drug hypersensitivity reaction.

      This review contains 5 highly rendered figures, 5 tables, and 115 references.

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    • 3

      Food Allergies

      By Edmond A. Hooker, MD, DrPH; Charles Kircher, MD
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      Food Allergies

      • EDMOND A. HOOKER, MD, DRPHAssistant Professor, Residency Research Director, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
      • CHARLES KIRCHER, MD Clinical Instructor, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH

      Food allergies are responsible for a considerable number of emergency department visits. Food allergy can be divided into classic (i.e., IgE-mediated) reactions to specific allergens after exposure via skin or mucosal membrane and non–IgE-mediated food allergies, which include T cell–mediated immunity, enteropathies to specific proteins, and mixed disorders (e.g., eosinophilic esophagitis). Food-induced anaphylaxis can be life threatening and requires immediate treatment with epinephrine, even if the causative agent has not been identified. This review describes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with food allergies. Figures show IgE-mediated allergic reactions to food and other allergens, classification of adverse reactions to foods, commercially available epinephrine autoinjectors, a sample anaphylaxis action plan, and a map showing school access to epinephrine in the United States as of September 4, 2014. Tables list potential food allergies with estimated self-reported prevalence, National Institute of Allergy and Infectious Disease clinical criteria of anaphylaxis, non–IgE-mediated food intolerance disorders, Rome III diagnostic criteria for irritable bowel syndrome, food allergy mimickers, and potential criteria for prolonged observation.

      This review contains 5 highly rendered figures, 6 tables, and 54 references.

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  • Endocrinology and Metabolism
    • 1

      Disorders of Water and Sodium Balance

      By David A. Peak, MD
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      Disorders of Water and Sodium Balance

      • DAVID A. PEAK, MDAssistant Professor of Emergency Medicine, Harvard Medical School, Associate Residency Director, Harvard Affiliated Emergency Medicine Residency, Emergency Medicine, Massachusetts General Hospital, Boston, MA

      Water accounts for approximately half of an adult human’s body weight. Two-thirds of body water is intracellular, and the remainder is contained in the extracellular fluid compartment, which includes intravascular (plasma) and interstitial fluid. Small amounts of water are also contained in bone, dense connective tissue, digestive secretions, and cerebrospinal fluid.  Hyponatremia and hypernatremia can be thought of as disorders of water metabolism. A complex system of regulation exists to maintain physiologic salt/water homeostasis; disease states that alter water and sodium balance may result in significant morbidity or even mortality either from the underlying disease or inappropriate treatment. This review covers the pathophysiology, assessment and treatment, and disoposition and outcomes of hyponatremia and hypernatremia. Figures show sodium reabsorption by the renal tubules, and the normal relation between plasma vasopressin levels and urine osmolality and the plasma sodium concentration. Tables list control of body fluid volumes, classifications for determining etiology of hyponatremia, physiologic settings in which antidiuretic hormone is released, causes and treatment of acute hyponatremia, causes of nonhypotonic hyponatremia, causes of the syndrome of inappropriate antidiuretic hormone, and causes of hypernatremia.

      This review contains 3 highly rendered figures, 7 tables, and 107 references

      Key words: Hyponatremia; Chronic hyponatremia; Hypernatremia; Syndrome of inappropriate antidiuretic hormone; SIADH; Water metabolism; Body fluid volumes; Water and sodium balance

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    • 2

      Acid-base Disorders

      By Aaron Skolnik, MD, FAAEM; Jessica Monas, MD, FAAEM, FACEP
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      Acid-base Disorders

      • AARON SKOLNIK, MD, FAAEMMedical Toxicologist, Banner – University Medical Center Phoenix, Assistant Medical Director, Banner Poison & Drug Information Center, Clinical Assistant Professor, Department of Emergency Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ
      • JESSICA MONAS, MD, FAAEM, FACEPEmergency Physician, Banner – University Medical Center Phoenix, Clinical Assistant, Professor, Dept. of Emergency Medicine, University of Arizona College of Medicine – Phoenix, Phoenix, AZ

      Under physiologic conditions, the acid-base balance of the body is maintained via changes in ventilation that eliminate carbon dioxide, buffering of acid loads, and renal excretion of hydrogen ions. Failure to maintain the pH of the blood between 7.35 and 7.45 can result in life-threatening conditions. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of acid-base disorders. Figures show the relationship between hydrogen ions and blood pH, proximal tubular bicarbonate reabsorption, the secretion of hydrogen ions, renal ammonia production, ammonium diffusion, metabolic alkalosis, electrocardiographic changes in hypokalemia and hyperkalemia, pseudoinfarction caused by hyperkalemia, and an algorithmic approach to suspected acid-base disorders. Tables list causes of high–anion gap metabolic acidosis, metabolic acidosis with a normal anion gap, type 1 renal tubular acidosis, type 4 renal tubular acidosis and aldosterone resistance, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis; treatment of hyperkalemia; and a stepwise approach for the evaluation of suspected acid-base disorders.

      This review contains 9 highly rendered figures, 9 tables, 64 references, and a list of pertinent Web sites.

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    • 3

      Disorders of Potassium, Calcium, and Magnesium

      By Katie E. Golden, MD; Emily S Miller, MD
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      Disorders of Potassium, Calcium, and Magnesium

      • KATIE E. GOLDEN, MDEmergency Medicine Resident Physician, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA
      • EMILY S MILLER, MDInstructor in Emergency Medicine Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA

      Potassium, calcium and magnesium play important roles in physiology, particularly cardiac and neurologic function. Abnormalities in these electrolytes can cause subtle symptoms, but are common in patients with multiple medical problems and significantly increase morbidity and mortality. This review details the pathophysiology, assessment, treatment, and disposition of patients with hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. Figures show approaches to identifying the causes of hypokalemia and hyperkalemia, changes in the electrocardiogram due to hypokalemia and hyperkalemia,  and demonstration of Trousseau sign (carpal spasm with inflation of the blood pressure cuff) and Chvostek sign (facial muscle spasm with tapping of the facial nerve). Tables describe replenishing potassium via oral route, factors contributing to increased plasma potassium, medications that cause hyperkalemia, contraindications to succinylcholine, a summary of emergency treatment for hyperkalemia, common causes of hypocalcemia in the emergency department, and a summary of emergency treatment for hypercalcemia.

      This review contains 4 highly rendered figures, 7 tables, and 39 references.

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    • 4

      Nondiabetic Endocrine Emergencies 1: Adrenal Crisis, Pheochromocytoma, and Hypopituitarism

      By Jason J Lewis, MD; Richard E Wolfe, MD
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      Nondiabetic Endocrine Emergencies 1: Adrenal Crisis, Pheochromocytoma, and Hypopituitarism

      • JASON J LEWIS, MDAttending Physician, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
      • RICHARD E WOLFE, MDChief, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

      Nondiabetic endocrine emergencies are less frequent but equally concerning as diabetic emergencies. The diagnosis of adrenal crises, pheochromocytoma, or pituitary deficiencies can be difficult in the emergent setting given the nonspecific findings frequently confused with other presenting illnesses. Although the differential is broad for patients presenting with shock and hypotension, as seen in adrenal crises, hypertensive emergencies in pheochromocytoma, or a litany of potential symptoms in pituitary abnormalities, the diagnosis should be considered in a patient presenting to the emergency department with severe metabolic abnormalities, undifferentiated shock, or cardiovascular lability. This review demonstrates how to recognize and manage acute adrenal crisis, pheochromocytoma, and pituitary deficiencies in the acute care setting. Patients with nondiabetic endocrine emergencies may present in extremis, and immediate stabilization, typically without confirmatory testing, is necessary. Early intervention is key in treating such presentations.

      This review contains 1 figure, 2 tables and 21 references

      Key words: adrenal crisis, adrenal insufficiency, catecholamine surge, pheochromocytoma, pituitary deficiency

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    • 5

      Nondiabetic Endocrine Emergencies 2: Hypoparathyroidism, Hyperparathyroidism, Myxedema Coma, and Thyroid Storm

      By Jason J Lewis, MD; Richard E Wolfe, MD
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      Nondiabetic Endocrine Emergencies 2: Hypoparathyroidism, Hyperparathyroidism, Myxedema Coma, and Thyroid Storm

      • JASON J LEWIS, MDAttending Physician, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
      • RICHARD E WOLFE, MDChief, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

      Acute emergent presentations of the thyroid and parathyroids are rarer occurrences in the emergency department but essential to diagnose and treat early in the course of illness. Disorders of the parathyroids are typically related to circulating calcium levels and the metabolic effects thereof, whereas thyroid deficiency or excess can lead to profound shock, coma, hypothermia, hyperthermia, and death. The diagnosis of parathyroid disease should be considered in patients presenting with signs and symptoms consistent with hyper- or hypocalcemia. Myxedema coma should be considered in any patient presenting with evidence of severe sepsis or shock, particularly when there is a history of hypothyroidism. Thyroid storm should be suspected in any patient with unexplained increased adrenergic activity, hyperpyrexia, or multiorgan failure. Empirical treatment must begin prior to definitive diagnosis in all cases. This review demonstrates how to recognize and manage acute presentations of hypo- and hyperparathyroidism, myxedema coma, and thyroid storm in the emergency setting. Patients with nondiabetic endocrine emergencies may present in extremis, and immediate stabilization, typically without confirmatory testing, is necessary. Early intervention is key in treating such presentations.

      This review contains 3 figures, 8 tables and 28 references

      Key words: disorders of the parathyroids, hyperparathyroidism, hypoparathyroidism, hypothyroidism, myxedema coma, thyroid storm, thyrotoxicosis

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    • 6

      Type I Diabetes Mellitus

      By Joseph I. Wolfsdorf, MB, BCh; Katharine Garvey, MD, MPH
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      Type I Diabetes Mellitus

      • JOSEPH I. WOLFSDORF, MB, BCHProfessor of Pediatrics, Harvard Medical School, Boston, MA
      • KATHARINE GARVEY, MD, MPHInstructor of Pediatrics, Harvard Medical School, Boston, MA

      Type 1 diabetes mellitus is characterized by severe insulin deficiency, making patients dependent on exogenous insulin replacement for survival. These patients can experience life-threatening events when their glucose levels are significantly abnormal. Type 1 diabetes accounts for 5 to 10% of all diabetes cases, with type 2 accounting for most of the remainder. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment, disposition and outcomes of patients with Type 1 diabetes mellitus. Figures show the opposing actions of insulin and glucagon on substrate flow and plasma levels; plasma glucose, insulin and C-peptide levels throughout the day; the structure of human proinsulin; current view of the pathogenesis of Type 1 autoimmune diabetes mellitus; pathways that lead from insulin deficiency to the major clinical manifestations of Type 1 diabetes mellitus; relationship between hemoglobin A1c values at the end of a 3-month period and calculated average glucose levels during the 3-month period; different combinations of various insulin preparations used to establish glycemic control; and basal-bolus and insulin pump regimens. Tables list the etiologic classification of Type 1 diabetes mellitus, typical laboratory findings and monitoring in diabetic ketoacidosis, criteria for the diagnosis of Type 1 diabetes, clinical goals of Type 1 diabetes treatment, and insulin preparations.

      This review contains 10 figures, 8 tables, and 40 references.

      Keywords: Type 1 diabetes mellitus, optimal glycemic control, hypoglycemia, hyperglycemia, polyuria, polydipsia, polyphagia, HbA1c, medical nutrition therapy, Diabetic Ketoacidosis

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    • 7

      Type II Diabetes Mellitus

      By Saul Genuth, MD, FACP; Matthew C. Riddle, MD
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      Type II Diabetes Mellitus

      • SAUL GENUTH, MD, FACPProfessor, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine, Cleveland, OH
      • MATTHEW C. RIDDLE, MDProfessor, Department of Medicine, and Head, Section of Diabetes, Oregon Health & Sciences University, Portland, OR

      Hyperosmotic hyperglycemic nonketotic (HHNK) state (also known as hyperosmolar hyperglycemic state) is a significant acute complication of type 2 diabetes mellitus, especially for those over 65 years of age. It is characterized by extreme hyperglycemia and hyperosmolarity with little ketosis. The main clinical effect of extreme hyperosmolarity is somnolence or confusion. The absence of severe ketonemia is attributed to residual insulin secretion that is sufficient to restrain lipolysis. HHNK state is marked by extreme dehydration, with both a marked deficit of free water and serious compromise of intravascular volume and tissue perfusion. Most patients with HHNK state have hypotension, extremely dry mucous membranes, and gross elevation of urea nitrogen and creatinine. Urinary tract infection, pneumonia, stroke, myocardial infarction, and sepsis may precipitate HHNK state. Elderly patients are particularly vulnerable because their thirst mechanisms are less sensitive to a rising serum osmolality. Fluid replacement is the most important component of therapy for HHNK state. Restoration of circulating volume is an urgent first priority and is accomplished by relatively rapid intravenous infusion of 2 L of 0.9% normal saline followed by 0.45% normal saline. Later, when plasma glucose levels have declined to 250 to 300 mg/dL, 5% dextrose in water is given. Insulin treatment is started soon after administration of isotonic saline. Potassium must be added to intravenous fluids to prevent hypokalemia caused by insulin action but should not be started until hypokalemia is proven, because potassium levels can be high initially. The mortality from the HHNK state is high, ranging from 10 to 20%, and is most often from the precipitating illness.

      This review contains 6 figures, 6 tables, and 74 references.

      Key words: dehydration, fluid deficit, hyperglycemia, hyperglycemic nonketotic state, hyperosmolar, hyperosmotic insulin, potassium, type 2 diabetes mellitus

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  • ENT and Oropharynx
    • 1

      Upper Airway Disorders

      By Lawrence Proano, MD, DTMH ; Seth Gemme, MD; Robert Partridge, MD, MPH, DTMH
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      Upper Airway Disorders

      • LAWRENCE PROANO, MD, DTMH Clinical Professor of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI
      • SETH GEMME, MDRhode Island Hospital; Chief Resident, The Alpert Medical School of Brown University, Providence, RI
      • ROBERT PARTRIDGE, MD, MPH, DTMH Adjunct Associate Professor of Emergency Medicine, he Alpert Medical School of Brown University, Providence, RI

      Upper airway disorders are frequently encountered in the primary care setting and present in both adults and children.  This review covers earache, sinusitis, sore throat, peritonsillar abscess, sialolithiasis and sialadenitis, parotitis, epiglottitis, epistaxis, foreign body in the ear, nose, or throat, and Ludwig angina. Figures show right-sided peritonsillar abscess demonstrating swelling and distortion of the anterior and posterior tonsillar pillars and uvular deviation, peritonsillar abscess demonstrated by an ultrasound image of a hypoechoic fluid collection, ultrasound imaging of sagittal view of the tonsillar pillars, lateral radiograph of the neck demonstrating a swollen epiglottis and widened vallecula, photographs of brawny swelling of the submandibular region of the neck in Ludwig angina, and a patient with peritonsillar abscess with extension to the base of the tongue. Tables list criteria for diagnosing acute sinusitis, and clinical presentations that best identify patients with acute bacterial versus viral rhinosinusitis.

       

      This review contains 7 highly rendered figures, 2 tables, and 62 references.

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    • 2

      Eye and Orbit

      By Steven Patrick Davis, MD
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      Eye and Orbit

      • STEVEN PATRICK DAVIS, MDAssistant Professor, Clerkship Director, Department of Emergency Medicine, The George Washington University School of Medicine & Health Sciences, Washington, DC

      Pathologic conditions involving the eye and orbit can range from benign lesions to conditions resulting in vision loss and, potentially, death. These conditions may be difficult for the clinician to identify, as many manifest similarly on gross examination. This review presents the assessment and stabilization, diagnosis, treatment and disposition, and outcomes for 15 conditions affecting the eye and orbit. Figures include photographs of a chalazion, dacrocystitis and postoperative cellulitis, preseptal cellulitis, orbital cellulitis, epidemic keratoconjunctivitis, hyperacute conjunctivitis caused by Neisseria gonorrhoeae, corneal abrasions, varicella-zoster virus keratitis, dendritic herpes simplex virus keratitis, corneal ulcers, chemical keratitis, acute angle closure glaucoma, posterior vitreous detachment, and acute and superior retinal detachment. Tables list ocular pain and visual disturbance in ocular disease, common predisposing conditions in preseptal and orbital cellulitis, common ocular chemical exposures, common pharmacologic therapies in acute angle closure glaucoma, and common predisposing conditions in scleritis, episcleritis, and uveitis. Videos show visualization of detaching retinas by bedside ultrasound imaging.

      This review contains 23 highly rendered figures, 5 tables, 2 videos, and 88 references.

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    • 3

      Ears

      By Peter Pruitt, MD; Thomas Osborne Stair, MD
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      Ears

      • PETER PRUITT, MDEmergency Medicine Resident, Brigham and Women’s / Massachusetts General Hospital Harvard Affiliated Emergency Medicine Residency, Boston, MA
      • THOMAS OSBORNE STAIR, MDDepartment of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

      As the structure of the ear is made of little more than cartilage, a limited blood supply, and a thin layer of skin, trauma in this area can easily manifest from a variety of causes. Some common examples of trauma involve laceration, piercing (intentional or otherwise), infection causing chondritis, blunt trauma causing necrosis, rupture of the tympanic membrane, perforation of the ear drum, and acoustic trauma that may result in hearing disorders such as tinnitus and high-frequency hearing loss. Acute hearing loss shows in two forms: conductive hearing loss and sensorineural hearing loss, the latter of which is caused by damage to the anatomic or neurologic structures of the ear dedicated to hearing. Sensorineural hearing loss generally has a poor prognosis and mandates prompt referral to an otolaryngologist. For information relating to Meniere disease, please refer to the Emergency Medicine topic review “Mouth and Oropharynx/Upper Airway.” Figures show illustrations of the inner ear and right ear serous otitis media, the canalith repositioning procedure (Epley maneuver), and the Dix-Hallpike maneuver. Tables list differential diagnosis for ear pain, ear equipment for the primary care office, and steps for the Epley maneuver to relocate otolith in benign paroxysmal positional vertigo (BPPV).

      This review contains 4 highly rendered figures, 3 tables, and 28 references.

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    • 4

      Dental Emergencies

      By Annelies L De Wulf, MD, MPH; E Brennan Bollman, MD
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      Dental Emergencies

      • ANNELIES L DE WULF, MD, MPHAssistant Professor, Section of Emergency Medicine, Louisiana State University, New Orleans, LA.
      • E BRENNAN BOLLMAN, MDResident Physician, Section of Emergency Medicine, Louisiana State University, New Orleans, LA

      Patients with dental complaints commonly present to the emergency department for initial management. Immediate airway assessment and stabilization as needed are imperative. Based on clinical signs and symptoms, providers may assess the degree of dental decay and make an appropriate referral. Nonsteroidal antiinflammatory drugs are effective for most dental pain, and antibiotics are not indicated in the absence of overt infection. Emergency providers may drain simple odontogenic abscesses, but referral for definitive endodontic therapy is still required. Abscesses may extend into the deep fascial spaces of the face and neck. When “red flag” findings are seen, it is critical to protect the airway and obtain early consultation with specialists, along with advanced imaging and likely admission for drainage and intravenous antibiotics. Complications such as Ludwig angina, vascular erosion, and necrotizing fasciitis may lead to significant morbidity and mortality in otherwise healthy patients. Gingivitis and periodontitis are typically chronic, slowly progressing diseases but also have acute necrotizing variants that require antibiotics and prompt dental follow-up. Dentoalveolar fractures may be temporized by an emergency provider with commercial splints and coverings. Tooth avulsion is a dental emergency that requires proper handling and prompt replantation within 60 minutes. Mandibular fractures should be suspected with malocclusion and a positive tongue blade test. After diagnosis, however, these may be managed on an outpatient, nonemergent basis. Given the significant force required to produce a mandible fracture, patients should be assessed for other acute traumatic injuries.

      This review contains 11 figures, 5 tables, and 45 references.

      Key words: antibiotic, dental infection, dentoalveolar trauma, gingivitis, mandible fracture, odontogenic abscess

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    • 5

      Upper Airway Disorders

      By Lawrence Proano, MD, DTMH ; Seth Gemme, MD; Robert Partridge, MD, MPH, DTMH
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      Upper Airway Disorders

      • LAWRENCE PROANO, MD, DTMH Clinical Professor of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI
      • SETH GEMME, MDRhode Island Hospital; Chief Resident, The Alpert Medical School of Brown University, Providence, RI
      • ROBERT PARTRIDGE, MD, MPH, DTMH Adjunct Associate Professor of Emergency Medicine, he Alpert Medical School of Brown University, Providence, RI

      Upper airway disorders are frequently encountered in the primary care setting and present in both adults and children.  This review covers earache, sinusitis, sore throat, peritonsillar abscess, sialolithiasis and sialadenitis, parotitis, epiglottitis, epistaxis, foreign body in the ear, nose, or throat, and Ludwig angina. Figures show right-sided peritonsillar abscess demonstrating swelling and distortion of the anterior and posterior tonsillar pillars and uvular deviation, peritonsillar abscess demonstrated by an ultrasound image of a hypoechoic fluid collection, ultrasound imaging of sagittal view of the tonsillar pillars, lateral radiograph of the neck demonstrating a swollen epiglottis and widened vallecula, photographs of brawny swelling of the submandibular region of the neck in Ludwig angina, and a patient with peritonsillar abscess with extension to the base of the tongue. Tables list criteria for diagnosing acute sinusitis, and clinical presentations that best identify patients with acute bacterial versus viral rhinosinusitis.

       

      This review contains 7 figures, 11 tables, and 61 references.

      Key words: Epiglottitis, epistaxis, parotitis, peritonsillar abscess, pharyngitis, sialolithiasis, sinusitis


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  • Hematology/oncology
    • 1

      Emergencies in Hematology and Oncology

      By David P Curley, MD, PhD
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      Emergencies in Hematology and Oncology

      • DAVID P CURLEY, MD, PHDAssistant Professor, The Warren Alpert Medical School of Brown University. Attending Physician, Rhode Island Hospital and The Miriam Hospital

      Clinicians must be able to recognize and treat emergencies associated with malignancies and cancer treatment. Such emergencies include metabolic, neurologic, cardiovascular, hematologic, and infectious emergencies. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment and disposition and outcomes for these emergencies in hematology and oncology. Figures show mechanisms of spinal cord compression, a magnetic resonance image showing a metastasis to the thoracic spine compressing the spinal cord, a contrast-enhanced magnetic resonance image of a 54-year-old female with metastatic ovarian cancer, an electrocardiogram and a cardiac echocardiogram of a 50-year-old female with malignant pericardial effusion with cardiac tamponade, a computed tomography scan of a mass compressing the superior vena cava, a blood smear from a patient with acute myeloid leukemia, and an algorithm showing the initial management of fever and neutropenia. Tables list the management of hypercalcemia of malignancy; Cairo-Bishop definition of laboratory and clinical tumor lysis; grading, risk stratification, and management of tumor lysis syndrome; management of intracranial hypertension and seizures in adults; factors favoring low risk of severe infection in patients with neutropenic fever; Multinational Association for Supportive Care in Cancer (MASCC) risk index score; and indications for the addition of a gram-positive antibiotic to the initial empirical regimen.

      This review contains 8 highly rendered figures, 9 tables, and 136 references.

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    • 2

      Sickle Cell Disease

      By Caroline Freiermuth, MD, FACEP; Idan Cudykier, MD
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      Sickle Cell Disease

      • CAROLINE FREIERMUTH, MD, FACEPAssistant Professor, Division of Emergency Medicine, Duke University, Durham, NC
      • IDAN CUDYKIER, MDResident Physician, Division of Emergency Medicine, Duke University, Durham, NC

      Sickle cell disease affects between 70,000 and 90,000 individuals in the United States, the majority of whom are of African-American descent. The genetic basis of the disease is an abnormality in the β-globin gene, which causes the red blood cells to change to a “sickle” shape due to low oxygenation. The life span of patients with this disease has improved over the past few decades, although morbidity remains high. This review covers the pathophysiology of sickle cell disease and the stabilization and assessment, diagnosis and treatment, maintenance and preventive therapies, and cure of patients with sickle cell disease. Figures show hemoglobin electrophoresis; age at death for individuals with sickle cell disease in the years 1979, 1989, 1999, and 2006; sickled cells blocking blood flow; acute chest syndrome; dactylitis; and avascular necrosis. Tables list important trials, topics in need of further research, common complications, most common intravenous pain medications, and indications for transfusion.

      This review contains 6 highly rendered figures, 5 tables, 97 references, and a list of educational resources.

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    • 3

      Platelet Disorders

      By Michael Perry, MD PGY-3; John Bedolla, MD; Truman John Milling, MD
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      Platelet Disorders

      • MICHAEL PERRY, MD PGY-3Emergency Medicine, Post-Graduate Education, University of Texas Dell Medical School, Austin, Texas
      • JOHN BEDOLLA, MDAssistant Professor, Emergency Medicine and Medical Education, University of Texas Dell Medical School, Austin, Texas
      • TRUMAN JOHN MILLING, MDAssociate Professor, Seton Dell Medical School Stroke Institute, Austin, Texas

      Hemostasis occurs in two steps: platelet plug formation followed by fibrin deposition. Platelet disorders cause incomplete or absent platelet plug formation. Platelets form in bone marrow and have an 8- to 9-day life span. A careful history and physical examination can distinguish between platelets or the coagulation cascade as the cause of deranged hemostasis. Platelet disorders are characterized by mucosal and small vessel bleeding, and petechiae are characteristic. A complete blood count and prothrombin time/international normalized ratio testing reveal most causes. Many drugs can alter platelet production, function, and longevity, but antiplatelet therapy is the most common cause. Other causes include congenital, medication side effects, sepsis, bone marrow suppression, and systemic disease. The platelet count may be low, elevated, or normal. Bleeding time is virtually always prolonged in platelet dysfunction. Therapy for platelet dysfunction depends on the etiology and severity. Platelets are short-lived, and platelet transfusion may be necessary in the unstable or actively bleeding patient. In most other cases, removing the cause or treating the systemic disease will improve hemostasis. Emergency physicians treating patients with abnormal bleeding should understand the coagulation cascade and drug-induced coagulopathy from older and newer agents.

      Key words: bleeding time, coagulopathy, drug induced, hemostasis, megakaryocyte, mucosal bleeding, petechiae, platelet plug, platelet transfusion, platelets, thrombocytopenia

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    • 4

      Coagulopathies

      By Michael Levine, MD
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      Coagulopathies

      • MICHAEL LEVINE, MDDivision of Medical Toxicology, Department of Emergency Medicine, University of Southern California, Los Angeles, CA

      Coagulopathy can be caused by numerous hereditary or acquired etiologies. Although some of these conditions are known and the patient is aware of the bleeding disorder, other bleeding disorders are diagnosed only after the onset of excessive hemorrhage. This review discusses both hereditary and acquired disorders of coagulopathy. Platelet disorders are discussed elsewhere.

      Key words: Coagulopathies; Coagulopathy; Bleeding disorder; Hereditary bleeding disorder; Acquired bleeding disorder; von Willebrand disease; Hemophilia; Coagulation cascade; Hemorrhage; Anticoagulant-associated hemorrhage

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  • Infectious Diseases
    • 1

      Skin and Soft Tissue Infections

      By Daniel J. Pallin, MD, MPH
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      Skin and Soft Tissue Infections

      • DANIEL J. PALLIN, MD, MPHAssistant Professor of Emergency Medicine, Harvard Medical School, Director of Research, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

      The skin is the largest organ of the human body, and has diverse functions including protection from infection, temperature regulation, sensation, and immunologic and hormonal functions. Skin infections occur when the skin’s protective mechanisms fail. Some infections may be life-threatening (eg, necrotizing fasciitis) or may require the patient to be placed on contact precautions; thus, the initial goals of assessment of patients with skin and soft tissue infections are to assess the patient’s stability and to determine whether precautions are necessary to protect others. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for a variety of skin and soft tissue infections. Figures show an algorithm for treatment of bacterial infections of the skin, and photographs of  various infections including necrotizing fasciitis, cellulitis, an abscess caused by methicillin-resistant Staphylococcus aureus, a furuncle, a carbuncle, nonbullous and bullous impetigo, echythma, folliculitis, anthrax lesion, tinea corporis, condyloma acuminatum, and plantar warts. Tables list cellulitis treatment with particular exposures, the dermatophytoses, and yeast infections of skin and mucous membranes.

      This review contains 16 highly rendered figures, 3 tables, and 32 references.

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    • 2

      Lyme Disease and Other Spirochetal Zoonoses

      By Nahzinine Shakeri, MD; Sukhjit Takhar, MD
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      Lyme Disease and Other Spirochetal Zoonoses

      • NAHZININE SHAKERI, MDInstructor of Emergency Medicine, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL
      • SUKHJIT TAKHAR, MD Instructor in Medicine, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

      Spirochetal zoonoses are becoming more common worldwide. Lyme disease is a tick-borne spirochetal infection caused by the bacterium Borrelia burgdorferi and transmitted by the Ixodes tick. Lyme disease is the most common tick-borne infection in North America and Europe. Leptospirosis is a worldwide zoonosis caused by a pathogenic spirochete from the Leptospira genus and transmitted to humans by a variety of mammals. It is relatively uncommon outside of developing countries but is considered to be the most widespread zoonosis in the world. Relapsing fever, caused by spirochetes of the Borrelia genus, is a febrile illness characterized by recurrent episodes of fever and septicemia separated by afebrile periods. Rat bite fever is a systemic febrile illness that results from infection with Streptobacillus moniliformis in North America and Europe and with Spirillum minus in Asia. This review discusses the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of these four spirochetal zoonoses. The figures show the Ixodes tick; reported cases of Lyme disease by year, United States, 1995 to 2013; reported cases of Lyme disease, United States, 2013; erythema migrans; clinical manifestations of confirmed Lyme disease cases, United States, 2001 to 2010; cases of tick-borne relapsing fever, United States, 1990 to 2011; Ornithodoros hermsi tick; general timeline for tick-borne relapsing fever relapse intervals; and peripheral blood smear with spirochetes. The table lists Infectious Diseases Society of America oral treatment regimens for Lyme disease.

      This review contains 9 highly rendered figures, 1 table, and 79 references

      Key words: Lyme disease; Spirochetal zoonoses; Ixodes tick; Leptospirosis; Rat bite fever; Relapsing fever; Tick-borne infection

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    • 3

      Septic Arthritis and Osteomyelitis

      By Melissa Leber, MD, RDMS, RMSK
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      Septic Arthritis and Osteomyelitis

      • MELISSA LEBER, MD, RDMS, RMSKAssistant Professor, Department of Orthopedics, Assistant Professor and Director of Sports Medicine, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY

      Septic arthritis is an inflammatory condition within the joint in reaction to bacterial infection in the joint space. Emergent diagnosis and initiation of therapy are necessary to prevent joint destruction and, in some cases, serious systemic illness. This review covers the epidemiology, assessment and stabilization, diagnosis, treatment and disposition, and outcomes of septic arthritis. Figures show the pathophysiology of bone infection; an algorithm for the initial evaluation and management of a suspected septic joint; a magnetic resonance image of vertebral body osteomyelitis; a cutaneous sinus in a patient with underlying chronic posttraumatic osteomyelitis at the site of a previous tibial fracture; the probe-to-bone test for diagnosing osteomyelitis in the diabetic foot; an algorithm for the initial evaluation and management of suspected vertebral body osteomyelitis; nonsurgical treatment of osteomyelitis of the foot in a patient with diabetes; and algorithms for the evaluation and management of osteomyelitis in diabetic patients with neuropathic ulcers and no or mild foot infection, osteomyelitis in diabetic patients with neuropathic ulcers and moderate or severe foot infection, and chronic posttraumatic osteomyelitis. Tables list supportive findings for diagnosis of chronic osteomyelitis, risk factors for the development of septic arthritis in patients with underlying joint disease, microbiology in septic arthritis, empirical antibiotic therapy for septic arthritis, microbiology in vertebral osteomyelitis, antibiotic therapy for vertebral osteomyelitis awaiting culture results, representative studies with likelihood ratios for diagnostic tests used in the evaluation of native joint septic arthritis, antibiotic therapy for vertebral osteomyelitis with unknown or established microbiology, and antibiotic therapy for diabetic pedal osteomyelitis with unknown or established microbiology.

       

      Key words: osteomyelitis, probe-to-bone test, septic arthritis, septic joint, vertebral osteomyelitis

      This review contains 10 highly rendered figures, 9 tables, and 110 references.

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    • 4

      Sepsis

      By Michael R. Filbin, MD
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      Sepsis

      • MICHAEL R. FILBIN, MDAssistant Professor, Harvard Medical School, Department of emergency Medicine, Massachusetts General Hospital, Boston, MA

      Sepsis accounts for approximately one in three hospital deaths and is associated with very high health care costs due to prolonged lengths of stay in the intensive care unit and hospital. Sepsis is essentially an immunologic response to infection that is propagated systemically, leading to diffuse cellular and microcirculatory dysfunction, vasodilation, vital organ hypoperfusion, and eventual failure. This review covers the pathophysiology, stabilization/assessment, diagnosis, treatment, and disposition and outcomes of sepsis. Figures show the inflammatory and thrombotic response to infection, the action of nitric oxide on vascular smooth muscle cells, accelerated glycolysis and increased lactate production as a result of the catecholamine surge seen in septic shock, sepsis mortality associated with number of organ failures identified in the emergency department (ED), and protocolized therapy for septic shock. Tables list definitions of sepsis syndromes; frequently cited scoring systems for mortality prediction in ED patients with sepsis; Sequential Organ Failure Assessment (SOFA) score; current recommendations regarding treatment bundles at 3 and 6 hours of resuscitation; antibiotic recommendations based on suspected source; and vasopressors used in septic shock with recommended dosing, mechanism of action, and indications.

      This review contains 5 highly rendered figures, 6 tables, and 42 references.

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    • 5

      Viral Upper Respiratory Infection

      By James Creswell Simpson, MD; Kristin H. Dwyer, MD, MPH
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      Viral Upper Respiratory Infection

      • JAMES CRESWELL SIMPSON, MDResident Physician, Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
      • KRISTIN H. DWYER, MD, MPHBrigham and Women’s Hospital, Clinical Instructor, Department of Emergency Medicine, Boston, MA

      The upper respiratory tract includes the sinuses, nasal passages, pharynx, and larynx, and is susceptible to a variety of pathogens including many viruses.  Although other pathogens can also cause infections of the upper respiratory tract, we are focusing on viral illnesses for the purposes of this review.  Upper respiratory tract infections (URIs) include sinusitis, nasopharyngitis (common cold), pharyngitis, epiglottitis, and tracheitis.  URI’s are one of the most frequent causes for visits to see a physician in the United States. Despite the fact that many URIs are caused by viral pathogens, more than half of patients in both the clinic and the emergency department setting with a diagnosis of URI received antibiotics. URIs are generally mild, and self-limited illnesses; however, it is important to recognize clinical entities that may be severe and warrant more extensive diagnostic workup and treatment such as epiglottitis and tracheitis. This review covers the pathophysiology, diagnosis, treatment, disposition and outcome for multiple viral URIs seen commonly in the emergency department setting.

      Key words: Common cold, epiglottitis, nasopharyngitis, pharyngitis, sinusitis, tracheitis, upper respiratory tract infection

       

      This review contains 3 highly rendered figures, 2 tables, and 81 references.

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    • 6

      Central Nervous System Infections

      By Nicholas J. Johnson, MD; David F. Gaieski, MD
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      Central Nervous System Infections

      • NICHOLAS J. JOHNSON, MDFellow, Critical Care Medicine Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA
      • DAVID F. GAIESKI, MDAssociate Professor of Emergency Medicine, Vice chair, Resuscitative Services, Director, Emergency Critical Care, Thomas Jefferson University, Philadelphia, PA

      Infections of the central nervous system (CNS) are among the most devastating diseases that present to the emergency department (ED). Because of the great potential for morbidity, as well as the importance of prompt treatment, emergency physicians must remain vigilant of these diseases, which are also fraught with diagnostic challenges. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of CNS infections. Figures show causes of viral meningitis, an algorithm for the initial evaluation and management of patients with a suspected CNS infection, clinical manifestations of community-acquired meningitis in patients 16 years of age and older, assessment of nuchal rigidity, Kernig sign, and Brudzinski sign for meningeal irritation, proper positioning of the patient for lumbar puncture, and a sagittal view of the lumbar puncture needle as it is advanced into the subarachnoid space. Tables list CNS pathogens based on predisposing and associated conditions, cerebrospinal fluid diagnostic studies for meningitis, adult patients who should receive computed tomography prior to lumbar puncture, classic cerebrospinal fluid characteristics in meningitis, empirical therapy for bacterial meningitis based on predisposing and associated conditions, recommended doses for antibiotics commonly used in the treatment of bacterial meningitis, and antimicrobial therapy for selected CNS infections.

       

      This review contains 8 highly rendered figures, 7 tables, and 94 references

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  • Nephrology/urology
    • 1

      Acute Kidney Injury

      By Lee Grodin, MD; Joshua McHugh, MD; Richard Sinert, DO
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      Acute Kidney Injury

      • LEE GRODIN, MDClinical Instructor, Department of Emergency Medicine, State University of New York Downstate Medical
      • JOSHUA MCHUGH, MDClinical Instructor, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, NY
      • RICHARD SINERT, DOProfessor and Vice-Chairman in Charge of Research, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, NY

      Acute kidney injury (AKI) is defined as a syndrome in which there is an abrupt (hours to days) absolute increase in serum creatinine (SCr) of 0.5 mg/dL or a 25% increase from baseline. Even a modest rise in SCr of 0.3 mg/dL during hospitalization is associated with increased mortality and morbidity. Because of difficulties using SCr as a determinant of AKI, a variety of serum (neutrophil gelatinase–associated lipocalin, interleukin-18) and urine (kidney injury molecule–1) biomarkers of AKI are currently undergoing intense investigation. AKI may be defined pathophysiologically, as a decrease in renal blood flow (prerenal), or an intrinsic renal parenchymal disease (renal), or obstruction of urine flow (postrenal). Indications for emergent dialysis include hyperkalemia, fluid overload, acidosis, and signs and symptoms of uremia. If AKI is diagnosed in the emergency department, the patient should be admitted for further workup. In the majority of patients who survive AKI, renal function essentially returns to normal.
       

      Key words: acute kidney injury, dialysis, hyperkalemia, serum creatinine

      This review contains 3 highly rendered figures, 11 tables, and 49 references.

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    • 2

      Nephrolithiasis

      By Peregrine Dalziel, MD; Nicholas Schirmer, MD
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      Nephrolithiasis

      • PEREGRINE DALZIEL, MDResident in Emergency Medicine, Department of Emergency Medicine, George Washington University Hospital, Washington, DC
      • NICHOLAS SCHIRMER, MDEmergency Physician, Department of Emergency Medicine, McGill University Health Centre, Montreal, Quebec

      The term nephrolithiasis, often used synonymously with urolithiasis, refers to the formation of solid concretions consisting of both protein and crystalline materials in the lumen of the urinary tract. These calculi, or “stones,” become symptomatic when they cause acute obstruction, and as such, there are an unknown but probably large number of individuals with nephrolithiasis who are subclinical, without signs or symptoms. This review covers the pathophysiology, stabilization and assessment, diagnosis, and treatment of nephrolithiasis. Figures show ultrasound images of a stone with shadowing, a stone with a twinkling artifact, hydronephrosis, and a stone with shadowing at the ureterovesicular junction and a computed tomographic (CT) image showing a renal calculus at the ureterovesicular junction. Tables list drug-induced renal calculi, the proportion of stones spontaneously passing depending on size category as identified on CT, diagnostic test characteristics for renal colic diagnosis, the clinical prediction rule for the risk of renal stones, an example of the theoretical probability of stone disease using Moore and colleagues’ risk stratification, pooled test characteristics, bayesian analysis, and important pathology diagnosed on CT scan in the investigation of flank pain in four studies.

       

      Key words: kidney stone, nephrolithiasis, renal calculus, renal stone, urolithiasis

      This review contains 5 highly rendered figures, 6 tables, and 75 references.

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    • 3

      Approach to Male Urologic Emergencies

      By Jonathan E. Davis, MD, FACEP, FAAEM; Jeffrey S. Dubin, MD, MBA
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      Approach to Male Urologic Emergencies

      • JONATHAN E. DAVIS, MD, FACEP, FAAEMProgram Director, Emergency Medicine Residency, Department of Emergency Medicine, Associate Professor of Emergency Medicine, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Georgetown University School of Medicine, Washington, DC
      • JEFFREY S. DUBIN, MD, MBAVice Chair, Department of Emergency Medicine, Associate Professor of Clinical Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC

      This review details the evaluation and management of the acute scrotum in the emergency department setting and emergent penile complaints in adults, with an emphasis on the most serious and most common conditions. Other emergent conditions include necrotizing fasciitis of the perineum (Fournier disease), incarcerated or strangulated inguinal hernia, and genitourinary (GU) trauma. Emergency practitioners need to be most concerned with the entities that, if left untreated, can result in ischemia and necrosis of the penis. Basic anatomy and bedside evaluation are reviewed. Acute scrotal and penile pain and GU trauma are discussed in terms of assessment and stabilization, diagnosis, and treatment and disposition. Tables describe the differential diagnosis of scrotal pain; differentiating characteristics of testicular torsion, epididymitis, and appendage torsion; selected etiologies of ischemic (low-flow) priapism; stepwise treatment of priapism; GU trauma; and priority actions for GU emergencies. Figures depict scrotal and penile anatomy, a testicular Doppler sonogram, cremasteric reflex, and paraphimosis reduction.

      This review contains 5 highly rendered figures, 6 tables, and 91 references.

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    • 4

      Urologic Infections

      By Tatyana Vayngortin, MD; Nisa S Atigapramoj, MD
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      Urologic Infections

      • TATYANA VAYNGORTIN, MDPediatric Emergency Medicine Fellow, Department of Emergency Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, CA
      • NISA S ATIGAPRAMOJ, MDAssistant Clinical Professor of Pediatrics and Emergency Medicine, Department of Emergency Medicine, UCSF Benioff Children’s Hospital, San Francisco, CA

      Urinary tract infections (UTIs) affect people of all ages. Although the incidence of invasive bacterial diseases continues to decline, the prevalence of UTIs in febrile pediatric patients continues to remain a focus for serious bacterial infection in this population. In older age groups, symptoms become more obvious and present more classically. Clinical practice guidelines have been developed because morbidity can be dependent upon the rapid identification of a UTI with prompt initiation of appropriate antimicrobials. This review provides a summary for the evaluation of UTIs with discussion of diagnosis and management. 

      This review contains 6 figures, 5 tables and 47 references

      Key words: antibiotics, cystitis, pyelonephritis, urinary tract infection, uropathogens

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  • Women's Health and Gynecologic Emergencies
    • 1

      Pregnancy-related Emergencies

      By Amy Hideko Kaji, MD, PhD
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      Pregnancy-related Emergencies

      • AMY HIDEKO KAJI, MD, PHDAssociate Clinical Professor, Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA

      This review provides an overview of spontaneous abortion, ectopic pregnancy, gestational trophoblastic disease or molar pregnancy, hyperemesis gravidarum, placental abruption, placental previa, hypertensive disorders of pregnancy, and amniotic fluid embolism. Assessment and stabilization, diagnosis, treatment and disposition, and outcomes are discussed. Tables include classifications of abortion or miscarriage, differential diagnosis of patients presenting with vaginal bleeding during pregnancy, risk factors for ectopic pregnancy, treatment modalities for hyperemesis gravidarum, classification of hypertensive disorders of pregnancy, and risk factors for preeclampsia and eclampsia. Figures show ectopic pregnancy on a sonogram, free fluid in hepatorenal fossa on a focused abdominal sonogram in trauma, double decidual sign in a normal intrauterine pregnancy, pseudogestational sac in an ectopic pregnancy, and “snowstorm” appearance of molar pregnancy on a sonogram.

      This review contains 5 highly rendered figures, 6 tables, and 61 references.

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    • 2

      Gynecologic Emergencies in the Nonpregnant Patient

      By Nadia Huancahuari, MD; Alissa Genthon, MD
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      Gynecologic Emergencies in the Nonpregnant Patient

      • NADIA HUANCAHUARI, MDInstructor, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
      • ALISSA GENTHON, MDCritical Care Fellow, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

      Nonpregnant patients with gynecologic emergencies often present with pelvic pain that may or may not be unilateral. Many gynecologic emergencies are associated with high morbidity and, occasionally, mortality if left untreated. This review examines the assessment and stabilization, diagnosis, and treatment and disposition of patients with various gynecologic emergencies, including ovarian torsion, cervicitis, pelvic inflammatory disease, uterine fibroids, endometriosis, dysfunctional uterine bleeding, Bartholin cysts, and vulvovaginitis. Figures show an algorithm of gynecologic emergencies, a longitudinal sonogram and a computed tomography (CT) scan showing ovarian torsion, a CT scan and sonogram of  a tubo-ovarian abscess, and illustrations of a Bartholin cyst and a Word catheter. Tables list risk factors for ovarian torsion, criteria for the clinical diagnosis of pelvic inflammatory disease in high-risk patients, 2010 Centers for Disease Control and Prevention (CDC) sexually transmitted diseases treatment guidelines, anovulatory and ovulatory causes of dysfunctional uterine bleeding, and 2010 CDC recommendations for the treatment of vulvovaginitis.

      This review contains 7 highly rendered figures, 5 tables, and 77 references.

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  • Societal and Psychiatric Conditions
    • 1

      Sexual Assault: Acute Care and Beyond

      By Judith Linden, MD; Emily I Gorman, MD
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      Sexual Assault: Acute Care and Beyond

      • JUDITH LINDEN, MDAssociate Professor and Vice Chair for Education, Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
      • EMILY I GORMAN, MDDepartment of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA

      Sexual assault, which encompasses any nonconsensual sexual contact, is, unfortunately, common. It results in considerable costs to society, including intangible costs such as loss of quality of life among victims. This review covers the approach to the patient and definitive treatment, disposition, and outcomes for adult and adolescent victims of sexual assault. Figures show female anatomy and common areas for genital injury after rape, a Centers for Disease Control and Prevention algorithm for evaluation of possible nonoccupational HIV exposures and nonoccupational post-exposure prophylaxis, a questionnaire for determining additional key aspects of the history of the assault to be completed and explored in detail by the sexual assault examiner, and the components and steps of the Massachusetts Sexual Assault Evidence Collection Kit. Tables list characteristics that define rape, key aspects of the history, recommended treatment to prevent sexually transmitted infections and pregnancy, calculated risks of acquiring HIV from an isolated sexual contact with a known HIV-positive person, and trauma-informed care.

      This review contains 5 highly rendered figures, 5 tables, 95 references, and a list of helpful Web sites.

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    • 2

      Intimate Partner Violence

      By Wendy Macias-Konstantopoulos, MD, MPH
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      Intimate Partner Violence

      • WENDY MACIAS-KONSTANTOPOULOS, MD, MPHAssistant Professor, Department of Emergency Medicine, Harvard Medical School; and Assistant Physician, Emergency Department, Massachusetts General Hospital, Boston, MA

      Intimate partner violence (IPV) includes physical violence, sexual violence, threats of violence, and psychological abuse. It is a pervasive issue that often remains hidden; in fact, psychological abuse may not be perceived as abusive behavior by the victim. IPV may lead to the death of the victim by homicide or suicide. The health care provider has a unique opportunity to identify IPV, and a high level of vigilance should be maintained. This review examines the epidemiology of IPV, the approach to the patient, and definitive treatment, disposition, and outcomes. Figures show the prevalence of IPV in the United States, the Abuse Assessment Screen-Disability for assessing abuse in women with disabilities, and batterer intervention programs. Tables list four commonly used IPV screening instruments, information required to assess the danger in any IPV situation, and questions used to predict the outcome of female emergency department patients.

      This review contains 3 highly rendered figures, 3 tables, and 95 references.

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    • 3

      Integrating Principles and Practice of Palliative Medicine in Emergency Care

      By Patricia J. O’Malley, MD
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      Integrating Principles and Practice of Palliative Medicine in Emergency Care

      • PATRICIA J. O’MALLEY, MDMedical Director, Pediatric Palliative Care, Massachusetts General Hospital for Children, Assistant Professor, Pediatrics Harvard Medical School, Boston, MA

      Trajectories of serious illness and dying have changed in the last century; people now live longer, often with prolonged debility in advanced stages of illness. With more options for aggressive interventions at the end of life, patients and families face increasingly complex medical decisions. Many of these patients will present repeatedly to the emergency department (ED) before their death, and emerging evidence suggests that integrating palliative care into the treatment of advanced illness, including in the emergency setting, can improve outcomes. This review covers changing trajectories of illness and death, palliative care as a medical specialty, emerging models of integration, essential palliative care competencies for the ED clinician, and managing the actively dying patient in the ED. Figures show palliative care through the trajectory of serious illness, theoretical trajectories of disease, life expectancies for women and men, and patient-centered communication. Tables list philosophy of palliative care, domains of suffering addressed by palliative care, palliative performance scale, NURSE mnemonic for accepting and responding to emotion, palliative care communication competencies in the intensive care unit: effect on clinical outcomes and family satisfaction, and SPIKES mnemonic for breaking bad news.

       

      This review contains 4 highly rendered figures, 6 tables, and 113 references

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    • 4

      Mistreatment of Elders

      By Emily I Gorman, MD; Judith Linden, MD
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      Mistreatment of Elders

      • EMILY I GORMAN, MDDepartment of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA
      • JUDITH LINDEN, MDAssociate Professor and Vice Chair for Education, Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA

      Elder mistreatment affects a considerable proportion of individuals older than 60 to 65 years of age and may include intentional abuse (physical, sexual, emotional, or financial) and neglect. As the proportion of the population that is older than 65 years of age increases, elder mistreatment will become an increasingly common issue. Only a minority of cases of elder abuse are reported; thus, an interview with the patient should be conducted in private if elder mistreatment is suspected. Patient risk factors for elder mistreatment include cognitive or behavioral impairment, poor physical health, and poor social supports. This review examines the approach to the patient, as well as definitive treatment, disposition, and outcomes for victims of elder abuse. The figure shows an algorithm for elder abuse assessment and intervention. Tables list types of elder abuse, factors predisposing to elder mistreatment, indicators of abuse, and the Elder Abuse Suspicion Index.

      This review contains 1 highly rendered figure, 4 tables, and 42 references.

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    • 5

      The Suicidal Patient

      By Jessica Brooks, MD; David Gitlin, MD
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      The Suicidal Patient

      • JESSICA BROOKS, MDInstructor of Emergency Medicine, Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
      • DAVID GITLIN, MDVice Chair for Clinical Programs, Chief Division of Medical Psychiatry, Department of Psychiatry, Brigham and Women's Hospital, Boston, MA

      Suicidal ideation is a common psychiatric emergency seen across a broad range of patients. Although admission to a dedicated psychiatric unit is preferable, patients with suicidal ideation are often admitted to internal medicine or family medicine services, either for management of comorbid medical conditions or because of a lack of available psychiatry beds. Primary care physicians and emergency physicians are particularly likely to encounter suicidal patients, given their high clinical volume and the relatively high prevalence of suicidality in their community of patients. In addition, many patients who present with nonpsychiatric complaints will also have concurrent suicidal ideation. This review discusses the approach to the patient, and definitive treatment, disposition, and outcomes. Figures show suicide in 2010 was the 10th leading cause of death in the United States, accounting for 38,364 deaths, men are more likely to use firearms and hanging, while women are more likely to attempt suicide by poisoning, and suicide is more common in whites and Native Americans compared to Hispanics or Asians. Tables list risk factors for suicide, and warning signs for suicide.

      Keywords: Suicidal ideation, suicide risk, intervention, suicidal management, mental health, suicidal presentation

      This review contains 3 highly rendered figures, 2 tables, and 61 references.

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    • 6

      Acute Psychosis

      By James Kimo Takayesu, MD, MS; Suzanne Bird, MD
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      Acute Psychosis

      • JAMES KIMO TAKAYESU, MD, MSAssistant Residency Director, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
      • SUZANNE BIRD, MDAcute Psychiatric Service, Massachusetts General Hospital, Boston, MA

      Acute psychosis can be a true emergency, and the primary goal in the evaluation of an acutely psychotic patient should be to maintain safety and prevent harm to the patient and staff. The defining symptoms of psychosis include hallucinations, delusions, disorganized thought or speech, abnormal motor behavior, and negative symptoms. This review covers the approach to the patient, and definitive treatment, disposition and outcomes for patients experiencing acute psychosis. The figure shows an interview setting in a triangular arrangement, allowing for safe egress. Tables list goals in the evaluation of the acutely psychotic patient; causes of secondary psychosis; common medication classes causing mental status change; four key questions for assessing psychotic behavior; screening assessment for psychosis; clinical features of dementia, delirium, and psychiatric illness; brief mental status examination; common medications for the treatment of acute psychosis and chemical sedation; QT-prolonging effects of commonly used antipsychotic medications; and documentation required in the use of chemical and/or physical restraints.

      This review contains 1 highly rendered figure, 10 tables, and 57 references.

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    • 7

      Panic Attacks and Anxiety Disorders

      By Curtis Wittmann, MD
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      Panic Attacks and Anxiety Disorders

      • CURTIS WITTMANN, MDAssociate Director, Acute Psychiatry Service, Massachusetts General Hospital Instructor in Psychiatry, Harvard Medical School, Boston, MA

      This review discusses the acute diagnosis and management of panic and anxiety disorders. Anxiety disorders are among the most common psychiatric disorders in the country and are a relatively common cause of presentation to the emergency department. Most anxiety disorders can be conceptualized as fear- or phobia-based disorders, including panic disorder, specific phobia, social phobia, acute stress disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. Each of these disorders is discussed, including prevalence and common clinical presentations. The initial evaluation of patients with a suspected or diagnosed anxiety disorder will be based on their current symptoms. Some patients may be highly agitated and may require deescalation or sedation to perform a reasonable history and physical examination. To achieve this, providers should ensure their own safety first, with attention to the physical layout of the emergency department, ensuring that they are closer to the room exit than the patient (so that they cannot be trapped). The presence of police or security may be necessary to provide optimal care and an appropriate evaluation. Typical treatment of acute exacerbations of anxiety disorders includes medical management, most often benzodiazepines, which can provide immediate relief. Psychiatric consultation may be necessary in certain cases. For most patients, outpatient management rather than inpatient admission will lead to the most effective management of their anxiety.

       

      Key words: anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, stress disorder

      This review contains 1 highly rendered figure, 15 tables, and 27 references.

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    • 8

      Human Trafficking 1: Epidemiology

      By Wendy Macias-Konstantopoulos, MD, MPH
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      Human Trafficking 1: Epidemiology

      • WENDY MACIAS-KONSTANTOPOULOS, MD, MPHAssistant Professor, Department of Emergency Medicine, Harvard Medical School; and Assistant Physician, Emergency Department, Massachusetts General Hospital, Boston, MA

      Trafficking in persons, or human trafficking, is the obtaining of persons by force, fraud, coercion, or other improper means, with the intention of exploiting them for financial gain. According to the US Department of State, the more prominent global forms of human trafficking include forced labor, bonded labor (or debt bondage), forced commercial sexual exploitation (or sex trafficking), involuntary domestic servitude, forced child labor, child sex trafficking, child soldiering, and organ trafficking. In the United States, the forced exploitation of persons in the labor industry (i.e., labor trafficking) and in the commercial sex industry (i.e., sex trafficking) account for the majority of human trafficking cases recognized, reported, investigated, and prosecuted. Women and girls account for 55% (11.4 million) of the global trafficked population, whereas men and boys comprise the difference. Three quarters of trafficked persons are adults, whereas children younger than 18 years represent 26% (5.5 million) of victims. Risk factors that have been associated with increased risk of human trafficking include but are not limited to a childhood history of abuse and neglect; financial insecurity; housing instability associated with homelessness, running away, or being thrown out of the home; kinship placements with distant family members, foster care, and other residential placements; intellectual and learning disabilities; identification as lesbian, gay, bisexual, transgender, and questioning (LGBTQ); racial and ethnic minority status; status as an immigrant, migrant worker, and refugee; and involvement in gangs or illicit substance use. Due to the inherently abusive and violent nature of this crime, human trafficking has profound negative implications for the health and well-being of affected persons.

      This review contains 2 figures, 4 tables and 53 references

      Key words: commercial sexual exploitation, debt bondage, domestic servitude, forced labor, forced substance use, HIV, modern-day slavery, posttraumatic stress disorder, trafficking in persons 

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    • 9

      Human Trafficking 2: Approach to the Patient

      By Wendy Macias-Konstantopoulos, MD, MPH
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      Human Trafficking 2: Approach to the Patient

      • WENDY MACIAS-KONSTANTOPOULOS, MD, MPHAssistant Professor, Department of Emergency Medicine, Harvard Medical School; and Assistant Physician, Emergency Department, Massachusetts General Hospital, Boston, MA

      Trafficking survivors most commonly cite the emergency department (ED) as their health care access point while previously trafficked. A majority of trafficking survivors surveyed report accessing medical care at least once while trafficked. ED physicians should adhere to guiding principles of care, keeping in mind at all times the need for patient privacy and the use of paced evaluations and neutral language. It is incumbent upon ED physicians to recognize both the clinician-related barriers to helping trafficked patients (which may include an underappreciation of the relevance of trafficking to clinical practice and a lack of education and training) and patient-related barriers (which range from restriction and confinement by their abuser to the patient’s own shame, guilt, and self-blame; distrust of authorities; and fear). Once the trafficked patient presents to the ED, the physician should acknowledge that the identification of at-risk and trafficked patients can be the first step toward prevention and assistance, respectively. No singular or defined set of diagnostic signs or symptoms has been shown to cut across all forms of trafficking with any degree of sensitivity or specificity, but familiarity with the potential indicators of human trafficking can help the emergency provider recognize patterns and raise the suspicion of trafficking. If a clinician suspects that a patient might be trafficked, the clinician should engage the patient in a trauma-informed and culturally sensitive assessment.

      This review contains 2 tables and 34 references

      Key words: commercial sexual exploitation, debt bondage, domestic servitude, forced labor, forced substance use, HIV, modern-day slavery, neutral language, patient privacy, posttraumatic stress disorder, trafficking in persons  

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    • 10

      Human Trafficking 3: Intervention and Therapy

      By Wendy Macias-Konstantopoulos, MD, MPH
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      Human Trafficking 3: Intervention and Therapy

      • WENDY MACIAS-KONSTANTOPOULOS, MD, MPHAssistant Professor, Department of Emergency Medicine, Harvard Medical School; and Assistant Physician, Emergency Department, Massachusetts General Hospital, Boston, MA

      Emergency department (ED) physicians must familiarize themselves with all mandatory reporting laws that apply to those whom they suspect of being the victims of human trafficking. Furthermore, ED physicians must be aware of when to require a forensic evaluation and when to enlist social services to help with the process of documentation, keeping in mind the medical, legal, and safety considerations of the patient. Subspecialty consultation should proceed in accordance with typical practice. Following the identification of a trafficked patient, a comprehensive interdisciplinary response should ensue: in addition to social workers, other hospital-based health professionals whose knowledge and skills may be needed include addiction service providers, child protection specialists, forensic and sexual assault nurse examiners, mental health providers, case managers, hospital legal counsel, and risk management specialists. Despite ED physician and related professional intervention, little is known regarding the outcomes of human trafficking.

      This review contains 1 figure, 3 tables and 13 references

      Key words: forensic evaluation, mandatory reporting laws, medical record documentation, neutral language, reported human trafficking, suspected human trafficking, trafficking in persons  

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  • Genitourinary Problems
    • 1

      Approach to Male Urologic Emergencies

      By Jonathan E. Davis, MD, FACEP, FAAEM; Jeffrey S. Dubin, MD, MBA
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      Approach to Male Urologic Emergencies

      • JONATHAN E. DAVIS, MD, FACEP, FAAEMProgram Director, Emergency Medicine Residency, Department of Emergency Medicine, Associate Professor of Emergency Medicine, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Georgetown University School of Medicine, Washington, DC
      • JEFFREY S. DUBIN, MD, MBAVice Chair, Department of Emergency Medicine, Associate Professor of Clinical Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC

      This review details the evaluation and management of the acute scrotum in the emergency department setting and emergent penile complaints in adults, with an emphasis on the most serious and most common conditions. Other emergent conditions include necrotizing fasciitis of the perineum (Fournier disease), incarcerated or strangulated inguinal hernia, and genitourinary (GU) trauma. Emergency practitioners need to be most concerned with the entities that, if left untreated, can result in ischemia and necrosis of the penis. Basic anatomy and bedside evaluation are reviewed. Acute scrotal and penile pain and GU trauma are discussed in terms of assessment and stabilization, diagnosis, and treatment and disposition. Tables describe the differential diagnosis of scrotal pain; differentiating characteristics of testicular torsion, epididymitis, and appendage torsion; selected etiologies of ischemic (low-flow) priapism; stepwise treatment of priapism; GU trauma; and priority actions for GU emergencies. Figures depict scrotal and penile anatomy, a testicular Doppler sonogram, cremasteric reflex, and paraphimosis reduction.

      This review contains 5 highly rendered figures, 6 tables, and 91 references.

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    • 2

      Pregnancy-related Emergencies

      By Amy Hideko Kaji, MD, PhD
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      Pregnancy-related Emergencies

      • AMY HIDEKO KAJI, MD, PHDAssociate Clinical Professor, Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA

      This review provides an overview of spontaneous abortion, ectopic pregnancy, gestational trophoblastic disease or molar pregnancy, hyperemesis gravidarum, placental abruption, placental previa, hypertensive disorders of pregnancy, and amniotic fluid embolism. Assessment and stabilization, diagnosis, treatment and disposition, and outcomes are discussed. Tables include classifications of abortion or miscarriage, differential diagnosis of patients presenting with vaginal bleeding during pregnancy, risk factors for ectopic pregnancy, treatment modalities for hyperemesis gravidarum, classification of hypertensive disorders of pregnancy, and risk factors for preeclampsia and eclampsia. Figures show ectopic pregnancy on a sonogram, free fluid in hepatorenal fossa on a focused abdominal sonogram in trauma, double decidual sign in a normal intrauterine pregnancy, pseudogestational sac in an ectopic pregnancy, and “snowstorm” appearance of molar pregnancy on a sonogram.

      This review contains 5 highly rendered figures, 6 tables, and 61 references.

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  • General Medicine
    • 1

      On Being A Physician

      By Elizabeth G Nabel, MD, FACP
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      On Being A Physician

      • ELIZABETH G NABEL, MD, FACPPresident, Brigham and Women’s Hospital, Professor of Medicine, Harvard Medical School, Boston, MA

      The role of a physician as healer has grown more complex, and emphasis will increasingly be on patient and family-centric care. Physicians must provide compassionate, appropriate, and effective patient care by demonstrating competence in the attributes that are essential to successful medical practice. Beyond simply gaining medical knowledge, modern physicians embrace lifelong learning and need effective interpersonal and communication skills. Medical professionalism encompasses multiple attributes, and physicians are increasingly becoming part of a larger health care team. To ensure that physicians are trained in an environment that fosters innovation and alleviates administrative burdens, the Accreditation Council for Graduate Medical Education has recently revamped the standards of accreditation for today’s more than 130 specialties and subspecialties.

      This review contains six references.

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    • 2

      Ethical and Social Issues in Medicine

      By Roberta Springer Loewy, PhD (PHIL, ETHICS); Erich H. Loewy, MD, FACP (deceased); Faith T. Fitzgerald, MD, MACP
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      Ethical and Social Issues in Medicine

      • ROBERTA SPRINGER LOEWY, PHD (PHIL, ETHICS)Professor and Bioethics Education Consultant, VCF, University of California, Davis, Sacramento, CA
      • ERICH H. LOEWY, MD, FACP (DECEASED)Professor and Founding Chair of the Bioethics Program (Emeritus), University of California, Davis, Sacramento, CA
      • FAITH T. FITZGERALD, MD, MACPProfessor of Internal Medicine, University of California, Davis, Sacramento, CA

      So rapidly has the field of health care ethics continued to grow that, when recently “googled,” the term produced 28.2 million hits. The challenge is to address the ethical and social issues in medicine in this very limited article space. It remains an impossible task to present more than a superficial discussion of these complex issues and the complicated cases in which they are to be found. Like good medicine, good ethics cannot be practiced by algorithm. The authors have opted to provide an operational guide to help clinicians sort through the ethical and social quandaries they must face on a daily basis. To that end, the authors have chosen to divide this chapter into the following sections:
      1. A brief description of the biopsychosocial nature of ethics and how it differs from personal morality
      2. A method for identifying and dealing with ethical issues
      3. A discussion of the role of bioethicists and ethics committees 
      4. The professional fiduciary role of clinicians
      5. Listings of some of the common key bioethical and legal terms (online access only)
      6. A very brief discussion of the terms cited in the above listings (online access only)

      This reviews contains 2 tables (common bioethical concepts and legal concepts), 6 references, 1 appendix, and 24 additional readings.

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    • 3

      Practicing Evidence-based Medicine

      By Michael Barnett, MD; Niteesh Choudhry, MD, PhD
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      Practicing Evidence-based Medicine

      • MICHAEL BARNETT, MDFellow in General Internal Medicine, Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
      • NITEESH CHOUDHRY, MD, PHDAssociate Professor, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

      Today, a plethora of resources for evidence-based medicine (EBM) are available via alert services, compendia, and more. In theory, a clinician researching a topic or looking for information regarding a clinical decision should easily find the literature or synopses needed. However, the real challenge lies in recognizing which resources (out of hundreds or possibly thousands) present the best and most reliable evidence. As well, evidence from research is only part of the decision calculus, and the clinician, not the evidence, makes the final decisions. Medical decision analysis attempts to formalize the process and reduce it to algebra, but it is difficult or impossible to represent all the components of a decision mathematically and validly let alone do so in “real time” for individual patients. This review discusses these challenges and more, including how to ask answerable questions, understand the hierarchy for evidence-based information resources, critically appraise evidence, and apply research results to patient care. Figures show the total number of new articles in Medline from 1965 to 2012, a “4S” hierarchy of preappraised medicine, percentage of physician and medical student respondents with a correct or incorrect answer to a question about calculating the positive predictive value of a hypothetical screening test, a nomogram for Bayes’s rule, an example of nomogram use for pulmonary embolism, and a model for evidence-informed clinical decisions. Tables list selected barriers to the implementation of EBM; Patient, Intervention, Comparison, and Outcome (PICO) framework for formulating clinical questions; guides for assessing medical texts for evidence-based features; clinically useful measures of disease frequency and statistical significance and precision; definitions of clinically useful measures of diagnostic test performance and interpretation; definitions of clinically useful measures of treatment effects from clinical trials; summary of results and derived calculations from the North American Symptomatic Carotid Endarterectomy Trial (NASCET); and selected number needed to treat values for common therapies.

      This review contains 6 highly rendered figures, 9 tables, and 28 references.

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    • 4

      Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

      By Allen Kachalia, MD, JD; Sonali P. Desai, MD, MPH
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      Quality of Care: Performance Measurement and Quality Improvement in Clinical Practice

      • ALLEN KACHALIA, MD, JDAssociate Chief Quality Officer, Co-Director, Center for Clinical Excellence, Brigham and Women's Hospital, Boston, MA
      • SONALI P. DESAI, MD, MPHAmbulatory Director, Patient Safety, Center for Clinical Excellence, Associate Director of Quality, Department of Medicine, Division of Rheumatology, Brigham and Women's Hospital, Boston, MA

      Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement.

      This review contains 1 highly rendered figure, 3 tables, and 56 references.

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  • Pediatric Emergency Medicine
    • 1

      Pediatric Respiratory Illness

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      Pediatric Respiratory Illness

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    • 2

      Pediatric Fever

      By Clifford C. Ellingson, MD; Dale P. Woolridge, MD, PhD
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      Pediatric Fever

      • CLIFFORD C. ELLINGSON, MDDepartment of Pediatric and Emergency Medicine, University of Arizona and Banner University Medical Center, Tucson, AZ
      • DALE P. WOOLRIDGE, MD, PHDProfessor, Department of Pediatric and Emergency Medicine, University of Arizona, Tucson, AZ

      Fever is one of the most common chief complaints among pediatric emergency departments. The evaluation and approach to a pediatric fever can be challenging. Although most cases of fever are viral in origin, the potential for a deadly bacterial infection would make even the most seasoned practitioner attentive. This review discusses the initial assessment of the pediatric patient and both necessary and recommended workups for pediatric fevers among various age groups. Common infections of bacterial and viral causes for fever are discussed and treatment recommendations offered. 

      Key words: Pediatric fever, otitis media, pneumonia, urinary tract infection, neonatal sepsis, bacteremia, meningitis, serious bacterial infection, viral illness.

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    • 3

      Pediatric Rashes

      By Summer Stears-Ellis, MD
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      Pediatric Rashes

      • SUMMER STEARS-ELLIS, MDClinical Instructor, Emergency Ultrasound Fellow, Department of Emergency Medicine, The University of Arizona, Tucson, AZ

      Pediatric rashes are a common chief complaint in the emergency department (ED) and a source of anxiety for both parents and providers. Many of these rashes will not require intervention aside from symptomatic relief and parental reassurance. However, there is a subset of rashes that are the result of underlying life-threatening conditions that will warrant immediate intervention and treatment to prevent further deterioration and possible death. This review focuses on outlining the pathology of seven potentially deadly pediatric rashes that ED physicians are likely to encounter, how they present, and how to treat and manage them according to the most recent available guidelines. Figures show primary lesions, pattern of lesions, and distribution of rash associated with bacterial meningitis, toxic shock syndrome (TSS), Rocky Mountain spotted fever, Stevens-Johnson syndrome/toxic epidermal necrolysis, erythema multiforme minor and major, necrotizing fasciitis, and Henoch-Schönlein purpura. Tables list bacterial meningitis antibiotic treatment, Centers for Disease Control and Prevention clinical and laboratory criteria for TSS, TSS antibiotic treatment regimens, scoring systems for toxic epidermal necrolysis and necrotizing fasciitis, and the latest guidelines as of June 2017.

      This review contains 9 figures, 6 tables, and 50 references.

      Key words: Pediatric rash, toxic shock syndrome, skin rash, rash distribution, Rocky Mountain spotted fever, Stevens-Johnson syndrome, toxic epidermal necrolysis,  necrotizing fasciitis, Henoch-Schönlein purpura

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    • 4

      Pediatric Minor Head Injury and Concussion

      By Chad Scarboro, MD; Simone Lawson, MD
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      Pediatric Minor Head Injury and Concussion

      • CHAD SCARBORO, MDAssistant Professor, Department of Emergency Medicine/Pediatric Emergency Medicine, Carolinas Medical Center, Charlotte, NC
      • SIMONE LAWSON, MDPediatric Emergency Medicine Fellow, Department of Emergency Medicine/Pediatric Emergency Medicine, Carolinas Medical Center, Charlotte, NC

      Head injury is one of the most common reasons children present to the emergency department (ED) and the leading cause of pediatric death and disability. Head injuries can range from having no neurologic deficits to death. Management in the ED centers on determining if there is a serious brain injury and preventing secondary brain injury. In most cases of mild traumatic brain injury, serious injuries can be ruled out based on the history of the injury, associated symptoms, and clinical assessment. Concussion is a common presentation of head injury and encompasses a wide range of symptoms. Computed tomography should be used judiciously, and extensive research has led to algorithms to aid in this decision. Prior to discharge from the ED, parents will often have questions about when their child may resume normal activity. This is a decision that most often will involve the patient’s primary care provider or a concussion specialist as the ED provider is unable to follow progression or resolution of symptoms. However, the ED provider should be able to provide anticipatory guidance.

       

      Key words: computed tomography, concussion, head injury, mild traumatic brain injury, traumatic brain injury

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    • 5

      Pediatric Trauma

      By Kathleen Bryant, MD; Jeremiah Smith, MD; Michael Gibbs, MD
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      Pediatric Trauma

      • KATHLEEN BRYANT, MDPediatric Emergency Fellow, Department of Emergency Medicine, Levine Children’s Hospital, Carolinas Medical Center, Charlotte, NC
      • JEREMIAH SMITH, MDAssistant Professor, Department of Emergency Medicine, Greenville Memorial Hospital, Greenville Health System, Greenville, SC
      • MICHAEL GIBBS, MDProfessor and Chair, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC

      Children have unique anatomy and physiologic responses to trauma that create different challenges for their management. It is important to follow the Advanced Trauma Life Support (ATLS) algorithm for assessing and treating a pediatric trauma patient, paying close attention to the primary survey. Once the primary survey is accomplished with adequate stabilization, the secondary survey proceeds with a focus on specific injuries. Head trauma is the leading cause of morbidity and mortality (M+M) in children. Early identification and prevention of secondary injury are important to optimize outcomes. The head and neck anatomic differences in a child cause a higher fulcrum of their cervical spine, leading to higher cervical spine injuries (CSIs). CSI is rare but carries a higher M+M due to higher spinal cord injuries. The National Emergency X-radiography Utilization Study (NEXUS) and Canadian C-spine Rule (CCR) are useful decision rules to clear cervical spines in adults but have limited strength in young children. PECARN has derived a pediatric cervical spine clearance rule, but this has yet to be prospectively validated. Similar to CSIs, thoracic injuries in children are rare but carry a higher M+M due to anatomic differences in children. A child’s chest anatomy and increased compliance cause more difficulty in injury identification. Abdominal trauma is common in children and can also be difficult to identify. Unlike adults, children can compensate for blood loss much longer while maintaining their blood pressure. Serial abdominal examinations are useful when imaging is negative and a patient has persistent symptoms.

      This review contains 5 highly rendered figures, 18 tables, and 92 references.

      Key words: abdominal trauma, Advanced Trauma Life Support (ATLS), cervical spine injury, head trauma, National Emergency X-radiography Utilization Study (NEXUS),  Pediatric Emergency Care Applied Research Network (PECARN), thoracic trauma, traumatic brain injury

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    • 6

      Pediatric Seizures and Status Epilepticus

      By Lindsey Retterath, MD ; Dale Woolridge, MD
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      Pediatric Seizures and Status Epilepticus

      • LINDSEY RETTERATH, MD Banner University Medical Center – Tucson, Resident Physician, Department of Emergency Medicine and Department of Pediatrics
      • DALE WOOLRIDGE, MD Banner University Medical Center – Tucson, Program Director, Emergency Medicine and Pediatrics Combined Residency Program

      Seizures represent a common neurologic complaint among pediatric patients in the emergency department (ED). They can be classified as generalized or focal. In terms of etiology, seizures are most basically broken down into “acute symptomatic” seizures, which are due to another primary medical cause, and unprovoked seizures which occur as a primary pathology. Febrile seizures are the most common types of seizures in children, which themselves can be simple or complex. The most concerning seizures are those which associate with meningismus, encephalitis, metabolic derangements, intracranial mass, and, of course those which progress to status epilepticus. Significantly, it is appropriate and even critical to assume status epilepticus and intervene accordingly whenever a child arrives to the ED seizing for an unspecified period of time. This review covers the initial evaluation, resuscitation, management, work-up, and disposition of pediatric patients who present to the emergency room with seizures. Figures in this chapter illustrate stepwise and algorithmic approaches to initial management, expanded differential, systematic diagnostic approach, and disposition for pediatric patients presenting with seizures and status epilepticus. Tables list important physical exam components for evaluating children with seizures, classifications of seizures, common seizure look-alikes in children, features of febrile seizures, etiologies of pediatric seizures.

      Key Words: Pediatric seizures, febrile seizures, pediatric neurologic emergencies, pediatric emergency medicine, status epilepticus 

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    • 7

      Congenital Heart Disease

      By Zachary Pittsenbarger, MD; Emily Roben, MD
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      Congenital Heart Disease

      • ZACHARY PITTSENBARGER, MDInstructor in Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Evanston, IL
      • EMILY ROBEN, MDClinical Fellow in Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Evanston, IL

      Congenital heart disease (CHD) is common, affecting approximately 8 in 1000 live-born children, and encompasses a broad range of diagnoses and presentations.  CHDs can include inborn derangements in almost any aspect of the hearts structure of function, but the most common type of congenital heart disease are structural lesions of the heart that affect the normal pattern of blood flow.  These structural lesions can present with varied symptoms and physical exam signs that are rooted in their underlying blood flow patterns often lead to one of four groups of diseases based on blood flow patterns.  Overcirculation, systemic outflow obstruction, systolic failure, and cyanosis are the four groups used as descriptive classifications of structural CHD.  CHD findings can be present prenatally, in the newborn nursery, and well child office visits, but very often present to the EDs without any cardiac history when the lesion progresses to a point of crisis when the cardiac output is no longer meeting the body’s perfusion demands.  Early presentations of CHD frequently are related to closure of the ductus arteriosus and may benefit from early treatment with prostaglandin E.  Lab tests, radiology studies, and exam findings may be suggestive of certain types of lesions, but the gold standard to determine the type of CHD is an echocardiogram.  Once the diagnosis of CHD is suspected, consultation with a pediatric cardiologist is highly recommended to arrange the timely evaluation of the child and prompt initiation of therapies if needed to mitigate the disease progression.

                             

      Key words: Congenital heart disease, overcirculation, systemic outflow obstruction, systolic failure, and cyanosis, ductus arteriosus

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    • 8

      Pediatric Diabetic Ketoacidosis and Hypoglycemia

      By Rachel J Williams, MD; Samantha L. Wood, MD, FAAEM, FACEP
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      Pediatric Diabetic Ketoacidosis and Hypoglycemia

      • RACHEL J WILLIAMS, MDResident Physician, Department of Emergency Medicine, Maine Medical Center, Portland, ME
      • SAMANTHA L. WOOD, MD, FAAEM, FACEPAssistant Professor of Emergency Medicine, Tufts University School of Medicine, Attending Physician, Department of Emergency Medicine, Department of Pediatrics, Pediatric Critical Care, Maine Medical Center, Portland, ME

      Abnormalities of serum glucose in pediatric patients are commonly encountered in the emergency department and represent an acute threat to life and neurologic function. Rapidly identifying and aggressively treating hyperglycemia with diabetic ketoacidosis and hypoglycemia are critical to ensure the best possible outcome. This review will guide the emergency provider in the identification, resuscitation, workup, and disposition of these critically ill patients.

      Key Words: cerebral edema, diabetic ketoacidosis, hyperglycemia, hypoglycemia

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    • 9

      Pediatric Orthopedic Emergencies

      By Priya Gopwani, MD; Joy Koopmans, MD
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      Pediatric Orthopedic Emergencies

      • PRIYA GOPWANI, MDAttending Physician, Assistant Professor of Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
      • JOY KOOPMANS, MDAttending Physician, Department of Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago at Central DuPage Hospital, Health Systems Clinician, Northwestern University Feinberg School of Medicine, Winfield, IL

      Proper care of orthopedic injuries and emergencies in children and adolescents requires knowledge of the altered bone and ligament characteristics, varying stages of skeletal development, and potential for congenital or developmental abnormalities. Pediatric fractures affecting the growth plate require unique management to maintain optimal growth. Whereas some specific fractures in these skeletally immature patients require urgent surgical repair, other fractures remodel extremely well and can be managed with a simple splint. Particular dislocations are common in this population and may have concomitant fractures. There are several overuse injuries seen primarily in children, and treatment aims to keep the patient active while allowing the injury to heal. Potentially devastating osteoarticular infections occur in the pediatric population and must be differentiated from more benign causes of joint pain, such as transient synovitis or congenital abnormalities. Children are also at risk for abnormalities such as slipped capital femoral epiphysis or Legg-Calvé-Perthes disease, which are rarely diagnosed in the adult population. It is imperative for a clinician to be aware of these and other nuances to optimally care for orthopedic injuries and emergencies in the pediatric population.

      Key words: bone, musculoskeletal, orthopedic, skeletal

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    • 10

      Comprehensive Overview of Pediatric Airway Management

      By Lisa Goldberg , MD; Garrett S. Pacheco, MD; Dale Woolridge, MD
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      Comprehensive Overview of Pediatric Airway Management

      • LISA GOLDBERG , MDResident Physician, Department of Emergency Medicine, University of Arizona at South Campus, Tucson, AZ
      • GARRETT S. PACHECO, MDAssistant Professor, Departments of Emergency Medicine and Pediatrics, University of Arizona, Tucson, AZ
      • DALE WOOLRIDGE, MD Banner University Medical Center – Tucson, Program Director, Emergency Medicine and Pediatrics Combined Residency Program

      Pediatric endotracheal intubation is a procedure that can be stress provoking to the emergency physician. Although the need for this core skill is rare, when confronted with this situation, the emergency physician must have knowledge of the anatomic, physiologic, and pathologic components unique to the pediatric airway to optimize success. Furthermore, the emergency physician should be well versed in the various equipment and adjuncts as well as techniques developed to effectively manage the pediatric airway. This review covers the pathophysiology and practice of endotracheal intubation. Figures show a gum elastic bougie; the Mallampati classification; appropriate oropharyngeal, laryngeal, and tracheal axes; advancing the laryngoscope to lift the epiglottis; endotracheal tube position in neonates; and synchronized intermittent mandatory ventilation pressure-regulated volume control mechanical ventilation. Tables list endotracheal tube sizes, neonatal endotracheal tube sizes, pediatric laryngeal mask airway sizes, commonly used induction agents, and endotracheal tube insertion depth guidelines.

      This review contains 6 highly rendered figures, 5 tables, and 74 references.

      Key words: emergent tracheal intubation; endotracheal tube; laryngoscopy; pediatric airway; pediatric airway management; pediatric endotracheal intubation; pediatric laryngeal mask; video laryngoscopy

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    • 11

      Pediatric Procedural Sedation

      By Sara W. Nelson, MD; J. Calvin Simmons, MD
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      Pediatric Procedural Sedation

      • SARA W. NELSON, MDAssistant Professor, Department of Emergency Medicine, Maine Medical Center, Tufts University School of Medicine, Portland, ME
      • J. CALVIN SIMMONS, MDResident Physician, Department of Emergency Medicine, Maine Medical Center, Portland, ME

      Children present to the emergency department with painful conditions or conditions that require diagnostic or therapeutic procedures every day. As emergency physicians, we need to have the skills to manage our patients’ pain and anxiety in a safe and efficient manner. Appropriately managing pain and anxiety facilitates medical interventions, decreases patients’ suffering, improves patient and parent satisfaction, and improves the quality of care. Conversely, failure to adequately provide analgesia and sedation can have negative consequences for pediatric patients. In the pediatric population, inadequate pain control not only causes immediate harm and fear but can also worsen the reaction to future medical care and potentially affect the child’s long-term psychological well-being. This review provides an overview of pediatric procedural sedation, as well as the pathophysiology and practice. Figures show the sedation continuum with associated physiologic responses, oxyhemoglobin desaturation during apnea for various types of patients, and examples of capnography waveforms in procedural sedation and analgesia (PSA). Tables list potential indications for pediatric PSA in the emergency department, American Society of Anesthesiologists’ classifications, drugs and pharmacokinetics of common agents used in PSA, focused history and physical examination for patients undergoing PSA, SOAPME (Suction, Oxygen, Airway, Pharmacy, Monitors, Equipment) acronym for PSA equipment, and suggested monitoring for PSA pre- and postprocedure.

      This review contains 3 highly rendered figures, 6 tables, and 41 references.

      Key words: pediatric analgesia; pediatric pain; pediatric procedural sedation; pediatric sedation; procedural pain relief; procedural sedation and analgesia

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    • 12

      Pediatric Upper Airway Obstruction

      By Michael W. Chan, MD; Suzanne M. Schmidt, MD
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      Pediatric Upper Airway Obstruction

      • MICHAEL W. CHAN, MDFellow, Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
      • SUZANNE M. SCHMIDT, MD Attending Physician, Pediatric Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Assistant Professor, Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL

      Upper airway obstruction is a common reason that children present for emergency care, and causes range from simple and benign etiologies to life-threatening conditions requiring emergent intervention. Both congenital and acquired conditions can result in airway obstruction at various levels, and due to the high risk of acute decompensation associated with some of these conditions, rapid diagnosis and treatment are essential. This review covers assessment and stabilization, diagnosis, and treatment of foreign-body aspiration, croup, bacterial tracheitis, epiglottitis, peritonsillar abscess, and retropharyngeal abscess. Figures show a diagram of the pediatric airway, an anteroposterior radiograph of the neck demonstrating the characteristic “steeple sign” in croup, an algorithm for the treatment of croup, lateral radiographs demonstrating a thickened epiglottis, consistent with a diagnosis of epiglottitis,  and a widening of the prevertebral soft tissues of the neck, consistent with a diagnosis of retropharyngeal abscess. Tables list causes of upper airway obstruction by anatomic location, symptoms of upper airway obstruction by anatomic location, severity of croup, and microbiology of deep neck abscesses.

      This review contains 5 highly rendered figures, 4 tables, and 37 references

      Key words: Upper airway obstruction; Pediatric upper airway obstruction, Foreign-body aspiration, Croup, Bacterial tracheitis, Epiglottitis, Peritonsillar abscess, Retropharyngeal abscess, Stridor

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    • 13

      Neonatal Resuscitation

      By Megan Litzau, MD; Sheryl E Allen, MD, MS
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      Neonatal Resuscitation

      • MEGAN LITZAU, MD Emergency Medicine Resident, Indiana University School of Medicine
      • SHERYL E ALLEN, MD, MS Associate Professor of Clinical Emergency Medicine and Pediatrics, Indiana University School of Medicine

      The resuscitation of a neonate in the emergency department is an infrequent occurrence. As such, it is imperative that emergency physicians are aware of the resources available at their institution in the event that resuscitation arises. The two mainstays of neonatal resuscitation are respiration and temperature. When resuscitation is required, it is due to a respiratory cause in the majority of neonates. Therefore, if the airway and breathing are managed properly, the heart rate and overall neonatal status will follow suit. Should the neonate’s heart rate continue to be below 60 beats per minute, then he or she will need chest compressions in addition to respiratory support. During the transition from intrauterine life to extrauterine life, neonates stand to lose substantial amounts of heat. Therefore, the temperature of the neonate also needs to be actively managed to prevent the loss of heat. The resuscitation will eventually end in one of two pathways: the termination of efforts or the successful resuscitation of the neonate. If the resuscitation is successful, the proper admission or transfer will need to be arranged for definitive care for the neonate. Figures include the review of fetal and neonatal circulation, proper use of equipment, and proper chest compression technique. Tables include equipment needed, Apgar scores, normal neonatal vital signs, disposition, and neonatal intensive care unit levels.

      Key words: Apgar scores, fetal circulation, neonatal chest compressions, neonatal circulation, neonatal resuscitation, neonatal intensive care unit levels

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    • 14

      Pediatric Infectious Diarrhea and Dehydration

      By John W. Martel, MD, PhD; Scott McCorvey, MD, MS
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      Pediatric Infectious Diarrhea and Dehydration

      • JOHN W. MARTEL, MD, PHDAssistant Professor, Department of Emergency Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME
      • SCOTT MCCORVEY, MD, MSResident, Department of Emergency Medicine, Maine Medical Center, Portland, ME

      Diarrhea is a common emergency department (ED) complaint, leading to more than 1.5 million outpatient visits and 200,000 hospital admissions in the United States alone. Although concomitant dehydration also exists in some cases, there are no standard clinical criteria to aid in identifying those children who merit intravenous resuscitation. Current pediatric volume repletion guidelines are based primarily on the estimated degree of volume depletion per the World Health Organization, Centers for Disease Control and Prevention, and American Academy of Pediatrics criteria. These practice guidelines stratify patients into mild (3 to 5% volume depletion), moderate (5 to 10% volume depletion), and severe (> 10% volume depletion). The vast majority of pediatric patients presenting with nausea, vomiting, and/or diarrhea suffer from virus-mediated enterocolitis and require no testing or intravenous fluid resuscitation due to the self-limiting nature of these syndromes; rotavirus and Norwalk virus are two of the most common causes of infectious diarrhea in both developing and developed countries. Although bacterial pathogens rarely cause infectious colitis, children who present with more severe symptoms, including fever, bloody stool, and significant abdominal discomfort, warrant additional diagnostic evaluation. Obtaining a careful history, including exposures to livestock, well water, travel, and antibiotic use, as well as recent intake of undercooked meat, is key to identifying patients who may be at higher risk for bacteria-mediated illnesses. Tables identify common diarrheal pathogens, diarrheal subtypes, and clinical abnormalities associated with volume depletion and more severe syndromes, such as hemolytic-uremic syndrome.

      This review contains 5 highly rendered figures, 7 tables, and 77 references.

      Key words: Clostridium difficile, dehydration, diarrhea, gastroenteritis, hemolytic-uremic syndrome, pediatrics

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    • 15

      Child Abuse and Nonaccidental Trauma

      By S Terez Malka, MD
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      Child Abuse and Nonaccidental Trauma

      • S TEREZ MALKA, MDAssistant Professor, Department of Emergency Medicine, Department of Pediatric Emergency Medicine, Massachusetts General Hospital, Boston, MA.

      Child abuse accounts for over 1% of visits to pediatric emergency departments (EDs), and injuries related to abuse have higher morbidity and mortality than accidental injuries. Recognizing child abuse and neglect in the ED is challenging but critical to prevent recurrent episodes of abuse and long-term physical and emotional sequelae. This review defines child abuse and neglect and explores historical and physical examination findings, assessment and diagnosis, treatment, disposition, and outcomes for victims of child abuse. Figures show x-rays demonstrating common fracture patterns associated with abusive injury and an algorithm for evaluation of nonaccidental trauma in the ED. Tables list key historical elements in the evaluation for abuse or neglect, bruising characteristics suggestive of abuse, fractures that are specific for abuse, and recommended laboratory evaluation for suspected abuse. 

      This review contains 4 figures, 4 tables, and 37 references.

      Key words: child abuse, child neglect, nonaccidental trauma, sexual abuse

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    • 16

      Pediatric Hematologic and Oncologic Emergencies

      By Rebecca Milligan, MD; Jenny Mendelson, MD
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      Pediatric Hematologic and Oncologic Emergencies

      • REBECCA MILLIGAN, MD
      • JENNY MENDELSON, MD

      Hematologic and oncologic emergencies that afflict children and adolescents are important for emergency medicine physicians to recognize. Pediatric patients can present with a previous formal diagnosis and have a complication related to their disease or with new symptoms that suggest a hematologic or oncologic process. Oncologic treatments can also lead to life-threatening complications. Recognizing these emergencies is very important for emergency physicians to prevent further morbidity. This review covers common patient presentations, diagnosis, and treatments for hematologic and oncologic emergencies.

       This review contains 6 figures, 6 tables and 57 references

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    • 17

      Pediatric Abdominal Emergencies

      By Jeffrey Bullard-Berent, MD, FAAP, FACEP; Aaron Kornblith, MD
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      Pediatric Abdominal Emergencies

      • JEFFREY BULLARD-BERENT, MD, FAAP, FACEPVice Chair, Emergency Medicine, Medical Director, Child Ready Virtual Pediatric Emergency Department, Professor of Emergency Medicine and Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM
      • AARON KORNBLITH, MDAssistant Professor, Emergency Medicine and Pediatrics, Benioff Children’s Hospital, San Francisco, University of California, San Francisco, San Francisco, CA

      Pediatric abdominal emergencies represent a diverse group of conditions affecting children of all ages and are a common cause of emergency department visits. The challenge for emergency physicians is discerning which child presenting with the common complaints of abdominal pain, nausea, vomiting, and diarrhea has an abdominal emergency. The emergency physician must use a thorough history, developmentally appropriate examination skills, and integration of his or her knowledge base to arrive at the correct diagnosis. This review evaluates the most common pediatric abdominal emergencies organized by chronicity from birth to adolescents: midgut volvulus, infantile hypertrophic pyloric stenosis, incarcerated inguinal hernia, ileocecal intussusception, Meckel diverticulum, and appendicitis. Readers will understand common presentations as well as the evaluation and treatment options for each diagnosis.  

      This review contains 7 figures, 6 tables and 61 references

      Key words: abdominal pain, appendicitis, hernia, hypertrophic pyloric stenosis, intussusception, Meckel diverticulum, midgut volvulus

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    • 18

      Pediatric Lower Respiratory Tract Emergencies: Bronchiolitis, Pneumonia, and Asthma

      By Amber M Richards, MD
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      Pediatric Lower Respiratory Tract Emergencies: Bronchiolitis, Pneumonia, and Asthma

      • AMBER M RICHARDS, MDAssistant Professor, Tufts University School of Medicine, Attending Physician, Department of Emergency Medicine, Maine Medical Center, Portland, Maine, United States

      Respiratory illnesses account for a significant proportion of pediatric morbidity and mortality. Respiratory complaints are a common cause of emergency department visits and hospital admissions. They range from mild and self-limited to severe and rapidly progressive. This review discusses the pathophysiology, assessment, stabilization, and management of asthma, community-acquired pneumonia, and bronchiolitis. Given the prevalence of these conditions and the morbidity and mortality attributed to them, it is important for clinicians to be familiar with their presentations and up to date on evidence-based management recommendations.

      This review contains 7 Figures, 20 Tables and 75 references

      Key Words: antibiotics, asthma, bronchiolitis, community-acquired pneumonia, pediatric respiratory, pneumonia, respiratory emergency, respiratory illness, respiratory syncytial virus

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