Emergency Medicine Secrets E-Book

Vincent J. Markovchick; Katherine A. Bakes; Jennie Buchanan; Peter T. Pons

BOOK

Emergency Medicine Secrets E-Book

Vincent J. Markovchick | Katherine A. Bakes | Jennie Buchanan | Peter T. Pons

(2015)

Additional Information

Book Details

ISBN: 978-0-323-37483-5
Edition: 6
Language: English
Pages: 61
Subjects: Clinical & internal medicine
Accident & emergency medicine
Medical study & revision guides & reference material

Abstract

For 30 years, the highly regarded Secrets Series® has provided students and practitioners in all areas of health care with concise, focused, and engaging resources for quick reference and exam review. The 6th Edition of Emergency Medicine Secrets, by Drs. Vincent J. Markovchick, Peter T. Pons, Katherine M. Bakes, and Jennie A. Buchanan, features the Secrets’ popular question-and-answer format that also includes lists, mnemonics, tables, and an informal tone – making reference and review quick, easy, and enjoyable.

Top 100 Secrets and Key Points boxes provide a fast overview of the secrets you must know for success in practice.

The proven Secrets® format gives you the most return for your study time – concise, easy to read, engaging, and highly effective.

Portable size makes it easy to carry with you for quick reference or review anywhere, anytime.

Thorough updates keep you current with what’s new in emergency medicine.

Section Title	Page	Action	Price
Front Cover	cover
Expert Consult page	IFC1
Emergency Medicine Secrets	i
Copyright Page	iv
Dedication	v
Contributors	vi
Preface	xv
Acknowledgment	xv
Table Of Contents	xvi
Top 100 Secrets	1
I Decision Making in Emergency Medicine	7
1 Decision Making in Emergency Medicine	7
Abstract	7.e1
Keywords:	7.e1
1. Is there anything unique about emergency medicine?	7
2. Describe the conventional method of evaluating a patient.	7
3. Why is the conventional methodology not ideal for use in the ED?	7
4. How do I identify the patient with a life-threatening condition?	7
5. What is so important about the chief complaint?	7
6. Why are vital signs important?	7
7. What are the determinants of (normal) vital signs?	7
8. What is the most inaccurate vital sign taken in the field and ED?	7
9. Why do I need to compare field vital signs with ED vital signs?	8
10. When are normal vital signs abnormal?	8
11. Why do I need to visualize, auscultate, and touch the patient?	8
12. Once I have identified the life threat, what do I do?	8
13. I have identified and stabilized or ruled out an immediate life threat in the patient. What else is unique about the approach to this patient in the ED?	8
14. Why does formulating a differential diagnosis sometimes lead to problems?	8
15. Is a diagnosis always possible or necessary in the ED?	8
16. If I cannot make the diagnosis, what do I do?	9
17. What is the most important question to ask a patient who comes to the ED with a chronic, persistent, or recurrent condition?	9
18. How do I decide if the patient needs hospitalization?	9
19. If the patient does not need admission, how do I arrange a satisfactory disposition?	9
20. What is the most important thing to consider and document in the ED discharge instructions?	9
21. What two questions should always be asked (and answered) before a patient is discharged from the ED?	9
22. Why is the previous question and answer one of the most important in this chapter?	10
23. What about the chart?	10
Questions	10.e1
2 Management of Cardiac Arrest and Principles of Resuscitation	11
Abstract	11.e1
Keywords:	11.e1
1. What are the ABCs of resuscitation?	11
2. What is CAB, and why is it recommended?	11
3. How should cardiopulmonary resuscitation (CPR) be performed as described by the American Heart Association?	11
4. How important is ventilation during resuscitation efforts in the out-of-hospital setting?	11
5. What is passive oxygen insufflation?	11
6. What is capnography, and how should it be used during resuscitation?	12
7. What is the “squeeze, release, release” method of providing mechanical ventilation?	12
8. What are the exceptions to the rule of the ABCs?	12
9. Explain the mechanism of blood flow during CPR?	12
10. Is blood flow to the brain and heart adequate during CPR?	12
11. What is coronary perfusion pressure (CPP)?	12
12. What is the association between CPR, CPP, and ROSC?	12
13. Describe hands-off CPR?	12
14. Discuss the role of pharmacologic therapy during CPR.	12
15. Under what circumstances should CPR be used before defibrillation?	13
16. What are the indications for open-chest cardiac massage?	13
17. What are the most common causes of cardiopulmonary arrest?	13
18. What are other reversible causes and immediate treatments of cardiopulmonary arrest?	13
19. How should VF be treated?	14
20. What’s the difference between monophasic and biphasic defibrillation?	14
21. Should you administer one shock at a time or a sequence of shocks (also referred to as stacked shocking)?	14
22. What is the optimal placement of electrode pads used for defibrillation?	14
23. What if VF persists after initial treatment?	14
24. Describe the three-phase model of cardiac arrest?	14
25. How should asystole be treated?	14
26. Is defibrillation or electrical pacing useful for asystole?	15
27. What are the appropriate routes of drug administration?	15
28. I thought IO cannulation was only used as a last resort and for pediatric patients. What’s the deal?	15
29. When may prehospital resuscitation efforts be terminated?	15
30. Which vasopressor should I administer in the setting of cardiac arrest: epinephrine, vasopressin, or both?	15
31. Should I use amiodarone in the setting of cardiac arrest?	16
32. Should I routinely administer sodium bicarbonate during resuscitation?	16
33. Should I routinely administer calcium during resuscitation?	16
34. What should I do after ROSC?	16
35. What percentage of all cardiac arrest patients survive to hospital discharge?	16
Questions	16.e1
Bibliography	16
3 Airway Management	17
Abstract	17.e1
Keywords:	17.e1
1. Which ED patients need airway assessment?	17
2. What are the different mechanisms of respiratory failure?	17
3. How do I assess a patient’s respiratory status?	17
4. Does a lack of a gag reflex mean my patient can’t protect his or her airway?	17
5. What is a definitive airway?	17
6. What is the most common cause of airway obstruction?	17
7. How can I initially assist a patient in respiratory failure?	17
8. How do I predict patients who will be difficult to assist with a BVM?	17
9. What is rapid-sequence intubation (RSI)?	18
10. How do I assess for a difficult intubation?	18
11. What basic equipment is necessary for ET intubation?	18
12. What is a video laryngoscope, and what types are there?	19
13. What are the steps (seven Ps) to RSI?	19
14. What is passive apneic oxygenation?	21
15. What medications are used for RSI?	21
16. What are the contraindications to using succinylcholine?	21
17. How deep do I advance an ET tube?	21
18. How do I confirm ET tube placement?	21
19. What are the contraindications to RSI?	21
20. What are the steps to awake fiberoptic intubation?	21
21. What is delayed sequence intubation (DSI)?	21
22. What is an extraglottic airway?	21
23. What is a laryngeal mask airway (LMA)?	22
24. What is a King airway? What is a Combitube?	22
25. What are the indications for a surgical airway?	22
26. What factors make pediatric airway interventions more difficult?	22
27. How do I know what equipment size to use for pediatric airway interventions?	23
28. What is the surgical airway option for pediatric patients?	23
Acknowledgment	23
Bibliography	23
Questions	23.e1
4 Shock	24
Abstract	24.e1
Keywords:	24.e1
1. Define shock.	24
2. How common is shock?	24
3. What is the overall mortality rate of patients who develop shock?	24
4. List the five categories of shock and provide examples of each.	24
5. How do I identify a patient in shock?	24
6. How should urine output be used during resuscitation of a patient in shock?	24
7. Describe compensated and decompensated shock.	24
8. What is the initial management of a patient who is experiencing shock?	25
9. Define oxygen delivery (DO2).	25
10. How useful are vital signs in assessing and treating someone in shock?	25
11. If a patient has normal vital signs, should I be reassured?	25
12. Are orthostatic vital signs a sensitive indicator of hypovolemia? What determines a positive orthostatic test?	25
13. Are there other signs that are helpful in assessing an acutely ill patient?	25
14. How should I use and interpret serum lactate concentration?	25
15. What is the lactate clearance index, and how can it be used during resuscitation of a patient in shock?	25
16. What is a normal CVP, and how is it measured?	26
17. How is CVP used during resuscitation of a patient experiencing shock?	26
18. What is venous oxygen saturation, and what is the difference between ScvO2 and SvO2?	26
19. How do I use ScvO2 or SvO2 during resuscitation?	26
20. What is early goal-directed therapy?	26
21. List the primary resuscitation goals in patients suffering from shock.	26
22. What is the Trendelenburg position? What purpose(s) does it serve?	26
23. Define systemic inflammatory response syndrome (SIRS).	26
24. Define sepsis, severe sepsis, and septic shock, and discuss their specific therapies.	27
25. How do I treat cardiogenic shock?	27
26. Explain the mechanism of dobutamine.	27
27. Explain the mechanism of dopamine.	27
28. How do I treat shock resulting from anaphylaxis?	27
29. Explain the mechanism of epinephrine.	27
30. How do I treat shock caused by PE?	27
31. How do I treat shock resulting from cardiac tamponade?	27
32. What is neurogenic shock, and how is it treated?	27
33. Explain the mechanism of phenylephrine.	27
Bibliography	28
Questions	28.e1
5 Emergency Ultrasound	29
Abstract	29.e1
Keywords:	29.e1
1. What is ED ultrasound all about?	29
2. Why should ultrasound be performed in the ED?	29
3. How does emergency ultrasound differ from ultrasound performed by the radiology department?	29
4. How about some basic ultrasonography physics?	29
5. Describe the basics of the trauma ultrasound examination.	29
6. Where is the best place to look for intraperitoneal fluid?	30
7. How does ultrasound compare with traditional means of evaluating the traumatic abdomen?	30
8. How should I use ultrasound in my evaluation of patients with blunt trauma?	30
9. Can I determine how much intraperitoneal fluid is present based on the ultrasound image?	31
10. What are some of the pitfalls I may encounter during a trauma ultrasound examination of the abdomen?	31
11. What is extended focused assessment with sonography for trauma (EFAST)?	31
12. What are the sonographic appearances of the gallbladder and related structures?	32
13. What findings are suggestive of acute cholecystitis?	32
14. What are the indications for pelvic ultrasonography in the ED?	32
15. How early can an IUP be detected using ultrasound? What value of β-human chorionic gonadotropin (HCG) does this correspond to?	32
16. How sensitive is ultrasound for the evaluation of ectopic pregnancy?	32
17. Describe the pitfalls in pelvic ultrasonography.	33
18. What other abdominal structures can be evaluated by emergency ultrasound?	33
19. What is the significance of increased aortic diameter?	33
20. Describe the uses of cardiac ultrasonography in the ED.	33
21. How can ultrasound be used in the ED to evaluate patients with undifferentiated hypotension?	34
22. What is the role of ultrasound in the evaluation of patients with suspected renal colic?	34
22. How is lower extremity venous ultrasound performed in the ED to diagnose DVT?	34
23. How can soft-tissue/musculoskeletal ultrasound be utilized in the ED?	35
24. What are some future applications for emergency ultrasound?	35
25. Has the political environment changed with respect to emergency physicians using ultrasound?	35
Bibliography	36
Questions	36.e1
6 Geriatric Emergency Medicine	37
Abstract	37.e1
Keywords:	37.e1
1. Why dedicate a chapter to geriatric emergency medicine?	37
2. What is a geriatric ED?	37
3. What important physiologic changes occur with aging?	37
4. Don’t elderly patients always have abnormal laboratory values?	37
5. How can prehospital personnel facilitate the care of elderly patients?	37
6. Aren’t falls a fact of life in elderly patients?	38
7. What is different about evaluating the elderly patient who falls?	38
8. Do emergency physicians have a role in prevention of recurrent falls in the elderly?	38
9. What about coronary artery disease in the older patient?	38
10. Should I be concerned about atypical presentations of AMI in elderly patients?	38
11. What is the significance of fever in elderly patients?	38
12. Speaking of infections, how do infectious pathologies present in older patients?	39
13. Why is it important to know the elderly patient’s current medications?	39
14. What presenting complaints should lead me to suspect that the patient is experiencing an adverse reaction to medications?	39
15. Do elderly patients tolerate trauma very well?	39
16. Should I worry if a geriatric victim of trauma has normal vital signs with apparently minor injuries?	39
17. Which presentations in geriatric trauma are associated with an extremely high mortality rate?	39
18. Can procedural sedation be performed safely in the geriatric patient?	39
19. Should I resuscitate the elderly patient in cardiac arrest?	40
20. How does my approach to acute abdominal pain change in elderly patients?	40
21. Which is more serious, dementia or delirium?	40
22. How do I differentiate between delirium and dementia?	40
23. What are the four types of elder abuse?	40
24. What red flags in the history should alert the physician to the possibility of elder abuse?	41
25. What red flags in the physical examination should alert the physician to the possibility of elder abuse?	41
26. What special concerns are there in discharging elderly patients?	41
Bibliography	41
Questions	41.e1
7 Palliative Care and Advance Directives	42
Abstract	42.e1
Keywords:	42.e1
Palliative Care	42
1. What is palliative care (PC) medicine?	42
2. What is the difference between PC and hospice?	42
3. Why should PC skills be part the scope of emergency medicine?	42
4. How does emergency medicine fit in with the specialty of PC and hospice?	42
5. What are the core PC skills that emergency physicians need to know?	42
6. Why would a hospice patient call 911? Shouldn’t they be calling their hospice provider?	42
7. What is an advance directive?	43
8. How should advance directives be used when they are available to the emergency physician in the ED?	43
9. Why is the patient’s capacity for decision-making important?	43
10. What happens when patients or family members of patients change their goals of care while in the ED?	43
11. What is appropriate vocabulary if you think the patient would benefit from hospice or PC?	46
12. Who do I call if I need help managing a patient who needs hospice or PC?	46
13. When is it appropriate to withhold resuscitation in a patient who comes to the ED?	46
14. What are the new advance directive forms called Physician Orders for Life-Sustaining Treatment (POLSTs)?	46
15. Withdrawing or stopping resuscitation feels worse than not starting. Which is more ethical?	46
Bibliography	47
Questions	47.e1
8 How to Critically Review Emergency Medicine Literature	48
Abstract	48.e1
Keywords:	48.e1
1. Can I skip this chapter if I don’t plan to do research?	48
2. Why should I read medical journals?	48
3. Which study design is the best?	48
4. Are there any other types of study designs I should be familiar with?	48
5. What is blinding? Why is it important?	48
6. Do sample size and power matter?	48
7. What does number needed to treat mean?	48
8. What should I look for when evaluating a chart review study?	49
9. What does a p value refer to?	49
10. How do I interpret confidence intervals?	49
11. Does it matter who sponsors a study?	49
12. Should I read reviews on clinical topics?	49
13. How do I practice evidence-based medicine?	50
14. How should I interpret blog posts or other online reviews of clinical medicine?	50
15. What are some of the statistical terms I should be familiar with?	50
Bibliography	50
Questions	50.e1
9 Evidence-Based Rational Use of Diagnostic Imaging	51
Abstract	51.e1
Keywords:	51.e1
1. What does evidence-based rational use of imaging mean?	51
2. Describe the evidence-based approach.	51
3. How is the evidence used by the clinician?	51
4. When should I consult a radiologist before ordering an imaging study?	51
5. How can I apply evidence-based imaging in my clinical practice?	51
6. Are clinical prediction rules helpful?	51
7. Is radiation exposure from x-rays and computed tomography (CT) dangerous when used for patients in the ED?	52
8. Which patients are at highest risk from imaging-related radiation exposure?	52
9. What question should be asked when ordering diagnostic imaging studies in young patients?	53
10. What else should be considered when ordering diagnostic imaging?	53
11. Should a cervical spine CT be obtained in all patients who are victims of trauma?	53
12. Which patients should get a cervical spine CT without cervical spine radiography?	53
13. Should all patients with chest pain get a CT to exclude pulmonary embolism?	53
14. When should patients with clinical suspicion of kidney stones get a noncontrast CT of the abdomen and pelvis (CT-KUB)?	53
15. What imaging other than CT-KUB should be considered for patients who often come to the ED with symptomatic urinary stone disease?	53
16. Is CT or MRI ever appropriate to evaluate extremity trauma?	54
17. Does the evidence support use of CT or plain films for facial fracture imaging?	54
18. What are the indications for emergent MRI for patients in the ED?	54
19. What imaging should be done when appendicitis is suspected clinically?	54
20. What imaging should be performed for a clinical diagnosis of acute pancreatitis?	55
21. What imaging should be performed to evaluate a palpable abdominal or pelvic mass?	55
22. What is appropriate evidence-based imaging for right upper quadrant pain?	55
23. What imaging should be done for suspected small bowel obstruction?	55
24. What is appropriate evidence-based imaging for left lower quadrant pain?	55
25. What imaging is appropriate for suspected abdominal abscess?	56
26. When is imaging appropriate for patients with scrotal pain?	56
27. Should a head CT be performed in all trauma patients?	56
28. How about a head CT for trauma patients who are receiving anticoagulants?	56
29. Should patients with closed head injury routinely receive a CT of the abdomen and pelvis at time of head CT?	56
30. Should imaging be repeated when a patient is transferred from another institution to my care?	56
Bibliography	57
Questions	57.e1
10 EMTALA, The Joint Commission, and HIPAA	58
Abstract	58.e1
Keywords:	58.e1
Emergency Medical Treatment and Labor Act	58
1. What is the Emergency Medical Treatment and Labor Act (EMTALA)?	58
2. Define EMC.	58
3. Why does such a statute even exist?	58
4. As a physician, can I personally be penalized for an EMTALA violation?	58
5. Will my malpractice insurance cover me for an EMTALA violation?	59
6. Does EMTALA apply when a patient in need comes to any part of a hospital’s campus, even if it is not an ED?	59
7. What is a dedicated ED?	59
8. Is a hospital obligated under EMTALA to medically screen and stabilize any patient seeking care in an ambulance it owns and operates?	59
9. How does EMTALA describe a proper MSE?	59
10. Who can perform the MSE?	59
11. When has the MSE been satisfactorily completed under EMTALA?	60
12. Is it an EMTALA violation if the patient decides to leave against medical advice before the MSE is complete?	60
13. What is meant by transfer under EMTALA?	60
14. When does EMTALA say it is OK to transfer a patient?	60
15. List the requirements for transferring a patient who is unstable.	60
16. Can an on-call consultant refuse to see a patient who is unstable?	61
17. How is the hospital’s on-call list determined?	61
18. Can a hospital refuse to accept a transfer under EMTALA?	61
19. If I receive an inappropriate transfer at my hospital, do I have an obligation to report an EMTALA violation?	61
The Joint Commission	61
20. What is The Joint Commission?	61
21. What are the standards and performance measurements that The Joint Commission requires?	62
22. How is compliance with the standards evaluated and enforced?	62
23. What is a sentinel event?	63
24. How do The Joint Commission standards influence the practice of emergency medicine?	63
Health Insurance Portability and Accountability Act	63
25. What is Health Insurance Portability and Accountability Act (HIPAA)?	63
26. Where did the Privacy Rule come from?	63
27. What prompted the enactment of such a statute?	64
28. What is protected health information (PHI)?	64
29. What is the difference between the use and the disclosure of PHI?	64
30. According to HIPAA, when is it okay to disclose PHI?	64
31. How is the statute enforced, and what are the penalties for a HIPAA violation?	64
32. What steps should be taken to prevent disclosure of PHI in the ED?	64
Risk Management	65
33. What is risk management?	65
34. Why are emergency physicians at high risk for malpractice lawsuits?	65
35. What must be proved in a malpractice case?	65
36. Give some examples of patients who place a provider at high risk for a malpractice suit.	66
37. What clinical problems tend to get emergency physicians into malpractice difficulty?	66
38. What is the most common error emergency physicians make with regard to their malpractice insurance policy?	66
39. What common deficiencies in the medical record exacerbate malpractice problems for emergency physicians?	66
40. What systems problems often lead to lawsuits?	67
41. When a patient refuses care, what are the two criteria that must be present?	67
42. What clinical problem-solving approach is most helpful in avoiding lawsuits?	67
43. What physician behaviors may help avoid lawsuits?	67
44. How can writing admission orders for patients cause problems for the emergency physician?	68
45. What are the criteria for reporting a physician to the National Practitioner Data Bank (NPDB)?	68
46. How can clinical policies (evidence-based practice guidelines) decrease malpractice risk for the emergency physician?	68
47. How can clinical policies potentially increase malpractice risk for emergency physicians?	68
48. Does emergency medicine residency training decrease my malpractice risk?	68
Bibliography	68
Questions	69.e1
11 Emergency Medicine Observation Medicine	70
Abstract	70.e1
Keywords:	70.e1
1. What is observation care?	70
2. What type of patients are appropriate for observation services?	70
3. How common are EDOUs?	70
4. What are some typical diagnoses that are appropriate for ED observation?	70
5. Can EDOUs provide services to pediatric patients?	70
6. What are some common pediatric conditions of patients admitted to an EDOU?	71
7. How does care provided in an EDOU compare with inpatient care for the same conditions?	71
8. I have heard that time is an important factor for observation. Why is it important and how is it calculated?	71
9. Does the time of ED services count toward observation time?	71
10. Does observation care have to occur in an observation unit?	71
11. What is the advantage of ED observation medicine to hospitals?	71
12. What are the different types of observation billing codes?	71
13. What is the difference from a billing and reimbursement perspective between an emergency medicine visit and an observation visit?	71
14. What is the difference between observation and inpatient services?	71
15. What is the difference between ED and non-ED (hospital-based) observation services?	72
16. Can patients be admitted to observation for only 24 hours?	72
17. What is required to bill for observation services?	72
18. I heard that there is some recent controversy about Medicare patients admitted for observation care. What is the issue?	72
References	72
Questions	73.e1
12 Performance Evaluation and Improvement in Emergency Medicine	74
Abstract	74.e1
Keywords:	74.e1
1. Why should I care about my performance in my delivery of health care?	74
2. What are the broad aims specified in the NQS?	74
3. What are the priorities outlined by the NQS?	74
4. How will this impact me and my practice?	74
5. Aside from CMS, who are the other major players in performance measures and performance measurement?	74
6. Please elaborate on the impact on reimbursement.	75
7. What are some examples of current emergency medicine provider performance measures that are in effect now?	75
8. Are there other performance measures related to emergency medicine?	75
9. Who can specify these performance measures?	75
10. What are some of the problems with performance measure development?	75
11. Are there any significant changes planned by CMS in dealing with performance measures?	75
12. How is cost of care playing into performance measures?	75
13. What other developments have there been in the area of addressing rising health care costs?	76
14. What are the Choosing Wisely recommendations from ACEP?	76
15. Have other lists been developed that I should think about?	77
16. Are there Choosing Wisely recommendations made by other specialties that might apply to emergency medicine?	77
17. These are recommendations for use of specific studies. Is there an overarching philosophy that I can use to guide me in appropriately ordering diagnostic studies?	77
18. Should I order tests to “cover” myself?	77
19. How much can be saved with no compromise in patient care?	77
Bibliography	78
Questions	78.e1
II Primary Complaints	79
13 Altered Mental Status and Coma	79
Abstract	79.e1
Keywords:	79.e1
1. What is coma? What terms should be used to describe altered sensorium?	79
2. What causes coma?	79
3. How can I remember the causes of coma and altered mental status?	79
TIPS	79
VOWELS	79
4. What important historical facts should be obtained from the patient with altered mental status or coma?	79
5. How can I perform a brief, directed physical examination on a patient with altered consciousness?	79
6. How do I evaluate the patient’s mental status?	80
7. What is the Glasgow Coma Scale?	80
8. How important is measuring the temperature of the patient who is comatose?	80
9. What is the significance of other vital signs?	80
10. What is the Cushing reflex?	81
11. Define decorticate and decerebrate posturing.	81
12. What information can be obtained from the eye examination of the patient who is comatose?	81
13. I want to impress the attending physicians. Do you have any tips on physical examination that will let me assume my rightful position as star student?	81
14. Which diagnostic tests should be obtained in the patient with a significantly altered level of consciousness?	81
15. Which radiologic studies should be obtained in the patient who is comatose?	81
16. When should I order a CT scan of the head?	81
17. When should a lumbar puncture (LP) be done?	82
18. I have made the diagnosis of coma. What are my initial treatment priorities?	82
19. I’ve addressed the ABCs. What do I do next?	82
20. I think my patient is faking it. How can I tell if this is psychogenic coma?	82
21. My patient has a history of seizures. Is there any special diagnosis I should consider?	83
22. What is locked-in syndrome?	83
Bibliography	83
Questions	83.e1
14 Fever	84
Abstract	84.e1
Keywords:	84.e1
1. What temperature constitutes a fever?	84
2. Are all methods of measuring temperature equivalent?	84
3. How does the body create fever?	84
4. What is the difference between a fever and hyperthermia?	84
5. How do I address a patient with a subjective fever at home who is afebrile in the ED?	84
6. Does the degree of fever indicate the severity of the illness?	84
7. What is the best way to reduce a fever?	85
8. What are the causes of fever?	85
9. Which medications can cause fevers?	85
10. What are some key elements of the history and physical in patients with fever?	85
11. What is the relationship between fever and tachycardia?	86
12. Do all patients with sepsis have a fever?	86
13. Should everyone with a fever get antibiotics?	86
14. What is a neutropenic fever?	86
15. What is a fever of unknown origin (FUO)?	86
16. Is there anything unique about fever in the elderly?	86
17. How long do typical febrile illnesses last?	86
Controversy	86
18. Is a fever a friend or foe?	86
19. Many physicians recommend alternating or combined acetaminophen and ibuprofen for fevers. Is this effective?	87
20. Should antipyretics be given routinely after pediatric immunizations to prevent fevers?	87
21. Should antipyretics be given to prevent febrile seizures?	87
Acknowledgment	87
Bibliography	87
Questions	88.e1
15 Chest Pain	89
Abstract	89.e1
Keywords:	89.e1
1. Why is the cause of chest pain often difficult to determine in the ED?	89
2. What life-threatening causes of acute chest pain must be considered first when evaluating a patient in the ED?	89
3. What are examples of other conditions that may present with chest pain?	89
4. Why is the location of chest pain not diagnostic of its cause?	89
5. What is the best initial approach to patients with chest pain?	90
6. How do I initially evaluate the patient with chest pain?	90
7. What are the major risk factors associated with ischemic heart disease, PE, and aortic dissection?	90
8. Is knowing risk factors for cardiac ischemia useful in the ED?	90
9. Are there any useful clinical prediction rules for stratifying patients with suspected PE according to their level of risk?	90
10. Is radiation of chest pain significant?	90
11. How does the patient’s appearance correlate with the origin of chest pain?	90
12. How are vital signs helpful?	92
13. Which physical examination findings may help differentiate the causes of acute chest pain?	92
14. How is the ECG helpful in the evaluation of chest pain?	92
15. What abnormalities may appear on the chest radiograph in diseases causing chest pain?	92
16. Are cardiac enzymes useful in the evaluation of chest pain in the ED?	93
17. Is bedside ultrasound useful in identifying the cause of emergency chest pain?	93
18. Are there any other bedside tests or medications that may help to identify the origin of acute chest pain?	93
19. Are there any other useful diagnostic imaging studies to help determine the cause of chest pain?	93
20. What special considerations must be taken into account when evaluating chest pain in patients patients who are geriatric, have diabetes, or are female?	93
21. Is provocative stress testing useful in the emergent assessment of chest pain?	94
22. Approximately 2% to 4% of patients with chest pain caused by acute MI are discharged to home. What factors have been associated with failure to make the diagnosis?	94
Acknowledgments	94
Bibliography	95
Questions	95.e1
16 Abdominal Pain, Nausea, and Vomiting	96
Abstract	96.e1
Keywords:	96.e1
Abdominal Pain	96
1. What is the difference between visceral and somatic pain? How is this of practical importance?	96
2. What is the difference between localized and generalized peritonitis?	96
3. Which tests for peritoneal irritation are best?	96
4. Why is it important to establish the temporal relationship of pain to vomiting?	96
5. What is the relationship of peritoneal inflammation to loss of appetite?	96
6. Discuss the pitfalls of evaluating elderly patients with acute abdominal pain.	97
7. What other factors should be sought in the history that may alter significantly the presenting symptoms of patients with abdominal pain?	97
8. What is the significance of obstipation?	97
9. What vital sign is associated most closely with the degree of peritonitis?	97
10. Does the duration of abdominal pain help in categorizing cause?	97
11. Name the two most commonly missed surgical causes of abdominal pain.	97
12. Is there a place for narcotic analgesics in the management of acute abdominal pain of uncertain cause?	97
13. Which are the most useful preliminary laboratory tests to order?	97
14. Are plain radiographs always indicated in the initial evaluation of suspected small bowel obstruction?	98
15. Is oral contrast necessary when performing CT scans for suspected appendicitis?	98
16. Do all patients with uncomplicated appendicitis require surgery?	98
17. A 7-year-old child comes to the ED with acute abdominal pain and a history of several similar bouts over the past 5 months. Physical examination is unremarkable. What is the most likely cause?	98
18. A patient with severe abdominal pain is found to be suffering from DKA. How do I decide whether the abdominal pain is a manifestation of the DKA or whether a surgical condition has precipitated the DKA?	98
19. Is a rectal examination necessary in the patient with suspected acute appendicitis?	98
20. Is there a reliable diagnostic test that will either rule in or rule out appendicitis?	98
Nausea and Vomiting	99
21. Vomiting? Do I really need to read this section when there are so many more interesting topics in this book?	99
22. What causes vomiting?	99
23. Can vomiting itself lead to potential complications?	99
24. List the common causes of vomiting.	99
25. Are there different gastrointestinal causes of vomiting in children?	99
26. Can the character of the vomit help me make a diagnosis?	99
27. What else do I need to ask the patient?	99
28. What do I look for during the physical examination?	100
29. Are laboratory tests indicated?	100
30. When should I order radiographs?	100
31. How should I treat the vomiting patient?	101
32. What medications should I use?	101
Bibliography	102
Abdominal Pain	102
Nausea and Vomiting	103
Questions	103.e1
17 Headache	104
Abstract	104.e1
Keywords:	104.e1
1. How common are headaches, and what percentage of patients in the ED have headache as a chief complaint?	104
2. When someone has a headache, what exactly is it that hurts?	104
3. Name the most common headaches for which patients seek treatment.	104
4. What causes of headache are cannot miss?	104
5. What are some clinical clues to distinguish primary headaches from cannot miss headaches?	104
6. Why are age and context important in the history of a patient with a headache?	105
7. What questions in the history are most important to ask in evaluating a patient with a headache?	106
8. Does the physical examination add any information?	106
9. What is the sensitivity of a noncontrast, head computed tomography (CT) for detection of a SAH?	106
10. What are the CSF findings in an SAH?	106
11. How do I differentiate between a traumatic tap and an SAH?	106
12. If the CT and LP are both normal, do I need to pursue the diagnosis of SAH with some form of angiography?	107
13. What are migraine headaches?	107
14. If a headache patient improves or the pain completely resolves with sumatriptan or ketorolac, does that mean that the diagnosis is migraine (or some other primary headache cause)?	108
15. What specific entities must be considered in patients with a headache and a history of cancer or immunosuppression?	108
16. What specific diagnosis should be considered in older patients with a new-onset headache and general malaise or other systemic symptoms?	108
17. What is a sentinel bleed?	108
18. How do I treat a migraine headache?	108
19. How are cluster headaches different from migraines? How are they treated?	108
20. How do I treat tension headaches?	109
21. Which toxin may bring in entire families complaining of headache?	109
22. Does sinusitis commonly cause headache? If a CT scan shows sinusitis, is that the likely cause of a patient’s headache?	109
23. What special diagnostic considerations must be given to a patient with AIDS and headache?	110
24. What rapidly progressive infectious entity presents with headache, fever, and altered mental status?	110
25. What is idiopathic intracranial hypertension, and what is the complication if not treated appropriately?	110
26. Which cranial nerves pass through the cavernous sinus?	110
27. How common are headaches in children?	110
28. What is a blood patch?	110
29. Are there other forms of low-pressure spinal headache?	111
30. In the pregnant (or recently postpartum) woman, are there particular causes of headache that I should worry about?	111
31. Is high blood pressure causing my patient’s headache?	111
32. When should I be concerned about a brain tumor?	111
Bibliography	112
Questions	112.e1
18 Syncope, Vertigo, and Dizziness	113
Abstract	113.e1
Keywords:	113.e1
1. Do I need to be concerned by a complaint of dizziness?	113
2. How do I approach the vague and ill-defined complaint of dizziness?	113
3. What causes dizziness?	113
4. How does the vestibular system work?	113
5. How do you differentiate central versus peripheral vertigo?	113
6. What are the common characteristics of peripheral vertigo?	113
7. What are the characteristics of central vertigo?	114
8. What are the key points for the main causes of peripheral vertigo?	114
9. What should be included in the physical examination of a patient with vertigo?	114
10. How is nystagmus evaluated in the workup of vertigo?	114
11. What is the head thrust maneuver? What does it mean?	114
12. What is the Dix-Hallpike maneuver?	115
13. What is the Epley maneuver?	115
14. How do I treat peripheral (and central) vertigo?	115
15. What is syncope?	116
16. What are the odds of determining the cause of a syncopal episode?	116
17. Discuss the causes of syncope as related to the head.	116
18. Discuss the cardiovascular causes of syncope.	116
19. What about the vascular causes of syncope?	116
20. Summarize the initial concerns when treating a patient with syncope.	116
21. I’ve ruled out the immediate life threats. Now what do I do?	117
22. What components of the history are most important?	117
23. How do I know it was not a seizure?	117
24. What is a directed physical examination?	117
25. What tests are needed to assist in diagnosis?	117
26. Who needs an ECG? What am I looking for?	117
27. If the basic evaluation is not diagnostic, who should receive further testing?	117
28. What factors help to assign a patient to a high-risk or low-risk group?	117
Acknowledgment	118
Bibliography	118
Questions	118.e1
19 Seizures	119
Abstract	119.e1
Keywords:	119.e1
1. What is a seizure?	119
2. How are seizures classified?	119
3. What are the causes of seizures?	119
4. What is included in the differential diagnosis of seizure?	119
5. What should my priorities be in managing a patient who is actively experiencing a seizure?	119
6. What do I do if the seizure does not stop?	119
7. What is status epilepticus? How is it managed?	120
8. Which historical and physical findings suggest a seizure?	120
9. In addition to the neurologic examination, what other parts of the physical examination are important?	120
10. What ancillary testing should I do in the patient with a history of seizures?	120
11. And if the patient does not have a history of seizures?	121
12. What imaging studies are indicated?	122
13. What should be the disposition of the patient who has a seizure?	122
14. What discharge instructions should the patient receive?	123
15. Should I start antiepileptic medication before discharge in the patient with a new seizure?	123
16. What is a pseudoseizure?	123
17. Name some etiologies of seizures that generally do not respond to the usual medications, and name the antidote (adult doses).	123
18. What are simple febrile seizures?	123
Acknowledgment	123
Bibliography	124
Questions	124.e1
20 Anaphylaxis	125
Abstract	125.e1
Keywords:	125.e1
1. What is anaphylaxis?	125
2. What is an anaphylactoid reaction?	125
3. Name the most common causes of anaphylaxis.	125
4. How do I make the diagnosis clinically?	125
5. What are the most common signs and symptoms?	125
6. What percentage of patients who come to the ED with anaphylaxis have no known history of allergies or anaphylaxis?	125
7. What is the role of diagnostic studies?	125
8. What is the differential diagnosis?	126
9. What is the most common form of anaphylaxis, and how is it treated?	126
10. What is HAE? How is it related to anaphylaxis?	126
11. How does the treatment of HAE differ from that of anaphylaxis?	126
12. Should I treat HAE and drug-induced angioedema in the same way?	126
13. Summarize the initial treatment for life-threatening forms of anaphylaxis.	126
14. What are the adjuncts to initial epinephrine and airway management?	126
15. What percentage of children who require IM epinephrine require a second dose?	127
16. What are the complications of bolus IV epinephrine administration?	127
17. What is biphasic anaphylaxis? How common is it?	127
18. Is there a role for prophylactic treatment in anaphylaxis? How is this performed?	127
19. What about steroids?	127
20. What is the disposition of a patient who initially responds to aggressive treatment?	127
21. What follow-up instructions are given to patients treated for anaphylaxis?	127
22. Is there an advantage of IM over subcutaneous epinephrine injection?	128
Bibliography	128
Questions	128.e1
21 Low Back Pain	129
Abstract	129.e1
Keywords:	129.e1
1. Can I skip this chapter?	129
2. What are the common causes of LBP?	129
3. What are the emergent causes of LBP?	129
4. How should I focus my history?	130
5. How should I focus my physical examination?	130
6. What does it mean when a patient with LBP also has leg pain?	131
7. How do I perform an SLR test? How do I interpret the results?	131
8. What imaging or laboratory testing should be routinely performed?	132
9. What should I know about children who come to the ED with back pain?	132
10. Is there a difference between spondylosis, spondylolysis, and spondylolisthesis?	132
11. How should patients with LBP be treated in the ED?	132
12. Who should be hospitalized for treatment?	132
13. How should patients with musculoskeletal LBP be treated as outpatients?	132
14. What aftercare instructions should I give my patients?	133
15. What happens to patients with LBP when they leave the ED?	133
Bibliography	133
Questions	133.e1
III Nontraumatic Illness	134
22 Nontraumatic Ocular Emergencies	134
Abstract	134.e1
Keywords:	134.e1
1. What are some tricks to evaluate the red eye?	134
2. What typical findings help with the differential diagnosis of the red eye?	134
3. What is conjunctivitis?	134
4. How is conjunctivitis treated?	134
5. What is endophthalmitis?	134
6. What is the difference between periorbital and orbital cellulitis?	134
7. How do I differentiate clinically between periorbital and orbital cellulitis?	134
8. What is the common clinical presentation of cavernous sinus thrombosis?	135
9. Describe the clinical presentation of iritis.	136
10. How is iritis treated?	136
11. What is acute angle-closure glaucoma?	136
12. How is acute angle-closure glaucoma treated?	136
13. What is a subconjunctival hemorrhage?	136
14. What are some common diseases of the cornea?	137
15. What are some of the unique issues regarding ophthalmologic pharmacology?	137
16. Name some of the considerations involving pupillary dilation.	137
17. What does the presence of an afferent pupillary defect (APD), also known as a Marcus Gunn pupil, indicate?	137
18. In a patient with anisocoria, how does one determine which pupil is abnormal?	137
19. What are common causes of a miotic pupil?	138
20. Is there another cause of light-near dissociation?	138
21. What are some common causes of nontraumatic loss of vision?	138
22. Describe the presentation and treatment of central retinal artery occlusion and central retinal vein occlusion.	138
23. What are other causes of sudden painless monocular loss of vision?	138
24. How do optic neuritis and papilledema differ?	139
25. What are a couple of tricks to prove that a patient can see?	139
Bibliography	139
Questions	139.e1
23 Nontraumatic Ear, Nose, and Throat Emergencies	140
Abstract	140.e1
Keywords:	140.e1
Epistaxis	140
1. What are the most common causes of epistaxis?	140
2. Doesn’t hypertension cause epistaxis?	140
3. Does bleeding originate from any one particular source?	140
4. List the key questions to ask the patient.	140
5. Summarize the key points to successful management of nosebleeds.	140
6. How do I treat epistaxis?	140
7. Any pearls about treatment with silver nitrate?	141
8. What are the important discharge instructions?	141
9. How do I diagnose posterior epistaxis?	142
10. Do I discharge a patient to home with a posterior pack?	142
11. When should I consult an ENT specialist?	142
12. What is the role of interventional radiology (IR)?	142
13. Didn’t you forget to mention laboratory studies?	142
Foreign Bodies	143
14. How should I remove a foreign body from the ear?	143
15. What symptoms do patients with nasal foreign bodies show?	143
16. Is there any special trick to removing foreign bodies from the nose?	143
17. “I think I’ve got something stuck in my throat.” How is the patient with this complaint managed?	143
18. If the physical examination does not reveal the foreign body, what should be done next?	143
19. If I can see a foreign body, how do I remove it?	144
20. Any other pearls?	144
Sinusitis	144
21. What is sinusitis? What are the common causes?	144
22. How do I make the diagnosis?	144
23. Which other diagnostic studies should I pursue?	145
24. How is sinusitis treated?	145
25. Which patients need referral and admission? What are the complications?	145
26. Any other pearls?	145
Epiglottitis	146
27. How did George Washington die?	146
28. List the signs and symptoms of epiglottitis in adults.	146
29. What is the thumbprint sign?	146
30. Name the most common organisms identified in adult epiglottitis.	146
31. How do I manage epiglottitis? What signs and symptoms indicate the need for airway intervention?	146
32. How is the definitive diagnosis of epiglottitis made?	146
Otitis Externa	147
33. How does otitis externa present?	147
34. What bacteria are usually responsible?	147
35. How is it treated?	147
36. What is malignant otitis externa?	147
Peritonsillar Abscess	147
37. State the typical signs and symptoms seen with peritonsillar abscess (quinsy).	147
38. What are the treatment options for a peritonsillar abscess?	147
39. Describe the presentation of a retropharyngeal abscess.	148
40. Why is this diagnosis so concerning?	148
41. What organisms are found in retropharyngeal and peritonsillar abscesses?	148
42. How is a retropharyngeal abscess diagnosed and treated?	148
Acute Mastoiditis	148
43. What is mastoiditis?	148
44. How do I make the diagnosis?	148
45. What are the complications?	149
46. How do I treat mastoiditis?	149
Acknowledgment	149
Bibliography	149
Questions	149.e1
24 Dental and Oral Surgical Emergencies	150
Abstract	150.e1
Keywords:	150.e1
1. For what conditions should I emergently consult the dental team versus the oral surgery team? Which other conditions require urgent follow-up care (24 to 48 hours)?	150
2. What are the important anatomic structures of the orofacial region?	150
3. How are teeth numbered?	150
4. How should I examine the orofacial region?	150
5. How do you examine the temporomandibular joint (TMJ)?	150
6. How do I assess open TMJ lock?	150
7. How do you treat open TMJ lock?	151
8. How do I examine the parotid gland and parotid duct?	151
9. What are some causes of parotid swelling?	152
10. Which sensory nerves innervate the orofacial structures, and how can they be anesthetized?	152
11. How are dental injuries treated?	152
12. What is a dental concussion and how is it treated?	152
13. What is a subluxation, and how is it treated?	152
14. What is luxation of a tooth, and how is it treated?	152
15. What is intrusion of a tooth, and how is it treated?	153
16. What is extrusion of a tooth and how is it treated?	153
17. How is an avulsed tooth treated by emergency medical services (EMS) on scene?	153
18. How should I treat avulsion of a tooth in the ED?	153
19. What are the tooth fracture classifications, and how are they treated?	153
20. What are the signs of maxillary and mandibular fractures?	154
21. What imaging should be ordered for known or suspected facial fractures?	154
22. What is an alveolar housing fracture?	154
23. How are mandible fractures classified?	154
24. Which fractures require antibiotics?	154
25. How are odontogenic abscesses treated?	154
26. Which spaces are typically involved with infections of odontogenic origin?	155
27. What are the indications for admitting odontogenic infections?	155
28. What is alveolar osteitis?	155
29. How is alveolar osteitis treated?	155
30. What is Ludwig’s angina?	155
31. What is Lemierre syndrome?	156
32. What are some causes of gingival bleeding and potential treatments?	156
33. Describe the process for closing perioral and intraoral lacerations.	156
34. How do I close a wound if tissue has been avulsed?	156
35. How do you treat animal bites to the orofacial region?	156
36. What is noma and how is it treated?	157
37. Patients taking bisphosphonate medications are at risk of developing what intraoral condition?	157
Acknowledgment	157
Bibliography	157
Questions	157.e1
IV Central Nervous System	158
25 Transient Ischemic Attack and Cerebrovascular Accident	158
Abstract	158.e1
Keywords:	158.e1
1. What is a cerebrovascular accident (CVA) or stroke?	158
2. What are the major types of acute stroke?	158
3. What are the causes of ischemic stroke?	158
4. What are the types of hemorrhagic stroke?	158
5. What are the causes of ICH?	158
6. What is the most common cause of SAH?	158
7. What are some of the potential mimics of acute stroke?	158
8. What is the definition of a transient ischemic attack (TIA)?	159
9. Why should I be concerned about a TIA?	159
10. Are there prognostic scoring systems that can be used to determine the risk associated with a TIA?	159
11. Do patients with suspected TIA have to be admitted to the hospital?	159
12. How do I differentiate between TIA and stroke?	159
13. How do I approach a patient with acute stroke symptoms?	160
14. Why is the time of onset an important historical factor for an acute stroke?	160
15. What bedside tests should be performed on patients with suspected CVA?	160
16. What laboratory tests should be performed on patients with suspected CVA?	160
17. What imaging test should be performed on patients with suspected CVA?	160
18. What historical factors are typical for SAH?	160
19. What is the sensitivity of noncontrast CT of the head for SAH?	160
20. If the noncontrast head CT is negative, what is the next step in a caring for patient with suspected SAH?	161
21. When should I consider extracranial arterial dissection as a cause of acute stroke?	161
22. What is a primary stroke center?	161
23. What role do prehospital personnel play in patients with suspected stroke?	161
24. What medications should be started in the ED for acute stroke?	161
25. What is the appropriate time frame from symptom onset to administration of systemic thrombolytics?	161
26. Do systemic thrombolytics save lives in patients with possible stroke?	161
27. What is the evidence for tPA in acute ischemic stroke?	161
28. What is the risk of tPA?	162
29. What is the importance of the National Institutes of Health Stroke Scale (NIHSS)?	162
30. What are the indications and contraindications for tPA?	162
31. Why is there controversy with tPA for acute ischemic stroke?	162
32. Is informed consent required before tPA administration?	163
33. What must I do after giving tPA?	163
34. Are there alternatives to systemic tPA for acute ischemic stroke?	163
35. How should I manage ICH in the setting of tPA?	163
36. What are the indications for aspirin therapy in the patient with acute ischemic stroke?	164
37. What are the indications for heparin in ischemic stroke?	164
38. How do I approach hypertension in the patient with acute ischemic stroke?	164
39. What should I do to treat the patient who is taking anticoagulant drugs and who has hemorrhagic stroke?	164
40. What about patients taking novel oral anticoagulants (NOACs)?	164
Acknowledgment	165
Bibliography	165
Questions	165.e1
26 Meningitis	166
Abstract	166.e1
Keywords:	166.e1
1. What is meningitis, and why is it important?	166
2. What are the causes of meningitis?	166
3. Which organisms are most commonly involved in each age group?	166
4. Who is at risk for meningitis?	166
5. List the common presenting symptoms of meningitis.	166
6. What clinical signs are characteristic of meningeal irritation?	166
7. List the presenting signs of meningitis in infants.	167
8. If the symptoms are not specific and physical findings are absent, what are the indications for lumbar puncture (LP)?	167
9. What tests should be done before doing an LP?	167
10. What is the most common error in ED management of meningitis?	168
11. Discuss the risks of LP.	168
12. What are the contraindications to performing an LP?	168
13. What is the secret to performing LP successfully?	168
14. When is it essential to perform the LP with the patient lying down?	168
15. What can cause a falsely elevated intracranial pressure?	168
16. Which laboratory studies should be ordered on the CSF?	168
17. What findings on LP are consistent with bacterial meningitis?	168
18. Which antibiotics should be prescribed when the causative organism is unknown?	169
19. What about steroids?	169
20. Do people exposed to a patient with meningitis need antibiotics?	170
Bibliography	170
Questions	170.e1
V Respiratory System	171
27 Breathing and Ventilation	171
Abstract	171.e1
Keywords:	171.e1
1. How useful is the respiratory rate in the evaluation of a patient?	171
2. Which breathing patterns are associated with pathologic conditions?	171
3. Which pulmonary function tests are commonly used in the ED?	171
4. How does pulse oximetry work?	171
5. When might the pulse recorded from the pulse oximeter be different than that shown on the cardiac monitor?	172
6. How can pulse oximetry be useful?	172
7. In which situations can pulse oximetry yield false readings?	172
8. Why can a good pulse oximetry reading be falsely reassuring?	172
9. What is end-tidal CO2 (EtCO2) monitoring?	172
10. When is EtCO2 monitoring useful?	172
11. What percentage of fraction of inspired oxygen (FiO2) corresponds with the various types of oxygen delivery systems?	172
12. What is noninvasive ventilation?	173
13. What forms of noninvasive ventilation are available to emergency physicians?	173
14. In what circumstances would noninvasive ventilation be preferred over standard invasive ventilation?	173
15. When is noninvasive ventilation contraindicated?	173
16. How do I determine the initial ventilator settings in someone who has just had his or her airway intubated?	173
17. Are ventilator settings always the same?	174
18. What are the different ventilator modes?	174
19. Are there different methods of delivering ventilation?	174
20. What are the most commonly used methods?	174
21. What is PEEP?	175
22. What is auto-PEEP?	175
23. What are the most common complications of mechanical ventilation?	176
24. How do I approach a patient on a ventilator with acutely worsening oxygenation or ventilation?	176
Acknowledgment	176
bibliography	176
Questions	176.e1
28 Asthma, Chronic Obstructive Pulmonary Disease, and Pneumonia	177
Abstract	177.e1
Keywords:	177.e1
Asthma	177
1. What is asthma, and what are the presenting symptoms of asthma exacerbation?	177
2. In addition to asthma, what should be included in the differential diagnosis of wheezing?	177
3. Which aspects of the asthmatic patient’s history are important to the current exacerbation?	177
4. Are there any helpful ancillary diagnostic tests?	178
5. What are the key objectives when treating an asthma exacerbation? How are they achieved?	178
6. How can I determine whether my patients are improving?	179
7. What measures are available if my patient is not responding as expected?	179
8. How should I decide whether a patient can be discharged or requires hospitalization?	179
9. What should be considered at time of discharge?	179
10. Does pregnancy change the management of acute asthma?	179
Chronic Obstructive Pulmonary Disease	180
11. What is COPD and what are the presenting symptoms of a COPD exacerbation?	180
12. In addition to COPD, what should be included in the differential diagnosis?	180
13. Which diagnostic tests are helpful in the management of COPD?	180
14. What is the role of pulmonary function tests (PFTs) for COPD?	181
15. What are the key objectives when treating a COPD exacerbation, and how are they achieved?	181
15. What about antibiotics?	181
16. How can I determine whether my patient is improving?	181
17. When should the airway of a patient with COPD be intubated?	181
18. How can I decide whether a patient can be discharged or requires hospitalization?	181
19. What should be considered at time of discharge?	182
20. When is ipratropium contraindicated in the management of patients with asthma or COPD?	182
Pneumonia	182
21. Why do I need to know about pneumonia?	182
22. How does a pulmonary infection develop? What predisposes people to it?	182
23. What are differences in presentation of typical pneumonia and atypical pneumonia?	182
24. What are the most common causative agents in CAP and nosocomial pneumonia?	183
25. What are the presenting signs and symptoms in a patient with pneumonia?	183
26. What diagnostic studies are useful in the evaluation of pneumonia?	184
27. What radiographic findings are helpful in making a microbiologic differential diagnosis?	184
28. How do I determine the disposition of a patient with pneumonia?	184
29. What treatment should be started in the ED?	186
30. Which antibiotic should I use?	186
31. Has the epidemiology of pneumonia changed in recent years?	186
32. What is the role of the sputum Gram stain and culture?	187
33. Are routine blood cultures helpful in the management of CAP?	188
Bibliography	188
Questions	189.e1
29 Venous Thromboembolism	190
Abstract	190.e1
Keywords:	190.e1
1. What is the Virchow triad of thromboembolism?	190
2. What two diseases represent the continuum of venous thromboembolism (VTE)?	190
3. What percentage of patients diagnosed with DVT have concomitant PE when studied?	190
4. What are major risk factors for VTE?	190
5. List other minor risk factors for VTE.	190
6. Are there any signs or symptoms of PE that are diagnostic?	190
7. Why is a clinician’s pretest probability for VTE so important?	190
8. When determining pretest probability for DVT, what are the Wells criteria?	190
9. Once I have calculated a patient’s Wells score for DVT, how do I interpret it?	191
10. What is the pulmonary embolism rule-out criteria (PERC) rule for PE?	191
11. How do I use the PERC rule?	191
12. When determining pretest probability for PE, what are the Wells criteria?	192
13. Once I have calculated the total Wells score for PE, how do I interpret it?	192
14. What other clinical decision rules have been validated to stratify patients with suspected VTE for risk?	192
15. What is a D-dimer test? How is it used?	192
16. Which patients can have VTE excluded, based on a negative D-dimer?	192
17. What are some clinical situations that cause a false-positive D-dimer test, lending to a decreased specificity?	192
18. What are two clinical situations that might cause a false-negative D-dimer result?	192
19. What noninvasive imaging methods are available for the diagnosis of DVT?	192
20. Can a single duplex ultrasound exclude DVT in isolation?	193
21. Are there classic chest radiography findings in patients with PE?	193
22. Are there classic electrocardiogram (ECG) findings in patients with PE?	193
23. What imaging studies can be used to evaluate PE?	193
24. What are the relative contraindications to CTA for PE?	193
25. What are the diagnostic test options for PE with the pregnant patient?	193
26. What happens if the diagnosis of PE is missed?	194
27. What is a massive PE?	194
29. What is a submassive PE?	194
29. What is the treatment for DVT?	194
30. What is the treatment for PE?	194
31. What is the role of low–molecular-weight heparin (LMWH) in the treatment of VTE?	194
32. Under what conditions can an inferior vena caval filter be considered in the treatment of VTE?	194
Bibliography	195
Questions	195.e1
VI Cardiovascular System	196
30 Congestive Heart Failure and Acute Pulmonary Edema	196
Abstract	196.e1
Keywords:	196.e1
1. What is congestive heart failure (CHF)?	196
2. What causes CHF?	196
3. Describe the symptoms of CHF.	196
4. What causes these symptoms?	196
5. Name the main determinants of cardiac function in CHF.	196
6. What is preload?	197
7. What are the effects of decreased contractility?	197
8. What about afterload?	197
9. What about HR?	197
10. How does this physiology relate to treatment?	197
11. Describe the role of B-type natriuretic peptides (BNPs) in CHF.	197
12. How do I interpret BNP levels?	197
13. How do patients with CHF appear upon arrival in the ED?	198
14. Discuss acute pulmonary edema.	198
15. How do patients with acute pulmonary edema usually experience symptoms?	198
16. What is the treatment of acute pulmonary edema?	198
17. What about drug therapy?	198
18. Are there other drugs that are useful in the treatment of acute pulmonary edema?	199
19. What about giving positive inotropic drugs?	199
20. When the initial treatment has begun, what else needs to be done?	199
21. Do all patients with CHF need to be admitted to the hospital?	199
22. What are the usual precipitating causes of CHF exacerbations?	199
23. What is the outpatient treatment of CHF?	200
24. How do ACE inhibitors work in CHF?	200
25. What is the long-term prognosis for patients with CHF?	200
Acknowledgment	200
Bibliography	200
Questions	200.e1
31 Ischemic Heart Disease	201
Abstract	201.e1
Keywords:	201.e1
1. How is ischemic heart disease classified?	201
2. How do patients with acute ischemic heart disease experience symptoms?	201
3. Which descriptors have the highest predictive value for true ACS?	201
4. To understand the discomfort better, what information should be obtained?	201
5. Describe the typical features of chest discomfort in stable angina.	201
6. How do patients with unstable angina experience symptoms?	201
7. What is Prinzmetal angina?	202
8. How does the pain of MI differ from that of angina?	202
9. What other symptoms are associated with the chest discomfort of ischemic heart disease?	202
10. Is there anything different about evaluating elderly patients?	202
11. Are there other groups at high risk for atypical presentation?	202
12. What are the risk factors associated with ischemic heart disease?	202
13. Should demographic features and the presence or absence of coronary risk factors change my mind about the diagnosis?	202
14. List the key elements of the initial evaluation of a patient with a suspected ACS.	202
15. What is the significance of abnormal ST-segment changes on an ECG?	203
16. How do I differentiate ST elevation owing to ischemia from other causes of ST elevation?	203
17. What is the typical course of ECG changes in ischemic cardiac injury?	203
18. Can the ECG be normal while a patient is having cardiac ischemia or an acute MI?	204
19. Are cardiac markers useful in the ED?	204
20. Can troponin be elevated in other conditions?	205
21. How can echocardiography be useful in ED patients with suspected ACS?	205
22. What other diagnoses should be considered in a patient with chest pain?	205
23. What are the indications for reperfusion therapy in acute MI?	205
24. What if persistent ST elevation is not present?	206
25. What is the preferred method of reperfusion therapy in acute MI with STEMI—thrombolytic therapy or PCI?	206
26. What if cardiac intervention is not available on site?	206
27. How do you choose which thrombolytic agent to use?	206
28. What is the preferred therapy for cardiogenic shock?	206
29. List the contraindications to thrombolytic therapy.	206
30. What other diagnoses should be considered before giving thrombolytic therapy?	207
31. What is the risk for fatal complications of thrombolytic therapy for acute MI?	207
32. What is the role of NTG?	207
33. Is there any use for morphine in patients with acute MI?	207
34. What other medications are useful adjuvants to reperfusion therapy?	207
35. When should β-blockers be given?	208
36. What other dysrhythmias occur with acute MI?	208
37. Which patients with unstable angina are at highest risk for MI and benefit from more aggressive treatment?	208
38. What is the management of unstable angina and NSTEMI?	209
39. Which is better, low–molecular-weight heparin or unfractionated heparin?	209
Bibliography	209
Questions	210.e1
32 Cardiac Dysrhythmias, Pacemakers, and Implantable Defibrillators	211
Abstract	211.e1
Keywords:	211.e1
1. What is a sinus beat?	211
2. What is the AV node?	211
3. Is it necessary to identify a dysrhythmia before treating it?	211
4. What is hemodynamic compromise?	211
5. How do I know whether a patient’s dysrhythmia is causing hemodynamic compromise?	211
6. How do I treat bradydysrhythmias?	211
7. How do I treat tachydysrhythmias?	211
8. What is a narrow-complex tachycardia?	212
9. How do I make the diagnosis of AF when the ventricular rate is fast?	212
10. How do I treat narrow-complex tachycardia in a hemodynamically stable patient?	212
11. Is there a time when I should not use adenosine or a calcium channel blocker for a narrow-complex tachycardia?	212
12. Define premature ventricular contraction.	212
13. What is a wide-complex tachycardia?	212
14. What is the most common cause of wide-complex tachycardia?	212
15. Does VT always cause a patient to be hemodynamically unstable?	213
16. What is a supraventricular rhythm with aberrancy?	213
17. Differentiate VT from SVT with aberrancy based on findings on the 12-lead ECG.	213
18. How do I treat wide-complex tachycardia?	213
19. What does amiodarone do?	213
20. What drug is contraindicated in the treatment of any wide-complex tachycardia?	213
21. What is synchronized cardioversion?	213
22. How do I perform synchronized cardioversion?	214
23. Does it make sense to use cardioversion with asystole?	214
24. When is it necessary to give anticoagulants to a patient with AF before cardioversion?	214
25. Should I be using monophasic or biphasic waveform defibrillation in the ED?	215
26. What is a pacemaker?	215
27. What are the indications for temporary pacemakers?	215
28. Where are external/transcutaneous pacemakers placed? How are they operated?	215
29. State the limiting factors in the use of external pacemakers.	215
30. Can an external pacemaker be used if a permanent pacemaker malfunctions?	215
31. What are the advantages of transvenous versus transcutaneous pacemakers?	215
32. How are transvenous and transthoracic pacemakers placed?	216
33. Can cardiopulmonary resuscitation (CPR) be performed with a pacemaker?	216
34. List the indications for a permanent pacemaker.	216
35. Describe the complications of permanent pacemaker implantation.	216
36. What does a pacer setting of DDD mean?	216
37. How can the type of permanent pacemaker be identified in the ED?	217
38. What is the most common cause of permanent pacemaker malfunction?	217
39. What is the most reliable indicator of pacer malfunction?	217
40. What does a magnet do?	217
41. How do I assess a patient with potential pacemaker malfunction?	217
42. What is pacemaker syndrome?	217
43. What is twiddler’s syndrome?	218
44. What is pacemaker-mediated tachycardia?	218
45. What is a runaway pacemaker?	218
46. What happens as pacemakers lose battery power?	218
47. Can a patient with a permanent pacemaker undergo defibrillation?	219
48. What is an AICD?	219
49. Discuss malfunctions associated with an AICD.	219
50. Name the most common type of AICD malfunction.	219
51. What will a magnet do when placed over an AICD?	219
Bibliography	219
Questions	220.e1
33 Hypertension, Hypertensive Crisis, Aortic Dissection, and Aortic Aneurysms	221
Abstract	221.e1
Keywords:	221.e1
1. What is the description of hypertension (HTN) according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) report?	221
2. How does the JNC8 report differ from the JNC7 report?	221
3. What is the difference between primary and secondary HTN?	221
4. What else might cause HTN, often transient, in the ED?	221
5. How do I explain to patients the importance of treating HTN?	222
6. Is diagnostic testing necessary in a patient with elevated BP and no symptoms in the ED?	222
7. Should treatment be initiated in the ED in asymptomatic patients with elevated BP?	222
8. What is a hypertensive emergency, or crisis?	222
9. What is hypertensive urgency?	222
10. What are the symptoms of patients with hypertensive emergency when they arrive in the ED?	223
11. What signs support the diagnosis of hypertensive crisis?	223
12. What diagnostic studies should be considered in a patient with a hypertensive emergency?	223
13. How do I diagnose hypertensive encephalopathy?	223
14. What is the pathophysiology of hypertensive encephalopathy?	223
15. How do I treat hypertensive encephalopathy?	224
16. What is the treatment threshold for HTN in ischemic stroke?	224
17. What are the recommendations regarding treatment of HTN in hemorrhagic stroke?	224
18. How do I treat HTN if it is associated with SAH?	224
19. How do I treat a patient with severe HTN and evidence of pulmonary edema?	224
20. How do I treat a patient with severe HTN and chest pain caused by ischemia?	224
21. What agents should I use to treat a patient with severe HTN and AKI?	225
22. What should I always think about in a pregnant or postpartum woman with HTN?	225
23. What antihypertensive medications, if stopped abruptly, can cause rebound HTN?	225
24. How do I treat catecholamine-induced hypertensive emergency?	225
25. What are the common parenteral antihypertensive medications and their indications and contraindications?	225
26. Can I use oral agents to treat hypertensive emergencies?	225
Aortic Dissection	225
27. How do aneurysms, pseudoaneurysm, and dissection differ?	225
28. Other than cardiac ischemia and aortic dissection, what causes chest pain in the hypertensive patient?	227
29. What are risk factors associated with aortic aneurysms?	227
30. What are the risk factors for aortic dissection?	227
31. What symptoms may be present in a patient with thoracic aortic dissection?	227
32. What physical examination findings may be present in a patient with thoracic aortic dissection?	228
33. What diagnostic imaging should be performed when thoracic aortic dissection is suspected?	228
34. What might I see on the chest radiograph of a patient with a thoracic aortic dissection?	228
35. What other tests should I perform?	228
36. What is the Stanford classification for aortic dissection?	228
37. How do I treat a patient with aortic dissection?	228
Abdominal Aortic Aneurysm	229
38. What are common presenting signs and symptoms of an AAA?	229
39. What common diseases may mimic ruptured AAA?	229
40. What are the risks of rupture in AAA?	229
41. What is the presentation of a ruptured AAA?	229
42. How do I treat a patient with a suspected ruptured AAA?	229
43. What are the dilemmas of aggressive fluid resuscitation in a hypertensive patient with ruptured AAA?	230
44. When should a symptomatic unruptured AAA be repaired?	230
45. How are AAAs surgically repaired?	230
46. What are the complications of endovascular aortic repair (EVAR)?	230
Acknowledgement	231
Bibliography	231
Questions	231.e1
34 Pericarditis and Myocarditis	232
Abstract	232.e1
Keywords:	232.e1
Pericarditis	232
1. Describe a normal pericardium.	232
2. What is pericarditis?	232
3. What causes pericarditis?	232
4. Who is most susceptible to infectious pericarditis?	232
5. Describe the clinical presentation of pericarditis.	232
6. What are the electrocardiograph (ECG) findings in pericarditis?	232
7. How can acute pericarditis be distinguished from acute MI?	232
8. How can acute pericarditis be distinguished from musculoskeletal chest pain?	233
9. Is pericardial effusion a concern in patients with pericarditis?	233
10. Besides pericardial effusion, can acute pericarditis cause an MI?	233
11. How much pericardial effusion is significant?	233
12. How can a pericardial effusion be diagnosed?	233
13. What is cardiac tamponade?	233
14. How is cardiac tamponade diagnosed?	234
15. What is pulsus paradoxus?	234
16. What is the appropriate ED management of pericarditis?	234
17. What is the prognosis for patients with pericarditis?	234
18. Do pediatric patients get pericarditis?	234
Myocarditis	234
19. What is myocarditis?	234
20. What causes myocarditis?	235
21. When should a diagnosis of myocarditis be considered in the ED?	235
22. What clinical findings may be present?	235
23. Are there any chest radiograph or ECG abnormalities?	235
24. How is myocarditis diagnosed?	235
25. How can acute myocarditis be distinguished from acute MI?	235
26. Is myocarditis a concern in AIDS?	236
27. In what other clinical situations should myocarditis be considered?	236
28. Describe the appropriate ED management of a patient with myocarditis.	236
29. What is the prognosis for patients with acute myocarditis?	236
30. Does myocarditis present differently in children?	236
Bibliography	236
Questions	236.e1
VII Gastrointestinal Tract	237
35 Esophagus and Stomach Disorders	237
Abstract	237.e1
Keywords:	237.e1
1. How are gastrointestinal (GI) problems differentiated from acute myocardial infarction?	237
2. What is a GI cocktail?	237
3. What is heartburn?	237
4. How is reflux esophagitis treated?	237
5. What are the esophageal causes of odynophagia?	237
6. How does esophageal obstruction present?	237
7. How is esophageal obstruction treated?	238
8. What is Mallory-Weiss syndrome?	238
9. What causes esophageal perforation, and how is it diagnosed and treated?	238
10. What are causes of abdominal pain that are gastric or duodenal in origin?	238
11. What are the common causes of gastritis and PUD?	239
12. How does perforated PUD present?	239
13. What differentiates upper from lower GI hemorrhage?	239
14. Do all patients with only lower GI bleeding require nasogastric (NG) tube placement?	239
15. How is a patient classified as low risk for having occult upper GI bleeding?	239
16. What are the causes of upper GI bleeding?	240
17. Discuss the emergency management of upper GI bleeding.	240
18. What medications improve GI bleeding outcomes?	240
19. How should a patient with continued GI bleeding be managed?	241
20. Is placement of a NG or orogastric tube contraindicated in someone with esophageal varices?	241
21. Should most patients with upper GI bleeding undergo endoscopy?	241
22. What is the disposition for patients with GI bleeding?	241
23. What are the criteria that allow a patient with low-risk upper GI bleeding to be sent home?	241
Bibliography	242
Questions	242.e1
36 Bowel Disorders	243
Abstract	243.e1
Keywords:	243.e1
1. When do I consider evaluating a patient for appendicitis?	243
2. What is the pathogenesis of acute appendicitis?	243
3. How does appendicitis present clinically?	243
4. Is the physical examination reliable in appendicitis?	243
5. What laboratory tests are helpful in evaluating RLQ pain?	243
6. What radiologic study is best at imaging the appendix?	243
7. What is the treatment for appendicitis?	244
8. What is mesenteric ischemia?	244
9. How do patients with mesenteric ischemia experience symptoms?	244
10. How do I diagnose mesenteric ischemia?	244
11. How is mesenteric ischemia treated?	244
12. What is intussusception?	245
13. What is inflammatory bowel disease (IBD)?	245
14. How do CD and UC present?	246
15. What is the ED management for IBD?	246
16. Describe what happens during intestinal obstruction.	246
17. What are the common causes of mechanical small bowel obstruction (SBO)?	246
18. What are the clinical features of SBO?	246
19. Describe the radiographic findings in SBO.	247
20. What is the treatment for SBO?	247
21. What are the characteristics of an ileus?	247
22. How is an ileus treated?	247
23. What are the causes of large bowel obstruction (LBO)?	247
24. What are diverticula and what are common complications?	247
25. How does diverticulitis clinically present?	247
26. How do I manage diverticulitis?	248
27. What are common causes of lower GI bleeding?	248
28. How do I perform anoscopy?	248
29. What are hemorrhoids?	248
30. How do internal and external hemorrhoids differ?	248
31. How are hemorrhoids treated?	248
32. What is an anal fissure?	248
33. How do I treat an anal fissure?	248
34. Can I drain anorectal abscesses in the ED?	249
Bibliography	249
Questions	249.e1
37 Liver and Biliary Tract Disease	250
Abstract	250.e1
Keywords:	250.e1
1. What are the common manifestations of biliary disease?	250
2. Do all gallstones produce pain? Does a lack of stones preclude cholecystitis?	250
3. What is the Murphy sign?	250
4. Can a plain radiograph of the abdomen aid diagnosis?	250
5. What is the gold standard for diagnosing cholecystitis?	250
6. Describe the ultrasound findings in cholecystitis.	251
7. When should elective surgery be considered in patients with asymptomatic cholelithiasis?	251
8. What are Courvoisier law, Klatskin tumor, and Fitz-Hugh-Curtis syndrome?	251
9. What is porcelain gallbladder?	252
10. Are all gallstones created equal?	252
11. What is endoscopic retrograde cholangiopancreatography (ERCP)? What is the most common complication seen in the ED after an ERCP procedure?	252
12. What are liver function tests?	252
13. What is the difference between conjugated and unconjugated bilirubinemia?	252
14. State the major causes of acute hepatitis.	252
15. What are the risk factors for viral hepatitis? Which can result in a carrier state?	252
16. What is the new treatment for hepatitis C?	252
17. What is the most common form of liver disease in the United States?	252
18. What are discriminant function, the MELD score, and the Glasgow score?	253
19. What is the initial treatment of hepatic encephalopathy? What is asterixis?	253
20. What are complications of chronic liver disease to watch for in the ED?	253
21. Are there any special issues to watch for in the patient who has had a liver transplant?	254
Acknowledgment	254
Bibliography	254
Questions	254.e1
VIII Genitourinary Tract	255
38 Renal Colic and Scrotal Pain	255
Abstract	255.e1
Keywords:	255.e1
1. What are the most common forms of renal stones?	255
2. List factors that predispose to stone formation.	255
3. What lethal conditions are sometimes misdiagnosed as renal colic?	255
4. What clinical features help distinguish renal colic from other causes of abdominal pain?	255
5. What factors predict a high probability of ureteral stones?	255
6. In which patients would imaging be absolutely indicated to confirm the diagnosis of renal colic?	255
7. Why is helical computed tomography (CT) now the diagnostic test of choice for suspected ureteral calculus?	256
8. Is pregnancy a contraindication to CT of the kidney, ureter, and bladder (KUB)?	256
9. What IVP findings suggest a renal stone?	256
10. Why is the postvoid film important? What other special views are helpful?	256
11. What if the ureter is not visualized on the standard IVP?	256
12. Name the most common sites of ureteral stone impaction.	256
13. Can the likelihood of spontaneous passage be predicted based on the size and location of the stone?	256
14. What if the imaging study is normal, but the patient still appears to have renal colic?	256
15. Isn’t an ultrasound just as accurate as helical CT or an IVP?	257
16. List secondary signs of ureteral obstruction shown on helical CT.	257
17. What is the soft-tissue rim sign on helical CT? How is it useful?	257
18. What other tests are useful in the ED in patients with renal calculi?	257
19. Why is coexistent infection a major problem?	257
20. Has lithotripsy supplanted percutaneous and open surgical methods of stone removal?	257
21. What are the basics of ED treatment of renal colic?	257
22. Who requires hospitalization and/or urology consultation?	257
23. What advice should I give to patients being discharged from the ED?	258
24. Which analgesics are recommended for outpatient pain control?	258
25. Why should patients be given a urine strainer on discharge?	258
26. When should patients return to the ED?	259
27. What medical alternatives to active stone removal are available?	259
28. What is the differential diagnosis in a patient who has an acutely painful scrotum?	259
29. What is testicular torsion?	259
30. When is testicular torsion most likely to occur?	259
31. What history is suggestive of testicular torsion?	259
32. What clinical features are suggestive of testicular torsion?	259
33. What is the proper management of testicular torsion?	260
34. How is manual detorsion performed?	260
35. Is imaging testing helpful to confirm the diagnosis of testicular torsion?	260
36. What are the diagnostic imaging tests that can be used to evaluate the acute scrotum?	260
37. How is testicular torsion treated surgically?	260
38. What are appendix testis and appendix epididymis?	260
39. What are clinical features of torsion of testis and epididymal appendix?	260
40. How is torsion of testicular or epididymal appendix treated?	260
41. What is epididymitis?	260
42. List the most common causes of epididymitis.	261
43. What is the treatment for epididymitis?	261
44. What is Fournier gangrene?	261
45. What organisms are commonly seen with Fournier gangrene?	261
Bibliography	261
Questions	261.e1
39 Acute Urinary Retention	262
Abstract	262.e1
Keywords:	262.e1
1. What is acute urinary retention (AUR)?	262
2. Is there chronic urinary retention?	262
3. What is the most common cause of AUR? Who gets it?	262
4. How does benign prostatic hypertrophy (BPH) cause AUR?	262
5. List the other causes of AUR.	262
6. What are the important features in the history and physical examination?	263
7. Are there any red flags in the history and physical examination that might indicate a more serious, potentially surgical, cause?	263
8. How do I treat AUR?	263
9. What if I can not pass a Foley catheter?	263
10. Is a bigger catheter better?	263
11. What if nothing is working?	263
12. What is suprapubic catheterization? How is it done?	264
13. What diagnostic studies are useful in the evaluation of AUR?	265
14. Which medications may cause AUR?	265
15. Summarize the different neurogenic causes of AUR.	265
16. Name the most common complications of AUR.	266
17. What is autonomic dysreflexia/hyperreflexia, and what does it have to do with AUR?	266
18. What is postobstruction diuresis? How is it managed?	266
19. Who can I send home? Who needs admission? Can I remove that catheter?	266
20. Do medications play any role in the treatment of AUR?	266
Controversy	266
21. I have heard that gradual emptying of the distended bladder best helps prevent complications. Is this true?	266
Bibliography	267
Questions	267.e1
40 Urinary Tract Infection	268
Abstract	268.e1
Keywords:	268.e1
1. Define terminology pertinent to the range of urinary tract infections (UTIs).	268
2. What are the most common causes of UTI?	268
3. What is asymptomatic bacteriuria?	268
4. Should asymptomatic bacteriuria always be treated?	268
5. List the differential diagnoses of dysuria.	268
6. When should a pelvic examination be performed in a female patient with dysuria?	269
7. What tests can be done to evaluate for UTI?	269
8. When should a urine culture be ordered?	269
9. What comprises a complicated UTI?	269
10. What is the treatment for uncomplicated UTI?	270
11. Is there a role for nonantibiotic treatment?	270
12. What is the treatment for pyelonephritis?	270
13. Which patients with pyelonephritis require admission?	270
14. When should imaging be obtained for pyelonephritis?	270
15. What are the differences when treating complicated cystitis?	270
16. What is the presentation of acute bacterial prostatitis?	270
17. What is the treatment for acute prostatitis?	271
18. What are signs and symptoms of chronic bacterial prostatitis?	271
19. What is the treatment for chronic bacterial prostatitis?	271
Acknowledgment	271
Bibliography	271
Questions	271.e1
41 Chronic Kidney Disease and Dialysis	272
Abstract	272.e1
Keywords:	272.e1
1. Is kidney failure just another genitourinary disorder?	272
2. What are the special concerns in patients with kidney failure?	272
3. How is hemodialysis performed?	272
4. How is peritoneal dialysis (PD) performed?	272
5. What is the most common problem relating to the vascular access device in the ED?	272
6. How do I diagnose and treat a vascular access infection?	273
7. When can the vascular access device be used for giving intravenous (IV) infusions or for drawing blood?	273
8. How is PD-associated peritonitis diagnosed?	273
9. How is PD-associated peritonitis treated?	273
10. What are the indications for emergency dialysis?	274
11. What is unique about a dialysis patient with cardiac arrest?	274
12. What are the treatment options for acute pulmonary edema in patients with CKD?	274
13. How should I treat hyperkalemia in a dialysis patient?	274
14. What about air embolism?	275
15. How should a patient with acute shortness of breath be evaluated?	275
16. What are the main differential diagnostic considerations for chest pain in CKD?	275
17. What is the differential diagnosis of hypotension in a patient with CKD?	275
18. What are the major causes of altered mental status in patients with end-stage renal disease (ESRD)?	275
Bibliography	276
Questions	276.e1
IX Hematology/Oncology	277
42 Hemostasis and Coagulopathies	277
Abstract	277.e1
Keywords:	277.e1
1. What is meant by hemostasis?	277
2. Is hemophilia the main cause of hemostatic abnormality?	277
3. Do I really need to know the whole clotting cascade to manage patients?	277
4. What are the intrinsic and extrinsic coagulation pathways? How can I tell the difference?	277
5. What parts of the history and physical can help me assess a suspected bleeding abnormality?	278
6. How do I interpret PT, PTT, and international normalized ratio (INR)?	278
7. What are the causes of thrombocytopenia?	278
8. What are the differences between idiopathic and chronic thrombocytopenic purpura?	278
9. What are the five clinical signs of TTP?	278
10. What causes TTP? Is it worse than ITP?	279
11. What is HUS?	279
12. Should I worry about thrombocytopenia during a large-volume blood transfusion?	279
13. How does aspirin increase bleeding?	279
14. What are the indications for platelet transfusions?	279
15. What is the most common inherited bleeding disorder?	279
16. Do people with hemophilia A have low levels of factor VIII?	279
17. How is factor VIII dosed in hemophilia A?	280
18. What is Christmas disease?	280
19. What does Desamino-D-arginine vasopressin (DDAVP) do?	280
20. What factors are affected by vitamin K deficiency, warfarin, liver disease, and banked blood?	280
21. What happens in DIC?	280
22. What are heparin-induced thrombocytopenia (HIT) and HIT with thrombosis (HITT)?	280
23. Need help with hemolysis, elevated liver enzymes, and low platelet count (HELLP)?	281
24. How do heparin and LMWH work?	281
25. How do I treat hemorrhage secondary to heparin therapy?	281
26. How does warfarin work? How do I deal with elevated INR?	281
27. What about prothrombin complex concentrates (PCCs)?	282
28. What are all these new oral anticoagulants I keep hearing about?	282
29. That sounds great! So what’s the catch?	282
30. So what do I do if someone taking a factor Xa or thrombin inhibitor comes in with severe bleeding?	282
31. Can anything be done to control massive hemorrhage from trauma?	282
Bibliography	282
Questions	282.e1
43 Sickle Cell Disease	283
Abstract	283.e1
Keywords:	283.e1
1. What is sickle cell disease (SCD)?	283
2. What are the variants of SCD?	283
3. What is the epidemiology of SCD?	283
4. What is the pathophysiology of SCD?	283
5. What are the typical laboratory findings?	283
6. What are the causes of acute anemia in SCD?	284
7. What is an acute painful episode?	284
8. What are the triggers of acute painful episodes?	284
9. How is an acute painful episode treated?	284
10. Are patients with SCD at increased risk of infection?	284
11. How should I manage fever in a patient with SCD?	284
12. What is ACS?	285
13. What is the treatment of ACS?	285
14. Are patients with SCD at increased risk of cardiac complications?	285
15. What are the neurologic effects of SCD?	285
16. How does SCD affect pregnancy?	285
17. What is the role and indication for blood transfusion in SCD?	285
18. What are the types of transfusions that are available?	286
19. What are the interventions for priapism in SCD?	286
20. What are the ocular complications of SCD?	286
21. What are the orthopedic complications of SCD?	286
Acknowledgment	287
Bibliography	287
Questions	287.e1
44 Oncologic Emergencies	288
Abstract	288.e1
Keywords:	288.e1
1. What is an oncologic emergency?	288
2. Is this important in the ED?	288
3. Name several oncologic emergencies.	288
4. Which of the entities listed in Table 44-1 are life or limb threatening?	288
5. Tell me about these.	288
6. Are these common problems?	289
7. What other problems are common in patients with an underlying malignancy?	289
8. How is an oncologic emergency diagnosed?	290
9. What symptoms can be related to an underlying oncologic emergency?	290
10. When should the patient be admitted?	290
11. Anything special about care plans?	290
12. Can cancer be cured?	290
13. How is a patient with a terminal neoplastic disease treated?	290
Bibliography	290
Questions	290.e1
X Metabolism and Endocrinology	291
45 Fluids and Electrolytes	291
Abstract	291.e1
Keywords:	291.e1
1. Why is the study of fluid and electrolytes so difficult?	291
2. What is the anion gap (AG)?	291
3. Why must AG be calculated each time an electrolyte panel is evaluated?	291
4. There are two types of acidosis: wide gap and normal gap. What is hyperchloremic metabolic acidosis?	291
5. Is there an easy way to remember the differential diagnosis for wide gap metabolic acidosis?	291
6. What are the clues to each of the entities in MUDPILES?	291
7. What are the causes of narrow gap acidosis?	292
8. Why should normal saline (NS) or lactated Ringer (LR) solution, rather than half-normal saline (0.45 NS) dextrose in 5% water (D5W), be given to someone who needs volume replacement?	292
9. Which solution is better, NS or LR solution?	293
10. What is the most dangerous electrolyte abnormality? What are its most common causes?	293
11. What electrocardiogram (ECG) changes are associated with hyperkalemia?	293
12. Summarize the best treatment for hyperkalemia.	293
13. How can K+ be moved intracellularly?	293
14. After K+’s electrical effects have been counteracted (if indicated) and K+ has been driven intracellularly, how do I remove it from the body?	294
15. Discuss the most common causes of hyponatremia.	294
16. What is SIADH?	294
17. What are the classic neurologic signs of hyperkalemia? What are the classic ECG signs of hyponatremia?	294
18. How fast should hyponatremia be corrected?	295
19. Should Na+ levels ever be treated quickly?	295
20. What is osmolality? What is the osmolal gap?	295
21. How do I use the osmolal gap to figure out whether someone has ingested methanol or ethylene glycol?	295
22. What are the most common causes of hypercalcemia? How do they present?	295
23. Describe the emergency treatment of hypercalcemia.	295
References	296
Questions	296.e1
46 Acid-Base Disorders	297
Abstract	297.e1
Keywords:	297.e1
1. Which laboratory values do I need to determine a patient’s acid-base status?	297
2. Which six questions do I need answered to determine a patient’s acid-base status?	297
3. Name four types of primary acid-base disorders seen, describe the typical bicarbonate (HCO3) and partial pressure of carbon dioxide (PCO2) patterns, and give a common example of each.	297
4. How do I determine whether a primary respiratory disturbance is acute or chronic?	297
5. How do I determine whether compensation is adequate, and what is the physiologic limit of compensation?	298
6. What are the three ways I can identify more than one primary acid-base disturbance (a mixed disorder)?	298
7. What are four major etiologies of an AGMA, and which laboratory tests differentiate them?	298
8. Name three types of lactic acidosis, their causes, and examples of each.	299
9. Name a vitamin deficiency associated with a fatal lactic acidosis.	299
10. List disorders that can cause a hyperketonemic state.	299
11. In a patient with DKA who is clinically improving with appropriate therapy, why might the urine ketones increase?	299
12. How can glucose and albumin affect calculation of the AG?	299
13. How can a patient have a metabolic acidosis without evidence of an elevated AG?	300
14. How can I remember some of the causes of non-AGMA?	300
15. Which electrolyte is most commonly affected by a change in acid-base status?	300
16. What are potential causes of a metabolic acidosis in a patient with alcohol abuse?	300
17. What are the etiologies of a metabolic alkalosis?	300
18. How does a patient with metformin-associated lactic acidosis present, and what is the treatment?	300
19. How can the osmolal gap and the AG be used to differentiate toxic alcohol ingestions?	301
20. What etiologies should be considered when evaluating a patient with respiratory acidosis? How are they treated?	301
21. Why do patients suffer carpopedal spasms during hyperventilation?	301
Acknowledgment	301
Bibliography	301
Questions	301.e1
47 Diabetes Mellitus	302
Abstract	302.e1
Keywords:	302.e1
1. Describe the classifications of diabetes.	302
2. What are the diagnostic criteria for diabetes mellitus?	302
3. List the physiologic complications of hyperglycemia.	302
4. Describe the pertinent clinical and laboratory findings of DKA.	302
5. What causes DKA?	303
6. How do I make the diagnosis of DKA?	303
7. How should DKA be treated in the ED?	303
8. List the potential complications of therapy for DKA in the ED.	304
9. What is the hyperosmolar hyperglycemic state (HHS)?	304
10. How is plasma osmolarity determined?	304
11. What occurs pathophysiologically to cause HHS?	304
12. What are the precipitants of HHS?	304
13. What are the four key points in ED management of patients with HHS?	304
14. Describe hypoglycemia.	305
15. Who develops hypoglycemia?	305
16. Which overdoses of oral hypoglycemic agents do not cause hypoglycemia?	305
17. What are the presenting signs of hypoglycemia?	305
18. Which patients with hypoglycemia require admission to the hospital?	305
19. Can patients who have been treated for hypoglycemia in the field by paramedics refuse transport?	305
20. Describe GDM.	305
21. What types of infections are seen more commonly in patients with diabetes than in other patients?	306
22. What are the common manifestations of diabetic neuropathy?	306
Bibliography	306
Questions	306.e1
48 Thyroid and Adrenal Disorders	307
Abstract	307.e1
Keywords:	307.e1
1. What thyroid-related conditions are considered true emergencies?	307
2. What are the common clinical signs and symptoms of thyrotoxicosis?	307
3. What are the most common causes of hyperthyroidism? How do they present?	307
4. What laboratory tests should be ordered in a patient with suspected hyperthyroidism?	307
5. What is apathetic thyrotoxicosis?	308
6. What is thyroid storm?	308
7. What is the Burch-Wartofsky score?	308
8. Which patients with hyperthyroidism should be admitted to the hospital?	308
9. What conditions are included in the differential diagnosis of thyroid storm?	308
10. What conditions precipitate thyroid storm?	308
11. How is hyperthyroidism treated in the ED?	308
12. What is Graves ophthalmopathy?	309
13. When is treatment of Graves ophthalmopathy an emergent condition?	310
14. What is thyrotoxic periodic paralysis?	310
15. What are the common clinical manifestations of hypothyroidism?	310
16. What are the most common causes of hypothyroidism?	311
17. What additional features are present in severe hypothyroidism (or myxedema coma)?	311
18. What precipitates myxedema coma in the patient with hypothyroidism?	311
19. What is the treatment for myxedema coma?	311
20. What is the significance of a palpable thyroid nodule in an asymptomatic patient?	311
21. What advice should be given to the patient when a nonpalpable thyroid nodule is incidentally found on a radiologic study?	311
22. What are the adrenal emergencies that I need to worry about?	311
23. What is the difference between primary and secondary adrenal insufficiency?	312
24. List the signs and symptoms of primary adrenal insufficiency.	312
25. List the causes of adrenal insufficiency.	312
26. What are the most common causes of primary adrenal insufficiency?	312
27. What is the most common cause of secondary adrenal insufficiency?	313
28. How long must a patient be treated with steroids to cause suppression of the HPA axis, and how long does it take them to recover normal function?	313
29. What are the characteristic laboratory findings of primary adrenal insufficiency?	313
30. How is the presentation of secondary adrenal insufficiency different from that of primary adrenal insufficiency?	313
31. What is adrenal crisis?	314
32. What is the most common iatrogenic cause of acute adrenal crisis?	314
33. List some clinical features of acute adrenal insufficiency.	314
34. How is adrenal crisis diagnosed?	314
35. How is the rapid ACTH stimulation test performed?	314
36. What if the patient needs emergent treatment with steroids? Should I withhold treatment until the rapid ACTH stimulation test has been done?	314
37. How is acute adrenal insufficiency treated?	314
38. What should be done for the patient with chronic adrenal insufficiency who comes to the ED with a minor illness or injury?	315
39. What are the signs and symptoms of pheochromocytoma?	315
40. Which patients with hypertension should be evaluated for pheochromocytoma?	315
41. What is unique about the treatment of hypertension in a patient with pheochromocytoma?	315
Bibliography	315
Questions	316.e1
XI Infectious Disease	317
49 Sepsis Syndromes and Toxic Shock	317
Abstract	317.e1
Keywords:	317.e1
1. What is systemic inflammatory response syndrome (SIRS)?	317
2. What are the SIRS criteria?	317
3. How is sepsis defined?	317
4. What distinguishes sepsis from severe sepsis?	317
5. What is the significance of an elevated lactate level in sepsis?	317
6. What organ systems can become dysfunctional, suggesting severe sepsis?	317
7. What is the mortality rate of sepsis versus severe sepsis?	317
8. What is the primary goal of resuscitation in a septic patient?	317
9. What is an easy way to decrease an affected tissue’s increased oxygen demand from sepsis?	318
10. What are two means of increasing oxygen supply to affected tissues in a septic state?	318
11. What is the mortality benefit to initiating EGDT in patients with severe sepsis?	318
12. What are the goals outlined in EGDT for patients in severe sepsis?	318
13. What intervention should be used for a CVP that is less than 8 mm H2O?	318
14. What intervention should be initiated for a MAP that is less than 65 mm Hg?	318
15. Does one vasopressor have a proven benefit over another in the setting of severe sepsis?	318
16. What are the implications of a low venous oxygenation?	318
17. What intervention should be initiated for low venous oxygenation?	318
18. What are the drawbacks to transfusion?	318
19. What are the implications of meeting these goals as quickly as possible?	318
20. How is septic shock defined?	319
21. What is the role of vasopressin in septic shock?	319
22. What is the role of glycemic control in sepsis syndromes?	319
23. What is toxic shock syndrome (TSS)?	319
24. Which bacteria are associated with toxic shock syndrome (TSS)?	319
25. Who gets TSS?	319
26. Describe the pathophysiology of TSS.	319
27. List the criteria for defining a case of TSS caused by S. aureus.	319
28. How is the diagnosis of streptococcal TSS made?	320
29. Describe the rash associated with TSS.	320
30. When is desquamation likely to occur?	320
31. Given the previously mentioned criteria for TSS, list the differential diagnoses.	320
32. Summarize the treatment for TSS.	320
33. Do antibiotics help?	320
34. What antibiotics should I use?	320
35. Are there other therapies that can help control the immune response to the toxin?	321
36. Do all patients with TSS need admission?	321
37. What about the asplenic patient?	321
Bibliography	321
Questions	321.e1
50 Soft-Tissue Infections	322
Abstract	322.e1
Keywords:	322.e1
1. What is the difference between cellulitis and an abscess?	322
2. What are the causes of cellulitis? How does it progress?	322
3. What are the causes of abscesses? How do they progress?	322
4. Who is at increased risk for abscesses?	322
5. What is pus? What does the presence of pus signify?	322
6. How do I know if pus is present?	322
7. What are the differential diagnoses for cellulitis?	322
8. What are the differential diagnoses for abscesses?	323
9. What is folliculitis?	323
10. What is erysipelas?	323
11. What is the role of wound culturing for cellulitis or abscesses?	323
12. What is the role of blood cultures in management of cellulitis?	323
13. What is CA-MRSA?	323
14. What are the risk factors for CA-MRSA?	323
15. Should I order routine laboratory tests?	323
16. What is the appropriate ED treatment for cellulitis?	323
17. What is the appropriate ED treatment of an abscess?	323
18. What is the treatment for suspected CA-MRSA?	324
19. What are the concerning anatomic areas that may be affected by cellulitis and/or abscess formation?	324
20. What are the physical examination findings that help differentiate orbital and preseptal cellulitis?	324
21. What is the appropriate treatment for a Bartholin abscess?	324
22. Who requires hospital admission?	324
23. What is necrotizing fasciitis?	324
24. How does necrotizing fasciitis progress?	325
25. How do I diagnose necrotizing fasciitis?	325
26. What is the laboratory risk indicator for necrotizing fasciitis (LRINEC) score?	325
27. Who should be consulted for patients with suspected necrotizing fasciitis?	325
28. What antibiotics should I order if I suspect necrotizing fasciitis?	326
29. What other treatment is beneficial?	326
30. What is Fournier gangrene?	326
31. Who is at increased risk for Fournier gangrene?	326
32. What is the treatment for Fournier gangrene?	326
33. Are cat and dog bites concerning?	326
34. Any other needed treatment for patients with cellulitis or abscess?	326
Acknowledgment	326
Bibliography	326
Questions	327.e1
51 Sexually Transmitted Diseases and Human Immunodeficiency Virus Infection	328
Abstract	328.e1
Keywords:	328.e1
1. What are the most common sexually transmitted diseases (STDs)?	328
2. How should I evaluate abnormal vaginal discharge?	328
3. How do I evaluate a sexually active young man with dysuria?	329
4. Are there any single-dose treatment regimens for uncomplicated chlamydial infections?	329
5. Are there suitable oral alternatives to parenteral therapy for gonorrhea?	329
6. What is the significance of finding mucopurulent cervicitis (MPC) in a woman with lower abdominal pain?	329
7. How do I evaluate a sexually active young person who has an acutely swollen, warm, painful right ankle?	329
8. What are the most common causes of genital ulcers?	330
9. What is the Jarisch-Herxheimer reaction?	330
10. Proctitis is a problem primarily seen in MSM. Discuss the approach and treatment.	330
11. Do I need to report STD cases to the health department?	330
12. What are the important points to address in the discharge instructions for STD patients?	330
13. What is the significance of HIV infection in patients seen in the ED?	331
14. How is the diagnosis of AIDS made?	331
15. Should EDs test for HIV infection?	331
16. How do patients with HIV infection show symptoms in the ED?	331
17. What tests should be done for the patient who is infected with HIV and has systemic symptoms?	331
18. Explain the significance of fever in patients with HIV infection.	332
19. What are the common neurologic complications of AIDS?	332
20. What is HIV encephalopathy?	332
21. What are the pulmonary complications of HIV infection? How are they managed?	332
22. How should GI complaints be managed?	332
23. What are the common cutaneous presentations of AIDS, and how are they treated?	333
24. Describe ophthalmologic emergencies that occur in patients with AIDS.	333
25. Should patients with HIV receive tetanus and other immunizations?	333
26. How should symptoms of side effects from drugs be managed?	333
27. How can health care providers protect themselves from acquiring HIV?	333
28. What constitutes high-risk exposure to HIV?	333
29. Should postexposure prophylaxis (PEP) be administered after exposure to blood and body fluids?	334
30. What is ART?	334
Bibliography	334
Questions	335.e1
52 Tetanus, Botulism, and Food Poisoning	336
Abstract	336.e1
Keywords:	336.e1
Tetanus	336
1. What is the causative agent of tetanus, and what is its mechanism of action?	336
2. What are the forms of tetanus?	336
3. How is tetanus contracted?	336
4. What are the presentation and prognosis of neonatal tetanus?	336
5. What is the presentation of generalized tetanus?	336
6. What is the time course of tetanus?	336
7. How do I treat generalized tetanus in the ED?	337
8. Where should I admit patients with tetanus?	337
9. How do I vaccinate someone against tetanus?	337
10. What are the side effects of tetanus vaccine?	337
11. Is the tetanus vaccine safe for pregnant and immunocompromised patients?	337
Botulism	338
12. What is the causative agent of botulism? How does it cause disease?	338
13. What are the five types of botulism?	338
14. What are the differential diagnoses of botulism?	338
15. What is the presentation of infant botulism?	338
16. How does an adult patient with food-borne botulism present?	339
17. How is botulism diagnosed?	339
18. What is the treatment of food-borne botulism?	339
19. What is treatment for infant botulism?	339
20. Are systemic antibiotics indicated for infant botulism?	339
21. Are antibiotics indicated in wound botulism?	339
Food Poisoning	339
22. Name the causes of food poisoning.	339
23. What is the time course and geographic incidence of traveler’s diarrhea?	340
24. What are some of the more serious complications of traveler’s diarrhea? What are the causative agents?	340
25. Should antibiotics be used for infectious diarrhea?	340
26. In what patient population with infectious diarrhea should antibiotics be avoided?	340
27. Which diarrhea-producing agent is associated with febrile seizures in children?	340
28. What is scombroid poisoning, and how is it treated?	340
29. What is ciguatera poisoning, and how is it treated?	341
30. What is tetrodotoxin poisoning, and how is it treated?	341
31. Describe the toxic syndromes associated with ingestion of shellfish.	342
32. Which population of patients is at risk from eating raw oysters?	342
33. Describe the four stages of A. phalloides mushroom toxicity.	342
Acknowledgment	343
Bibliography	343
Questions	343.e1
53 Travel Medicine and Vector-Borne Diseases	344
Abstract	344.e1
Keywords:	344.e1
1. What is travel medicine?	344
2. Why is travel medicine important?	344
3. Should I visit a travel clinic before my trip?	344
4. What other pretravel preparation should take place?	344
5. How should I prepare professionally before embarking on volunteer clinical work overseas?	344
6. What clinical history should I obtain from the ill returned traveler?	344
7. What are the most common illnesses affecting returned travelers?	345
8. What causes traveler’s diarrhea (TD)?	345
9. What are the most common skin conditions seen in returned travelers?	345
10. What is leishmaniasis?	345
11. How is LCL treated?	345
12. What are the most important tools in diagnosing these vector-borne diseases?	345
13. What causes malaria?	345
14. Can malaria be prevented?	345
15. What is the presentation of malaria in ED patients?	345
16. How is malaria diagnosed?	346
17. How is malaria treated?	346
18. What is dengue, and where does it occur?	346
19. How does dengue fever present?	346
20. How do I diagnose and treat dengue fever?	346
21. What is West Nile virus?	347
22. What are the symptoms of West Nile infections?	347
23. How is West Nile encephalitis diagnosed and treated?	347
24. Are ticks a significant vector of disease?	347
25. List the principal vectors and distribution of tick-borne diseases.	347
26. How is Lyme disease transmitted?	347
27. Describe the three clinical stages of Lyme disease.	347
28. How is Lyme disease diagnosed?	348
29. How is Lyme disease treated?	348
30. Can Lyme disease be prevented?	349
31. An ED patient has a tick bite; should you treat prophylactically for Lyme disease?	349
32. What on earth is STARI and what can be done about it?	349
33. What is tick-borne relapsing fever?	349
34. What is Rocky Mountain spotted fever (RMSF)?	349
35. How dangerous is RMSF? What can be done about it?	349
36. What are ehrlichiosis and anaplasmosis?	349
37. How are ehrlichiosis and anaplasmosis diagnosed and treated?	350
38. What is Colorado tick fever?	350
39. What is babesiosis?	350
40. What is tularemia?	350
41. What is tick paralysis?	350
42. What is the proper method for tick removal?	350
Acknowledgment	351
Bibliography	351
Questions	351.e1
54 Arthritis	352
Abstract	352.e1
Keywords:	352.e1
1. What are the signs and symptoms of arthritis?	352
2. What are the common causes of acute arthritis?	352
3. What is the difference between an intraarticular and a periarticular process?	352
4. What are some examples of diseases that are monoarticular, polyarticular, and periarticular?	352
5. What other physical findings may be helpful in diagnosing a patient with arthritis?	352
6. What does the location and distribution of the joint pain reveal about the diagnosis?	352
7. Is radiography helpful in the diagnosis of arthritis?	352
8. Are the erythrocyte sedimentation rate (ESR) and peripheral white blood cell (WBC) count useful for the evaluation of acute arthritis?	353
9. What is the most important diagnostic test for determining the etiology of acute arthritis?	353
10. What are the general steps of an arthrocentesis?	353
11. What are some causes of arthritis with fever?	353
12. How do I interpret the results of the arthrocentesis?	353
13. Does a synovial fluid WBC count of less than 50,000 cells/mm3 completely rule out the diagnosis of a septic joint?	353
14. Are there any other synovial fluid tests for arthritis?	355
15. What is the most serious cause of arthritis?	355
16. What organisms cause bacterial arthritis?	355
17. How is bacterial arthritis treated?	355
18. What causes crystal-induced arthritis?	355
19. What are the risk factors for gout, and which joints are most commonly affected?	355
20. What medications can be used to treat gout in the acute setting?	355
21. Which tick-borne infection causes arthritis?	356
22. What are the signs and symptoms of OA?	356
23. What are the treatment options for OA?	356
Acknowledgment	357
Bibliography	357
Questions	357.e1
55 Skin Diseases	358
Abstract	358.e1
Keywords:	358.e1
1. What are the terms used to describe skin lesions?	358
2. What categories of skin conditions are life threatening or associated with life-threatening disease?	358
3. Which skin lesions could signify an emergent condition?	358
4. What types of skin diseases result in potentially life-threatening compromise to the skin barrier?	358
5. Identify the skin lesions found in meningococcal disease, Rocky Mountain spotted fever, toxic shock syndrome, and necrotizing fasciitis?	358
6. Describe findings seen in common childhood skin rashes.	359
7. Describe erythema multiforme (EM).	359
8. Which illness can mimic EM?	359
9. How do adverse drug reactions typically present?	362
10. Which medications are commonly implicated in drug eruptions?	362
11. Which illness commonly mimics drug eruptions?	362
12. What clinical signs should alert concern of a severe adverse medication reaction?	362
13. What are characteristics of melanoma?	362
14. What other skin findings can mimic melanoma?	362
15. Which spider bites cause necrosis?	362
16. Which skin findings may appear similar to a necrotic spider bite?	364
17. What kind of skin lesions do MRSA cause?	364
18. What kinds of purpura are associated with benign conditions?	364
19. Which skin lesions mimic cellulitis?	364
20. Debridement is generally contraindicated in which lower extremity eruption?	364
21. Should steroids be used to treat eczema?	364
22. Should steroids be used in psoriasis?	364
23. What are the classes of steroids, and on which part of the body should they be applied?	364
24. Which formulation of topical steroids is most potent?	364
Acknowledgment	365
Bibliography	365
Questions	365.e1
XII Environmental Emergencies	366
56 Lightning and Electrical Injuries	366
Abstract	366.e1
Keywords:	366.e1
Lightning Injuries	366
1. What causes lightning?	366
2. What is a “bolt from the blue”?	366
3. What causes thunder?	366
4. How does lightning cause injury?	366
5. What types of injuries does lightning cause?	367
6. Is lightning direct current (DC) or alternating current (AC)?	368
7. Is it true that lightning never strikes twice in the same place?	368
8. Is it true that I am safe from a lightning strike if I am in my car, because the rubber tires act as an insulator.	369
9. Am I safe from lightning if I am indoors.	369
10. Does lightning ever hit airplanes? What are the consequences?	369
11. What happens to the ground when lightning strikes it?	369
12. How common is lightning? How common are injuries or deaths?	369
13. Who tends to get struck by lightning? Where do most strikes occur?	369
14. What factors predispose someone or something to be struck by lightning?	369
15. I am treating a hiker who was found unconscious on the trail after a thunderstorm had passed. The patient has no memory of what happened. How can I tell if he was struck by lightning?	369
16. The hiker has regained a palpable carotid pulse, but he does not appear to be breathing on his own. Why? What should I do?	370
17. The hiker is also tachycardic, hypertensive, and has cool, pale skin with diminished peripheral pulses. He is awake, but unable to move his extremities. Why?	370
18. During mass casualty training, responders are taught to allocate resources to victims who are not breathing or moving only after they have taken care of victims with obvious signs of life. Should this same practice apply when there are multiple victims of a lightning strike?	370
19. Is prolonged cardiopulmonary resuscitation (CPR) beneficial in lightning-strike victims?	370
20. I am performing CPR on a lightning-strike victim when one of my colleagues notices that the victim has fixed and dilated pupils. Should I stop CPR based on these findings?	370
21. Do victims of lightning strike typically suffer extensive burns?	370
22. What are the best ways to prevent lightning-related injury or death?	370
23. What are the differences between lightning and low- and high- voltage injuries?	371
Electrical Injuries	371
24. What are the basic physics of electricity?	371
25. What is an easy way to classify electrical injuries? Does this help determine the nature and severity of electrical injuries?	371
26. How does the type of circuit relate to injury?	372
27. What types of electrical burns are there?	372
28. What is the epidemiology of electrical injuries?	372
29. What should I do if I am a responder to the scene of an electrical injury?	372
30. How does tissue resistance relate to electrical injury?	372
31. Which organ systems are affected by electrical injury? What types of injuries occur?	372
32. What are the most common long-term complications of electrical injuries?	372
33. An ambulance arrives at the ED with a 22-year-old, 75-kg man who was working on a ladder near a high-voltage electrical line when he received a shock. He has two burns: one on his palm, where it contacted the wire, and one on his shin, where he was touching the ladder. Together, these burns are about 2% of his total body surface area (TBSA). How much intravenous (IV) fluid should I give him?	373
34. I am caring for a patient after she suffered an electric shock. She has no recollection of the event, and she complained briefly of paresthesias. Should I obtain a computed tomography (CT) scan of the head, or is close observation enough?	373
35. Can I think of victims of high-voltage electrical injury as similar to lightning-strike victims?	373
36. Are there any medications to consider for electrical or lightning injury victims?	373
37. How should I triage victims of lightning-strike or electrical injury on scene?	373
38. Who needs to be admitted for lightning-strike or electrical injuries?	373
39. What laboratory result can be used to determine patients who may benefit from early fasciotomy, in an attempt to prevent future amputations from electrical burns?	375
40. What about children who get injured by a household electrical cord or appliance? Should I admit them to the hospital for observation, or can I discharge them home from the ED?	375
41. What about pregnant patients who sustain electrical injuries?	375
Acknowledgment	376
Bibliography	376
Questions	376.e1
57 Drowning	377
Abstract	377.e1
Keywords:	377.e1
1. Define drowning.	377
2. How many people drown each year?	377
3. Who drowns, and why?	377
4. What kills a drowning victim?	377
5. What happens in a drowning?	377
6. Describe the presenting symptoms of drowning victims.	378
7. What is the pulmonary pathophysiology?	378
8. How is the cardiac system affected in drowning?	378
9. What is the prehospital treatment?	378
10. When is endotracheal intubation indicated?	378
11. If aspiration is suspected, what treatment is needed?	378
12. Does a normal chest radiograph rule out pulmonary injury?	378
13. Is there a role for prophylactic antibiotics?	379
14. Is there an indication for the use of sodium bicarbonate during resuscitation?	379
15. Discuss the approach to patients with a decreased level of consciousness or coma.	379
16. Are glucocorticoids, barbiturate coma, or induced hypothermia indicated?	379
17. What is unique about cold-water submersion?	379
18. When should resuscitative efforts be withheld?	379
19. What is the disposition of a submersion victim?	379
20. What are the most important factors in estimating prognosis?	380
21. Can we prevent drowning?	380
Bibliography	380
Questions	381.e1
58 Hypothermia and Frostbite	382
Abstract	382.e1
Keywords:	382.e1
Hypothermia	382
1. What is accidental hypothermia?	382
2. What factors are important in the epidemiology of hypothermia?	382
3. How is body temperature normally regulated?	382
4. Describe the common findings in mild, moderate, and severe hypothermia.	382
5. What factors predispose a patient to hypothermia?	382
6. What decreases heat production?	382
7. What are the common causes of increased heat loss?	383
8. How is thermoregulation impaired?	383
9. When should hypothermia be suspected?	383
10. Are there decoys that confuse the physical examination?	383
11. What options are available to measure the core temperature?	383
12. How does temperature depression affect the hematologic evaluation of patients?	383
13. Should arterial blood gases be corrected for temperature?	383
14. What is the key decision regarding rewarming?	383
15. What conditions mandate active rewarming?	383
16. What is core temperature afterdrop?	384
17. Are there unique considerations with active external rewarming?	384
18. What constitutes active core rewarming?	384
19. When is airway rewarming indicated?	384
20. What are the techniques for heated irrigation?	384
21. When should heated peritoneal lavage be considered?	384
22. When is extracorporeal rewarming indicated?	384
23. What are the contraindications to cardiopulmonary resuscitation (CPR) in accidental hypothermia?	384
24. Are there unique pharmacologic considerations during hypothermia?	384
25. What is the significance of atrial and ventricular dysrhythmias?	384
Frostbite	384
26. What is frostbite?	384
27. Which factors predispose a patient to frostbite?	385
28. What peripheral circulatory changes precede frostbite?	385
29. Before frostbite occurs, what other cutaneous events take place in the prefreeze phase?	385
30. What happens during the freeze phase of frostbite?	385
31. Immediately after thawing, what may occur?	385
32. What is progressive dermal ischemia?	385
33. What delayed physiologic events occur?	385
34. What are the symptoms of frostbite?	385
35. What imaging techniques might help assess frostbite severity?	385
36. What is chilblain (pernio)?	385
37. What is trench foot?	385
38. How should frostbite be classified?	385
39. What do the various signs of frostbite indicate?	386
40. How should frozen tissues be thawed?	386
41. What steps should immediately follow thawing?	386
42. How are blisters treated?	386
43. Are any ancillary treatment modalities beneficial?	386
Bibliography	386
Questions	386.e1
59 Heat Illness	387
Abstract	387.e1
Keywords:	387.e1
1. How does the body regulate temperature?	387
2. What are the four mechanisms for heat dissipation?	387
3. Which mechanism is the most effective for heat loss?	387
4. How does the relative humidity of the atmosphere affect the normal body mechanisms of cooling?	387
5. Is there any way to predict heat stress?	387
6. How does heat harm the body?	387
7. Why is this epidemiologically important?	387
8. Why might someone be unable to dissipate heat appropriately?	388
9. What risk factors can lower the threshold for heat stroke?	388
10. Why are young children at higher risk for heat illness?	388
11. List the spectrum of heat illnesses and briefly describe them.	388
12. How are heat-related illnesses treated?	388
13. Tell me more about heat exhaustion.	389
14. Why is heat stroke so bad?	389
15. Describe the two types of heat stroke.	389
16. How do I treat a patient with heat stroke?	389
17. Are any medications indicated in the treatment of heat stroke, and are there any that should be avoided?	390
18. What laboratory abnormalities are seen in patients with heat illness?	390
19. What is the differential diagnosis for the etiology of heat stroke?	390
20. What is the mortality rate associated with heat stroke?	390
21. How do I prevent heat-related illness?	390
22. What about acclimatization?	390
Bibliography	391
Questions	391.e1
60 Altitude Illness and Dysbarisms	392
Abstract	392.e1
Keywords:	392.e1
1. What are the three disease states that comprise high-altitude illness?	392
2. What are the symptoms of AMS?	392
3. How quickly do symptoms of AMS develop, and what is the minimum elevation at which AMS occurs?	392
4. How do I treat AMS?	392
5. What is the number-one risk factor for AMS?	392
6. Is there any treatment that will prevent AMS?	393
7. What is HACE?	393
8. When does HACE occur?	393
9. What is the treatment for HACE?	393
10. Is there anything that will prevent HACE?	393
11. What is HAPE?	393
12. When does HAPE occur?	393
13. How do I treat HAPE?	393
14. Is there any preventive therapy for HAPE?	394
15. Will I ever see HAPE, HACE, or AMS at the same time?	394
16. Which form of altitude illness is most common, and which is most deadly?	394
17. What is dysbarism?	394
18. How much pressure does a diver experience at 10 m (33 ft) underwater?	394
19. What are the bends?	394
20. When would I see someone with the bends?	394
21. Why would nitrogen precipitate in tissues?	394
22. What is nitrogen narcosis?	394
23. What is MEBT?	395
24. How could a diver get a pneumothorax with ascent?	395
25. What is AGE?	395
26. What about the movies that show people bleeding from their eyes when diving? Does that really happen?	395
27. What is decompression sickness (DCS)?	395
28. What are the chokes?	395
29. What are the skinny bends?	395
30. What is spinal cord DCS?	395
31. Is there a CNS form of DCS?	396
32. How do I tell the difference between CNS DCS and AGE?	396
33. How are dysbarisms treated?	396
34. Is there anything that makes a particular person susceptible to DCS?	396
35. Is there anything that I can do to reduce my risk of DCS?	396
Bibliography	396
Questions	397.e1
XIII Neonatal and Childhood Disorders	398
61 Evaluation of Fever in Children Younger Than Age Three	398
Abstract	398.e1
Keywords:	398.e1
1. What is fever?	398
2. How should temperature be measured in infants and young children?	398
3. Is it safe to measure temperatures rectally?	398
4. What is a serious bacterial infection (SBI)?	398
5. Does it matter how much fever the child has?	398
6. What is meant by appearing toxic?	398
7. Which antipyretics work best for children?	399
8. What is the most common cause of antipyretic failure?	399
9. What is wrong with baby aspirin?	399
10. Is there any good reason not to treat a fever?	399
11. What are febrile seizures?	399
12. Does careful administration of antipyretics prevent recurrence of febrile seizures?	399
13. How should tiny babies with fever be evaluated?	399
14. What happens after the magic 1-month mark?	400
15. What about older infants and young children?	400
16. How do I decide when to do a LP in older babies and young children?	400
17. What if the child has a fever source or one is found during the workup?	400
18. Must I always follow the guidelines, or is there room for clinical judgment in there somewhere?	400
19. What if the child looks great; can he or she go home?	401
20. What are low-risk criteria?	401
21. What is the risk of occult bacteremia (presence of bacteria in the blood stream with no apparent focus of infection)?	401
22. What antibiotic should be used for empiric coverage of bacteremia?	402
23. Which infants should receive acyclovir?	402
24. What about children with fever and rapidly progressive petechial rash?	402
Bibliography	402
Questions	402.e1
62 Seizures in Infancy and Childhood	403
Abstract	403.e1
Keywords:	403.e1
1. How does one determine if an event in a child is actually a seizure?	403
2. What can be learned about the child’s history?	403
3. What things should be sought on physical examination?	405
4. How are pediatric seizures classified?	405
5. What are common reasons for a seizure in the neonate?	405
6. What tests should be done for a neonate experiencing seizures?	405
7. What medications are used to treat neonatal seizures?	405
8. What are common reasons for a child to have a seizure?	405
9. What is the definition of a febrile seizure?	406
10. Are genetics involved with febrile seizures?	406
11. What are the types of febrile seizures?	406
12. What factors make the recurrence of febrile seizures more likely?	406
13. What tests should be done after a febrile seizure?	406
14. Under what conditions should a child having febrile seizures be treated, and what treatments should be used?	406
15. What is the likelihood that a child suffering febrile seizures will eventually develop epilepsy?	407
16. What are infantile spasms, and what are some common causes?	407
17. What is the standard treatment for infantile spasms?	407
18. What is the prognosis for infantile spasms?	407
19. What is epilepsy?	407
20. What are some common forms of childhood epilepsy?	407
21. What workup should be done after an afebrile seizure in an asymptomatic child?	407
22. Under what conditions should afebrile seizures be treated using antiepileptic drugs?	408
23. What are the older and newer antiepileptics, and how do they vary?	408
24. What are important side effects of the different antiepileptic drugs?	408
25. If an individual stopped taking antiepileptic drug because he or she was not having seizures, and then started to have them again, at what dosage should the medication be restarted?	409
26. When should antiepileptic drugs be discontinued?	409
27. What happens if a dose of antiepileptic drug is missed?	409
28. What if vomiting occurs shortly after taking an antiepileptic drug?	409
29. What is status epilepticus?	409
30. What is the treatment for status epilepticus?	409
31. What should an onlooker do if the child has another seizure?	409
32. What cautions should I give to parents of children who have seizures?	409
Bibliography	410
Questions	410.e1
63 Acute Respiratory Disorders in Children	411
Abstract	411.e1
Keywords:	411.e1
1. What are the signs and symptoms of respiratory distress in a child?	411
2. Why are airway problems more serious in pediatric patients than in adults?	411
3. How can I determine where the problem is?	411
4. What are common causes of upper airway obstruction in children?	411
5. Discuss the signs and symptoms of croup, who gets it, what causes it, and what the physician can do for it.	411
6. Who needs nebulized epinephrine?	411
7. What about steroids and croup?	412
8. When should I worry about epiglottitis and bacterial tracheitis?	412
9. What is the appropriate initial management of a patient with suspected epiglottitis?	412
10. What are retropharyngeal space infections?	414
11. What imaging studies are helpful in the diagnosis of retropharyngeal infections?	414
12. How are retropharyngeal infections managed?	414
13. When should a foreign body be suspected?	414
14. How are suspected foreign bodies managed in pediatric patients?	414
15. What is bronchiolitis, and who does it affect?	415
16. What are the clinical signs and symptoms of bronchiolitis?	415
17. Do patients with bronchiolitis need chest radiographs?	415
18. When are laboratory tests needed for bronchiolitis?	415
19. What is the treatment for bronchiolitis?	415
20. Who is admitted for bronchiolitis?	415
21. How are bronchodilators used in the management of acute asthma?	416
22. When and how should steroids be administered?	416
23. When should a chest radiograph be obtained, and what are the typical findings?	416
24. Outline the evaluation and treatment of an asthma exacerbation in the ED.	416
25. What about magnesium?	417
26. Does aminophylline have any use?	417
27. What about parenteral β-agonists?	417
28. What should I do if my patient is going into respiratory failure?	418
Acknowledgment	418
Bibliography	418
Questions	418.e1
64 Pediatric Gastrointestinal Disorders and Dehydration	419
Abstract	419.e1
Keywords:	419.e1
1. What are the common causes of abdominal pain in children?	419
2. What are the strongest indicators of dehydration in children?	419
3. How do you manage the different levels of dehydration?	419
4. How are maintenance fluids determined in a child?	419
5. What role do antiemetics play in the management of pediatric vomiting?	419
6. What are potential causes of vomiting without diarrhea in children?	419
7. How do I differentiate between gastroenteritis and more severe abdominal pathology?	420
8. What diagnostic studies should be obtained on children with gastroenteritis?	420
9. How do I differentiate between bacterial and viral causes of diarrhea?	420
10. Which children with diarrhea require diagnostic studies?	420
11. Are antimotility agents and antibiotics recommended for children with diarrhea?	420
12. How does hemolytic uremic syndrome (HUS) typically present?	420
13. Should narcotics be withheld from children with acute abdominal pain while awaiting a surgical evaluation?	421
14. How does appendicitis present in younger children?	421
15. What physical examination findings are found in older children with appendicitis?	421
16. What laboratory tests are helpful in children with appendicitis?	421
17. What are the advantages and disadvantages of the different radiographic tests for appendicitis?	421
18. What is the treatment for appendicitis?	422
19. How does intussusception present?	422
20. How do I diagnose intussusception?	422
21. How should intussusception be treated?	422
22. What is the significance of bilious emesis in a neonate?	422
23. What characteristics of a patient’s history help differentiate pyloric stenosis from other causes of vomiting in infants?	423
24. What diagnostic findings arise with pyloric stenosis?	423
25. Are inguinal hernias dangerous?	423
26. What is the difference between a hernia and a hydrocele?	423
27. Why is jaundice concerning in a neonate?	423
28. Is it normal for a child to have constipation?	424
29. How can you treat constipation in the ED?	424
30. What are the most common causes of lower gastrointestinal bleeding in children?	424
31. What is a Meckel diverticulum?	424
32. What is Meckel’s rule of twos?	425
33. How do I manage an ingested gastrointestinal foreign body?	425
34. What are the possible complications of an esophageal foreign body?	425
35. How can I determine the location (trachea versus esophagus) of a coin in the pharynx?	425
36. How can I differentiate a button battery and coin on radiograph?	425
37. What diseases are associated with classic findings on radiograph?	425
Acknowledgment	425
Bibliography	426
Questions	426.e1
65 Pediatric Infectious Diseases	427
Abstract	427.e1
Keywords:	427.e1
1. Are infectious diseases important to recognize in pediatric patients?	427
2. What is the mechanism of spread of measles (rubeola)?	427
3. What is the incubation period for measles?	427
4. List the common signs and symptoms of patients with measles.	427
5. Name the complications of measles.	427
6. What is subacute sclerosing panencephalitis?	427
7. Describe the exanthem seen in rubella, and explain why rubella is also called 3-day measles.	427
8. What are Forschheimer spots?	427
9. What is the incubation period for mumps, and when is the patient contagious?	427
10. List the major complications of mumps.	428
11. Describe the characteristic rash in erythema infectiosum.	428
12. What is the typical progression of findings of roseola (erythema subitum)?	428
13. What is the incubation period for varicella (chickenpox), and when are patients infectious?	428
14. Name the mode of transmission and the cause of infectious mononucleosis (IM).	428
15. List the clinical manifestations of IM.	428
16. Which parenteral antibiotics are correlated with a rash in older children and adults with IM?	428
17. What are the hematologic findings in IM?	428
18. What are heterophil antibodies?	428
19. What is the monospot test?	428
20. Describe the treatment of uncomplicated IM.	429
21. Summarize the complications of IM.	429
22. What is the role of corticosteroids in the treatment of IM?	429
23. How long does the patient need to worry about the risk of splenic rupture?	429
24. What are the most common findings associated with botulism in children, and how are they treated?	429
25. What are the distinct clinical presentations of diphtheria?	429
26. What is the therapeutic approach to management of diphtheria?	429
27. What clinical findings must be present to make the diagnosis of Kawasaki disease?	430
28. What is the most significant complication of Kawasaki disease?	430
29. What infectious conditions should be considered in a child with diffuse erythroderma?	430
30. Describe the three stages of clinical progression of a child with pertussis.	430
31. What are the typical stages of Reye syndrome?	430
Bibliography	431
Questions	431.e1
66 Emergency Department Evaluation of Child Abuse	432
Abstract	432.e1
Keywords:	432.e1
1. What is child abuse?	432
Physical Abuse	432
2. When should I think about physical abuse?	432
3. What are some red flags that suggest child abuse?	432
4. Are there injuries that are particularly concerning for physical abuse?	433
5. Why do we do so much more testing for abusive injuries than we do for noninflicted trauma?	433
6. Once I think about abuse, what parts of the physical examination are most important?	433
7. Which children need a skeletal survey?	433
8. Why are metaphyseal fractures suggestive of abuse?	433
9. Which children need neuroimaging (computed tomography [CT] or magnetic resonance imaging [MRI])?	434
10. Which children need a dilated retinal examination?	434
11. Which children need screening for occult abdominal injury?	434
12. What are the most common myths about physical abuse?	434
13. Which conditions can mimic injuries seen in child abuse?	435
14. What about an infant who is dead on arrival without external signs of injury?	435
15. What should I do about siblings and other children in the home?	435
Sexual Abuse	435
16. If a child has not reported sexual abuse, what should make me think about it?	435
17. When there is a report of abuse, should I take any history?	435
18. How should I question a child to obtain history and direct my evaluation?	436
19. Which children need a genital examination immediately?	436
20. How should I do the genital examination?	436
21. What examination findings are most significant for sexual activity/abuse?	436
22. Which children need an evidence collection kit?	436
23. Which children need testing for sexually transmitted diseases (STDs)?	437
24. Should children suspected of sexual abuse receive empiric treatment for STDs?	437
25. Which children need pregnancy testing and/ or prophylaxis?	437
26. Which findings can mimic sexual abuse?	437
27. What information should I give to parents?	438
Reporting Concerns for Child Abuse	438
28. How reliable is a child’s disclosure of physical or sexual abuse?	438
29. When should I report my concerns to CPS?	438
30. How do I go about reporting?	439
31. Can I be sued for reporting when the child is not found to be abused?	439
Bibliography	439
Questions	439.e1
67 Procedural Sedation and Analgesia of the Pediatric Patient	440
Abstract	440.e1
Keywords:	440.e1
1. Why is it called procedural sedation and analgesia (PSA)?	440
2. Do I need sedation and analgesia when performing procedures on children?	440
3. What is “brutaine,” and should I use it?	440
4. What are the different levels of sedation?	440
5. List the ideal characteristics of an agent used for PSA?	441
6. What routes of administration are available for administrating a sedative?	441
7. What is key information to obtain in the medical history before beginning PSA?	441
8. Are there guidelines for presedation fasting?	441
9. What physical examination findings are important to note before providing PSA?	441
10. Are there any children who should not receive PSA?	442
11. What monitoring should occur with PSA?	442
12. What are the agents used for pediatric PSA?	442
13. What agents would I use if I needed to obtain a CT scan on a young child?	442
14. Would the agents used for obtaining a CT scan work for an MRI?	442
15. What are the advantages and disadvantages of propofol for PSA?	442
16. What medications would I use for a 2-year-old child with a facial laceration?	442
17. What medications would I consider for a 6-year-old child needing reduction of an angulated forearm fracture?	444
18. What makes ketamine or “kidamine” useful as a PSA agent?	444
19. What are the contraindications for ketamine?	444
20. What complications are seen with PSA?	444
21. What are the complications associated with fentanyl?	445
22. Are some agents safer than others?	445
23. What reversal agents are available for children?	445
24. When can I discharge a child home after performing PSA?	445
Bibliography	446
Questions	446.e1
68 Pediatric and Neonatal Resuscitation	447
Abstract	447.e1
Keywords:	447.e1
1. What is the pediatric assessment triangle?	447
2. What do I look for using the pediatric assessment triangle?	447
3. How do I prepare myself for a child with cardiac arrest coming to the ED?	447
4. What are some other specific things I can do to prepare?	447
5. Is survival rate after cardiopulmonary arrest better in children or adults?	447
6. What are the etiologies of pediatric arrests?	447
7. What are predictors of outcome in pediatric arrest?	448
8. What are the fundamental differences between the pediatric versus the adult airway?	448
9. Does the pediatric patient require cricoid pressure during active ventilation?	448
10. What about cricoid pressure during intubation?	448
11. How does the approach to the B (breathing) of ABCs (airway, breathing, and circulation) differ in pediatrics relative to adults?	448
12. What size of ETT should I use?	449
13. What are alternative airway devices that can be used in the pediatric population?	449
14. What about cricothyrotomies in children?	449
15. What drugs and dosing should I have committed to memory in my armamentarium for pediatric resuscitations?	449
16. At what point should chest compressions be initiated in children?	449
17. Where should I try for vascular access in the pediatric patient?	449
18. What is the earliest gestational age that a newborn has been successfully resuscitated after birth?	449
19. What should I expect in a normal newborn at the time of birth?	449
20. After delivery in the ED, what is the first priority in the care of the newborn?	450
21. When should central cyanosis resolve in a healthy newborn after delivery?	451
22. So what is a normal newborn pulse oximetry level?	451
23. How do I approach the meconium-stained newborn?	451
24. After the infant is dried, suctioned, and placed under the warmer, how do I decide whether further active intervention is needed?	451
25. For the newborn, define bradycardia and indications for intervention.	451
26. At what point do I need to initiate chest compressions?	452
27. How do I know when to stop chest compressions?	452
28. How many infants will require intubation to provide adequate ventilation?	452
29. When should I attempt vascular access, and what vessel should I use?	452
30. What drugs should be available for use in newborn resuscitation, and when should they be given?	452
31. What is the best means of documentation of the results of resuscitation in the neonate?	453
Bibliography	453
Questions	454.e1
XIV Toxicologic Emergencies	455
69 General Approach to Poisonings	455
Abstract	455.e1
Keywords:	455.e1
1. List the 15 most common causes of death from acute poisoning reported to poison centers.	455
2. What is the role of activated charcoal?	455
3. What is the role of gastric lavage in treating acute poisonings?	455
4. What about the asymptomatic overdose patient?	456
5. Is there a role for cathartics in treating acute poisoning?	456
6. What is the role of whole-bowel irrigation in the treatment of acute poisoning?	456
7. What is the role of multiple-dose charcoal in the treatment of acute poisoning?	456
8. Is forced diuresis of benefit in the treatment of acute poisoning?	456
9. When are extracorporeal techniques, such as hemodialysis or hemoperfusion, indicated?	457
10. How can the diagnosis of a drug overdose be made when the patient is unconscious and the history is unavailable?	457
11. How can a toxicology screen and other ancillary laboratory tests make the diagnosis of acute poisoning?	457
12. What other studies are useful in the evaluation of a poisoned patient?	459
13. Discuss some other useful antidotes for common poisonings.	459
Bibliography	460
Questions	460.e1
70 The Alcohols: Ethylene Glycol, Methanol, Isopropyl Alcohol, and Alcohol-Related Complications	461
Abstract	461.e1
Keywords:	461.e1
Ethylene Glycol and Methanol	461
1. Why is it important to understand the metabolism of ethylene glycol?	461
2. What is the toxicity of ethylene glycol?	461
3. Why is ethylene glycol so dangerous to animals?	461
4. Why does antifreeze have such a bright color?	461
5. Why is it important to understand the metabolism of methanol?	461
6. List the signs and symptoms of methanol poisoning.	461
7. Why are the symptoms of ethylene glycol and methanol overdose often delayed?	462
8. How are methanol and ethylene glycol poisonings similar?	462
9. What is an anion gap?	462
10. What causes an increased anion gap?	462
11. What is an osmolal gap?	462
12. How is an osmolal gap calculated?	463
13. What comes first, the anion gap or the osmolal gap?	463
14. How much methanol or ethylene glycol is dangerous?	463
15. How should patients with methanol and ethylene glycol poisoning be treated?	463
16. How do I choose between 4-MP and ethanol?	463
17. How do I use 4-MP?	463
18. What are the indications for hemodialysis?	463
19. What if dialysis is unavailable?	464
Isopropyl (Isopropanol) Alcohol	464
20. How is isopropyl alcohol poisoning different from methanol and ethylene glycol poisoning?	464
21. What are the symptoms of isopropanol alcohol ingestion?	464
22. Why is isopropanol so commonly abused?	464
23. What is the treatment for isopropyl alcohol poisoning?	464
Alcohol-Related Complications	465
24. What complications arise from ethanol?	465
25. When should an acutely intoxicated patient have their airways intubated?	465
26. Which medications are best for management of alcohol withdrawal?	465
27. What is an appropriate workup for repeat alcohol withdrawal seizures (AWDS)?	465
28. How should AWDS be managed?	465
29. Can AWDS be prevented?	465
30. Who is at risk for alcohol-induced hypoglycemia (AIH)?	465
31. What is the clinical presentation?	465
32. How does alcoholic ketoacidosis (AKA) develop?	465
33. How should I manage AKA?	466
34. What is the relationship between alcohols and metabolic acidosis?	466
35. How is coagulation affected in a patient with chronic alcoholism?	466
36. When is vitamin K useful?	466
37. Must thiamine be administered before glucose in the patient with alcoholism?	466
38. Is it dangerous to administer thiamine intravenously?	466
39. Is there a cure for a hangover?	466
Bibliography	467
Questions	467.e1
71 Antipyretic Poisoning	468
Abstract	468.e1
Keywords:	468.e1
Salicylate Poisoning	468
1. What are the causes of salicylate overdose?	468
2. What are the characteristics of a patient who is experiencing an acute salicylate overdose?	468
3. List some common clinical features of acute salicylate intoxication.	468
4. Describe the acid-base disturbances associated with salicylate toxicity.	468
5. What are some of the other metabolic disturbances seen in acute salicylate poisoning?	468
6. I thought aspirin was an antipyretic. How does it cause a fever?	468
7. Name some of the hematologic abnormalities.	468
8. How is the severity of salicylate overdose assessed?	468
9. Which laboratory tests are indicated?	469
10. What is the initial ED treatment for an acute salicylate overdose?	469
11. What else needs to be done in the ED?	469
12. Is there a role for repetitive dosing of activated charcoal?	469
13. What is the rationale for alkaline diuresis?	469
14. Explain the paradox of a decreasing serum salicylate concentration and increasing clinical toxicity.	470
15. What are the indications for hemodialysis?	470
16. What are the most common findings in chronic salicylate poisoning?	470
Acetaminophen Poisoning	470
17. Is there anything new in acetaminophen toxicology?	470
18. What are the characteristics of acetaminophen overdose?	470
19. Outline the four phases of acetaminophen overdose.	470
20. What are the initial CNS manifestations of acetaminophen poisoning?	470
21. Describe the pathophysiology of acetaminophen toxicity.	470
22. How is hepatotoxicity predicted?	471
23. Are serial serum acetaminophen levels helpful?	471
24. Why is hepatotoxicity in children rare?	471
25. Which laboratory tests are helpful?	471
26. Outline the general treatment of acetaminophen poisoning.	471
27. How is NAC administered?	472
28. Is there a critical window in time to administer NAC?	472
29. If the patient has hepatic encephalopathy, is it too late for NAC therapy?	472
30. Should I be concerned about potential adverse reactions to IV NAC?	472
31. What is the acetaminophen-alcohol syndrome?	472
32. What is the treatment for chronic acetaminophen toxicity?	473
Ibuprofen Poisoning	473
33. What are the characteristics of ibuprofen overdose?	473
34. List the primary symptoms of ibuprofen toxicity.	473
35. Should a serum ibuprofen level be obtained?	473
36. Describe the treatment for ibuprofen toxicity.	473
Bibliography	473
Questions	473.e1
72 Bites and Stings	474
Abstract	474.e1
Keywords:	474.e1
Arachnida (Chiggers, Scabies, Scorpions, and Spiders)	474
1. What is the difference between poisonous and venomous?	474
2. What is a tarantula?	474
3. What spider bites are likely to be an issue?	474
4. What is “mustov disease”?	474
5. A 5-year-old boy has genital itching that started several hours after sitting on the lawn watching a fireworks display. His examination reveals intensely pruritic, erythematous papules around his groin. What caused this, and what is the treatment? (Clue: He had been wearing shorts.)	474
6. What are the distinguishing features of scabies?	474
7. How dangerous are scorpion stings?	475
8. What are the signs of scorpion envenomation?	475
9. What is the treatment for a scorpion sting?	476
Formicidae (Ants)	476
10. I have a patient who received multiple stings from fire ants. What do I do?	476
Hymenoptera (Bees and Wasps)	476
11. What types of reactions occur from Hymenoptera stings?	476
12. How does a bee sting differ from a wasp sting?	476
13. What about killer bees?	476
14. After a patient has survived an anaphylactic reaction to a bee sting, what should be done to prepare the patient in case he or she is stung again in the future?	476
Heloderma (Lizards)	477
15. Are there any venomous lizards in the world?	477
16. How do I open the jaws of a Gila monster?	477
Culicidae (Mosquitoes)	477
17. What is the major clinical significance of mosquito bites?	477
Mammals (Bats, Dogs, Cats, Foxes, Horses, Humans, Raccoons, Skunks, and Woodchucks)	477
18. How many dog and cat bites are there annually in the United States, and what is the risk of infection?	477
19. Should I give prophylactic antibiotics to the victim of a dog or cat bite?	477
20. Can dog bites be closed primarily (sutured)?	477
21. What is Capnocytophaga canimorsus?	478
22. What types of bites are at risk for the transmission of rabies?	478
23. What is postexposure prophylaxis for rabies?	478
24. What is a fight bite?	478
Marine Fauna (Sea Jellies, Sharks, and Venomous Fish)	478
25. How do I treat jellyfish or other coelenterate stings?	478
26. Name some venomous fish, and state what their venoms have in common. How can that feature of their venom be used in treatment?	479
27. How do I acquire antivenom for exotic snake or marine envenomations?	479
28. How many people are killed by sharks worldwide annually?	479
Crotalinae (Rattlesnakes, Copperheads, Water Moccasins) and Elapidae (Coral Snakes)	479
29. What are distinguishing physical features of crotaline (pit vipers) and elapid snakes?	479
30. What is a dry snakebite?	479
31. How does a pit viper bite differ from an elapid bite?	479
32. True or false: Snakebites are uncommon but highly lethal in the United States.	479
33. List some of the epidemiologic characteristics of snakebites in the United States.	480
34. List the three main clinical effects of crotaline (pit viper) envenomation.	480
35. What FDA-approved antivenom is available in the United States for crotaline (pit viper) envenomation, and when should it be administered?	480
36. Is the antivenom maintenance dosing always required?	480
37. What aspect of CroFab antivenom theoretically contributes to the need for additional and/or maintenance doses of antivenom?	480
38. Can a crotaline bite cause compartment syndrome?	480
39. What is the importance of the coloring of coral snakes, and what are the active components of its venom?	481
40. How is coral snake envenomation treated?	481
41. Which prehospital treatments for crotaline bites are now considered to be ineffective or harmful?	481
42. Which prehospital non-antivenom treatments are reasonable?	481
43. What about exotic snakes (at least exotic by North American standards)?	481
44. What are other general guidelines for crotaline (pit viper) snakebite patient care?	481
Bibliography	482
Questions	483.e1
73 Smoke Inhalation	484
Abstract	484.e1
Keywords:	484.e1
1. What is the most common way to die in a fire?	484
2. Is smoke inhalation so lethal because it causes thermal injury to the lungs?	484
3. Why is smoke inhalation so dangerous?	484
4. Name the four clinical stages of smoke inhalation.	484
5. How should smoke inhalation victims be managed in the field?	484
6. What should I ask the emergency medical technicians (EMTs) about the fire?	484
7. Name some toxins produced by smoke and the materials from which they derive.	484
8. What are the earliest clinical manifestations of acute inhalation injury after smoke exposure?	485
9. Why is HBO therapy thought to be beneficial for smoke inhalation?	485
10. How do I make the diagnosis of smoke inhalation injury?	485
11. How should asymptomatic patients be managed?	485
12. If the patient’s pulse oximetry is normal, would arterial blood gas analysis yield additional information?	485
13. Should I get a chest radiograph on all patients with a history of smoke inhalation?	485
14. Can I use the standard burn formula for intravenous (IV) fluids if smoke inhalation is present?	485
15. Is HBO therapy the only available therapy for cyanide poisoning?	486
16. Tell me about hydroxocobalamin.	486
17. How does the Lilly cyanide antidote kit work?	486
18. When should I use the cyanide antidote kit?	486
19. How do I administer the cyanide antidote kit?	487
20. Why is CO so dangerous?	487
21. How do I make the diagnosis in the ED?	487
Controversy	487
22. Is the early respiratory failure seen in smoke inhalation victims worsened by aggressive crystalloid resuscitation?	487
23. How do I treat CO poisoning?	487
Bibliography	487
Questions	487.e1
74 Common Drugs of Abuse	488
Abstract	488.e1
Keywords:	488.e1
1. Are the occurrences of heroin and other opioid abuse decreasing in frequency?	488
2. What do the terms opium, opiate, opioid, and narcotic mean?	488
3. What is the typical clinical presentation of opioid poisoning?	488
4. Do all patients with opioid intoxication cases have miosis?	488
5. How should a patient with respiratory compromise from opioid overdose be treated?	488
6. What is the appropriate naloxone dose?	488
7. Can naloxone be administered by other routes besides IV?	489
8. Do all patients respond to a standard dose of naloxone?	489
9. How long does the clinical effect of naloxone last?	489
10. How should recurrent sedation and respiratory depression resulting from a long-acting opioid be treated?	489
11. Should naloxone be administered empirically to every patient with altered mental status?	489
12. Who should I observe in the ED, and for how long?	489
13. What are the signs of opioid withdrawal?	490
14. How is opioid withdrawal best treated?	490
15. What are body packers and stuffers?	490
16. How should body stuffers and packers be managed?	490
17. How useful are toxicologic screens for opioids, and which opioids are not often detected?	490
18. Are there any other tests that should be checked in patients with opioid ingestions?	491
19. What is the most common pulmonary complication of opioid use?	491
20. Can opioids cause seizures?	491
21. Is it safe to give dextromethorphan or meperidine to patients taking antidepressant medications?	491
22. Why should I avoid prescribing meperidine (Demerol)?	491
23. Which antidiarrheal agent can cause significant toxicity if ingested?	491
24. Which opioid can produce ventricular dysrhythmias, a wide QRS complex, mydriasis, and seizures?	491
25. What are designer drugs, and what are the two most notorious designer drugs that have been used?	491
26. What over-the-counter cold remedy is sometimes abused by teenagers?	492
27. Name another analog of codeine.	492
Sedative-Hypnotics	492
28. What is a sedative-hypnotic drug?	492
29. What medications fall into this category?	492
30. What are the Z-drugs?	492
31. What is a typical presentation of sedative hypnotic intoxication?	492
32. Many overdoses seem to present this way, so how are sedative hypnotics different?	493
33. How do sedative-hypnotics cause CNS depression?	493
34. How do I make the diagnosis of sedative/hypnotic overdose in a patient with undifferentiated CNS depression?	493
35. Is there a role for drug screens or specific drug levels?	494
36. What is the treatment for sedative-hypnotic overdose?	494
37. How do patients die of sedative-hypnotic overdose?	494
38. What is the appropriate way to decontaminate the gastrointestinal tract?	494
39. Are there specific antidotes for sedative-hypnotic intoxication?	494
40. How does flumazenil work?	494
41. Should flumazenil be given empirically to all patients with depressed mental status?	494
42. What is GHB?	495
43. How does a GHB overdose present?	495
44. What are the effects of GHB withdrawal?	495
45. What is a Mickey Finn, and what are date rape drugs?	495
Mushrooms	495
46. What are the symptoms and signs of mushroom poisoning?	495
47. Which mushroom’s toxins cause the most concern?	496
48. Do symptoms within 6 hours absolutely exclude amatoxin ingestion?	496
49. How do I treat someone who has ingested mushrooms?	496
Hallucinogens	496
50. What are hallucinogens?	496
51. List some examples of hallucinogens.	496
52. List the life-threatening effects of hallucinogens.	496
53. Why would someone “lick a toad”?	496
54. What is the treatment for hallucinogen toxicity?	496
Stimulants	496
55. What are examples of stimulants?	496
56. What is the difference between cocaine and amphetamines?	497
57. How should I screen for cocaine use?	497
58. What are freebase and crack cocaine?	497
59. What is the significance of chest pain after using cocaine?	497
60. Does concomitant ingestion of ethanol change the effects of cocaine?	497
61. What is “ice”?	497
62. What is “ecstasy,” and what is Eve?	497
63. How should I treat someone with toxicity from stimulants?	498
64. How do I treat stimulant-induced high blood pressure?	498
65. What are “bath salts”?	498
66. What are synthetic cannabinoids?	498
67. Can consumable (edible or drinkable) marijuana cause a patient to come to the ED?	498
68. I had a patient with ear and nose ischemia from cocaine use. Why did that happen?	498
Anticholinergic Agents	498
69. What are anticholinergic agents, and how do they present?	498
70. What is the stimulant-induced OTD?	499
Bibliography	499
Questions	500.e1
75 Cardiovascular Toxicology	501
Abstract	501.e1
Keywords:	501.e1
1. How do different poisons affect heart rate, blood pressure, and QRS duration?	501
2. What drugs cause cardiovascular toxicity by blocking cardiac sodium channels?	501
3. What is the antidote for drugs that cause sodium channel blockade?	501
4. What symptoms do patients with a calcium channel blocker (CCB) overdose experience?	501
5. What is the treatment for CCB overdose?	501
6. What are the symptoms in patients with β-blocker (BB)?	503
7. Describe the treatment for BB toxicity.	503
8. Describe the manifestations of acute and chronic digoxin poisoning.	503
9. What are the indications for digoxin immune antibody fragments (Fab)?	503
10. How is digoxin Fab administered?	503
Acknowledgment	504
Bibliography	504
Questions	504.e1
76 Pediatric Ingestions	505
Abstract	505.e1
Keywords:	505.e1
1. How common are pediatric ingestions?	505
2. What is different about children from adults with ingestions and exposures?	505
3. What are some household agents that can be dangerous?	505
4. What products contain caustics?	505
5. What are concerning signs after caustic ingestion?	505
6. What products contain hydrocarbons, and what are the symptoms of exposure?	505
7. How should hydrocarbon exposures be managed?	505
8. What products contain ethanol and the toxic alcohols?	506
9. When are button battery and magnet ingestions dangerous?	506
10. Are there any over-the-counter (OTC) products that can be dangerous?	506
11. How much iron is needed to cause significant toxicity, and what are the symptoms?	506
12. What are symptoms of OTC cough and cold medication overdose?	506
13. How do ingestions of camphor present?	506
14. Why are children more predisposed to methemoglobinemia?	506
15. How is methemoglobinemia treated?	506
16. Are there any plants that can cause serious illness?	507
17. What comprises the pediatric “one pill can kill” list?	507
18. What drugs may be found on the one pill can kill list?	507
19. What are the components and clinical presentation of Lomotil, and what are their mechanisms of action?	507
20. What is the potential lethal dosage of a tricyclic antidepressant (TCA)?	507
21. What electrocardiogram (ECG) finding in TCA ingestions is helpful in children?	507
22. Have deaths been reported in single ingestions of dihydropyridine (e.g., nifedipine) ingestions in children?	507
23. What is the pediatric dosage of calcium for calcium channel blocker ingestions?	507
24. What other therapy is used in treatment of calcium channel blockers and β-blockers?	508
25. What is a potential side effect of β-blocker and calcium channel blocker ingestions other than cardiovascular toxicity in children?	508
26. For how long should a sulfonylurea ingestion in a child be observed?	508
27. How often should blood sugars be monitored?	508
28. After a sulfonylurea ingestion in a child, should prophylactic dextrose or maintenance fluids with dextrose be given?	508
29. What is the rule of 50?	508
30. What is considered the antidote of sulfonylurea ingestions?	508
31. How is octreotide administered in pediatric sulfonylurea ingestions?	508
32. What are the cardiovascular effects that may be seen with clonidine ingestions?	508
33. Can naloxone be used in pediatric clonidine ingestions?	509
34. What are some common OTC products that contain pharmaceuticals with similar mechanisms of action to clonidine?	509
35. At what dosage of salicylate do children begin to manifest toxicity in an acute ingestion?	509
36. How does the potency of methyl salicylate compare to salicylate?	509
37. Approximately how much aspirin (or acetylsalicylate) is equal to 5 mL of 100% methyl salicylate?	509
38. What phenothiazine is believed to be the most dangerous in pediatric accidental ingestions?	509
39. What is the pathophysiology of chloroquine and hydroxychloroquine ingestions?	509
40. What other drug besides standard therapy has been used to treat chloroquine poisoning?	509
41. What newer opioid can result in significant toxicity with ingestion of one pill?	509
42. What symptoms develop after benzonatate (Tessalon) perle ingestion?	510
Acknowledgment	510
Bibliography	510
Questions	511.e1
XV Gynecology and Obstetrics	512
77 Pelvic Inflammatory Disease	512
Abstract	512.e1
Keywords:	512.e1
1. What is pelvic inflammatory disease (PID)?	512
2. What are the risk factors for PID?	512
3. What are the signs and symptoms of PID?	512
4. What are the microbiologic causes?	512
5. What are the diagnostic criteria for PID?	512
6. Which diagnostic tests should be performed in patients suspected of PID?	513
7. What other diseases should be considered?	513
8. What are the consequences of PID?	513
9. Who should be hospitalized?	513
10. Summarize the recommended antibiotic regimens for PID treatment.	513
11. Are there alternative outpatient treatment regimens for PID?	513
12. Does the presence of an intrauterine pregnancy effectively rule out PID?	514
13. Does a history of tubal ligation preclude the diagnosis of PID?	514
14. What is the appropriate follow-up care for patients with PID?	514
15. Summarize the principles of management of acute PID.	515
Acknowledgment	515
Bibliography	515
Questions	515.e1
78 Sexual Assault	516
Abstract	516.e1
Keywords:	516.e1
1. What is the definition of sexual assault?	516
2. How common is sexual assault?	516
3. What role does a medical provider have in cases of sexual assault?	516
4. What information should be elicited in the patient history?	516
5. What should be included in the physical examination?	517
6. What evidence is gathered as part of the forensic examination?	517
7. What laboratory studies are indicated?	517
8. What about blood alcohol levels and tests for drug use?	518
9. What historical features might indicate a drug-facilitated rape?	518
10. What are the most common STDs that may be contracted as a result of a sexual assault?	518
11. Is empiric antibiotic treatment of sexual assault victims indicated? How about vaccinations?	518
12. What is the risk of pregnancy after sexual assault?	518
13. What are the current options for pregnancy prophylaxis?	518
14. What are special characteristics of the male sexual assault victim?	519
15. Discuss the special characteristics of pediatric sexual assault.	519
16. Should pediatric patients be given prophylactic antibiotics?	519
17. State the important aspects of follow-up care for any victim of sexual assault.	519
18. What types of emotional trauma might sexual assault victims experience?	519
19. My patient is terrified of contracting HIV after her sexual assault. What do I do now?	519
20. What is nPEP?	519
21. What is the risk of acquiring HIV after a sexual assault?	519
22. How exactly do I provide nPEP for my patient?	520
Acknowledgment	520
Bibliography	520
Questions	520.e1
79 Spontaneous Abortion, Ectopic Pregnancy, and Vaginal Bleeding	521
Abstract	521.e1
Keywords:	521.e1
1. What are the important causes to consider in the ED evaluation of first-trimester vaginal bleeding or pain?	521
2. What is spontaneous abortion or miscarriage?	521
3. State the incidence and timing of spontaneous abortion.	522
4. What are the five types of miscarriage or abortion?	522
5. What are important questions to consider during the examination and treatment of spontaneous abortion?	522
6. What is a septic abortion?	522
7. What are the signs and symptoms of a septic abortion?	522
8. What are the earliest symptoms of a miscarriage?	522
9. What is the prognosis for the pregnancy in patients with threatened abortion?	522
10. Do diagnostic radiographs cause spontaneous abortion?	522
11. What factors are associated with spontaneous abortion and/or fetal abnormalities?	522
12. Is minor trauma a significant factor associated with spontaneous abortion?	523
13. Describe cervical incompetence.	523
14. Name the drug used to prevent Rh immunization.	523
15. What follow-up instructions should be given to a patient with a threatened abortion?	523
16. What about the emotional aspects of an early miscarriage?	523
17. What is an EP?	523
18. What are common risk factors for EP?	524
19. Define heterotopic pregnancy. What is the main risk factor for this condition, and what is its incidence?	524
20. How reliable are routine serum and urine pregnancy tests in a patient with EP?	524
21. What clinical signs and symptoms are useful to increase suspicion of an EP?	524
22. What are the incidence and risk factors for tubal rupture?	525
23. Why are corpus luteum cysts commonly confused with EPs?	525
24. What is the most efficient way to diagnose or exclude EP in the ED?	525
25. Describe the role of bedside ultrasonography in the ED evaluation of the patient with first-trimester complaints.	525
26. Describe the early sonographic findings in a healthy pregnancy.	525
27. Describe the concept of the discriminatory zone as it applies to the serum β-HCG level.	525
28. How else is quantitative β-HCG used?	525
29. Does every patient with bleeding or pain in the first trimester require ultrasound before discharge from the ED?	526
30. What are the ultrasound findings in patients with suspected EP?	526
31. What patients with EP can be discharged from the ED?	526
32. Which EPs should be treated medically with methotrexate?	526
33. What are contraindications to methotrexate therapy for EP?	527
34. What is gestational trophoblastic disease?	527
35. What is SH?	527
36. Name the sources and causes of third-trimester vaginal bleeding.	527
37. What is placenta previa?	527
38. How is placenta previa diagnosed?	528
39. How is placenta previa treated?	528
40. What is placental abruption (abruptio placentae)? Why is it dangerous?	528
41. Describe the treatment of placental abruption.	528
42. What is uterine rupture, and why is it dangerous?	528
43. What is the treatment of uterine rupture?	528
44. Describe the non–life-threatening causes of third-trimester vaginal bleeding.	528
Acknowledgment	529
Bibliography	529
Questions	529.e1
80 Third-Trimester Complications and Delivery	530
Abstract	530.e1
Keywords:	530.e1
1. What are the major hypertensive disorders in pregnancy?	530
2. What is preeclampsia?	530
3. What is gestational hypertension, and how does it differ from chronic hypertension?	530
4. Which conditions must be present to diagnose preeclampsia?	530
5. What are the diagnostic criteria for severe preeclampsia?	530
6. How is a diagnosis of preeclampsia superimposed on chronic hypertension made?	531
7. What causes preeclampsia?	531
8. What are the risk factors for preeclampsia?	531
9. How common is preeclampsia?	531
10. What is the definitive treatment for preeclampsia?	531
11. When is immediate delivery indicated?	531
12. What is the treatment for preeclampsia in the ED?	531
13. Which antihypertensive medications can be used?	531
14. Which antihypertensive medications should be avoided in pregnancy?	531
15. What are the findings of magnesium toxicity, and how should the patient be monitored?	531
16. What are the complications of preeclampsia?	532
17. What complications to the fetus can occur?	532
18. Is there a way to prevent preeclampsia?	532
19. What is eclampsia?	532
20. What is the treatment for eclampsia?	532
21. What is the most common cause of death in a patient with preeclampsia-eclampsia?	532
22. Does a woman have to be pregnant to have preeclampsia or eclampsia?	532
23. Are there atypical presentations of preeclampsia or eclampsia?	532
24. What is HELLP syndrome?	532
25. How is HELLP syndrome diagnosed?	533
26. How is HELLP syndrome treated?	533
27. What are the complications of HELLP syndrome?	533
28. What are the maternal and fetal mortality rates associated with HELLP?	533
29. What do I need to do to stabilize a pregnant patient brought into the ED?	533
30. What information do I need to care properly for the pregnant patient?	533
31. How are the baby and pregnancy evaluated?	533
32. How do I check cervical dilation?	534
33. What should be in an emergency delivery pack?	534
34. How can I determine whether a delivery is imminent?	534
35. I have a laboring pregnant patient in the ED, and the baby can be seen distending the mother’s perineum. The obstetrician is on the way but will not make it in time. What do I do now?	534
36. The baby is part way out. Should I pull on the baby to help the delivery?	534
37. What is shoulder dystocia?	534
38. What maneuvers are available to resolve shoulder dystocia during delivery?	534
39. If the umbilical cord is wrapped around the neck during a delivery, what should I do?	535
40. The placenta has not delivered. What should I do now?	535
41. How do I manage a breech presentation?	535
42. How do I recognize PPH?	535
43. What are the most common causes of PPH?	535
44. How is PPH managed?	535
Acknowledgment	536
Bibliography	536
Questions	536.e1
XVI Trauma	537
81 Multiple Trauma	537
Abstract	537.e1
Keywords:	537.e1
1. What is multiple trauma?	537
2. Describe mechanism of injury.	537
3. Are there any factors that should raise concern about the impact of the mechanism of injury?	537
4. Give some examples of significant mechanisms of injury.	537
5. List the first steps in managing multiple trauma in the ED.	537
6. How should the patient be undressed?	537
7. What are the ABCs (and D) of trauma?	538
8. Discuss assessment of the airway.	538
9. When do I need to manage the airway?	538
10. Is there any role for ketamine in the management of trauma patients?	538
11. What is the role of surgical airway management in the ED?	538
12. How is breathing assessed?	538
13. How is circulation assessed?	539
14. What is the role of ultrasound in the ED management of trauma?	539
15. What about DPL? Is there still any role for it?	539
16. How is disability assessed?	539
17. What type of intravenous (IV) access should be established in a patient with major trauma?	539
18. Where should cutdowns be performed?	539
19. What parameters should be monitored in multiple trauma victims?	540
20. When should blood be administered?	540
21. What is permissive hypotension?	540
22. What can I find out about tranexamic acid (TXA) and its role in trauma care?	540
23. Are laboratory tests useful?	540
24. What is the secondary survey?	540
25. Which radiologic studies need to be obtained immediately?	541
26. How do I prioritize diagnostic tests?	541
27. How are fluids managed in pediatric trauma?	541
28. What is the significance of blunt abdominal trauma in the pregnant woman?	541
Bibliography	541
Questions	541.e1
82 Maxillofacial Trauma	542
Abstract	542.e1
Keywords:	542.e1
1. What are the facial bones?	542
2. What is the initial approach to a patient with maxillofacial trauma?	542
3. How should the airway be managed in patients with maxillofacial trauma?	542
4. Which procedure is contraindicated in patients with maxillofacial trauma?	542
5. What is a blow-out fracture, and what is the entrapment syndrome?	542
6. What is a lateral canthotomy, and when is one necessary?	542
7. What findings indicate the need for a lateral canthotomy?	542
8. What are Le Fort fractures?	543
9. Is there a role for screening patients with Le Fort fractures for blunt cerebrovascular injury?	543
10. When are nasal radiographs indicated?	544
11. What is a septal hematoma, and why is it important?	544
12. When should a consultation be obtained for a nasal fracture?	544
13. How is a frontal sinus fracture diagnosed?	544
14. How are frontal sinus fractures treated?	544
15. What are the classic zygoma fractures?	544
16. What are the typical findings of a mandible fracture?	544
17. What is the tongue blade test?	545
18. Which imaging studies should be ordered to diagnose a mandible fracture?	545
19. What are the most commonly fractured areas of the mandible?	545
20. What is the mechanism for a temporomandibular joint dislocation, and how is it treated?	545
21. When is a CT scan indicated in the evaluation of maxillofacial trauma?	545
22. How do I recognize an injury to the Stensen duct?	545
23. When should closure of a facial laceration be deferred?	546
24. What deformity may arise from blunt trauma to the ear?	546
25. How is the ear anesthetized?	546
Bibliography	547
Questions	547.e1
83 Cervical Spine and Spinal Cord Trauma	548
Abstract	548.e1
Keywords:	548.e1
1. What is the annual incidence of spinal cord injury (SCI) in the United States?	548
2. Name the most common causes of SCI.	548
3. What are the most common levels of injury?	548
4. Who gets SCIs?	548
5. In patients discharged from the hospital with neurologic impairment, what percentage has paraplegia and what percentage has tetraplegia (quadriplegia)?	548
6. If most spinal injuries do not cause neurologic injury, why should I worry?	548
7. What is the financial impact of an SCI?	548
8. Name the causes of reduced life expectancy in patients with SCI.	548
9. Are there any underlying conditions that could precipitate or heighten the chance of an SCI?	549
10. How do I immobilize the patient with a potential spinal injury?	549
11. Why is using a backboard considered a problem?	549
12. If the backboard causes all of these problems, should it ever be used?	549
13. How should I approach the patient with potential spinal injury?	549
14. What should be assessed on physical examination?	549
15. What is neurogenic shock, and how is it treated?	550
16. What are the general principles of emergency treatment in the patient with spinal cord trauma?	550
17. How do I determine which patients need spine radiographs?	550
18. What are the NEXUS criteria?	550
19. What is the CCR?	550
20. What are distracting injuries?	550
21. Can these decision rules be applied to children?	551
22. Which radiographs should be obtained?	551
23. How do I interpret the lateral cervical spine radiograph?	551
24. What are the indications for flexion-extension views of the cervical spine?	552
25. When would a CT or MRI be ordered?	552
26. What is SCIWORA?	552
27. Describe the Jefferson, Hangman, Clay shoveler, and Chance fractures.	553
28. Describe the incomplete cord syndromes or injuries.	553
29. What is the significance of sacral sparing and spinal shock?	553
30. What can emergency physicians do to prevent spinal injuries?	553
Controversy	553
31. What is the status of steroids in spinal cord trauma?	553
Bibliography	554
Questions	554.e1
84 Head Trauma	555
Abstract	555.e1
Keywords:	555.e1
1. What is the scope of head injury in the United States?	555
2. What groups of patients are at particular risk from head trauma?	555
3. What is a cerebral concussion?	555
4. What is postconcussive syndrome?	555
5. What is second impact syndrome?	556
6. What complications are associated with basilar skull fractures?	556
7. How are CSF leaks treated?	556
8. What are signs or symptoms of a patient with epidural hematoma?	556
9. How does an SDH present?	556
10. What is axonal shear injury?	557
11. What is brain herniation?	557
12. List the four types of herniation syndrome.	557
13. Describe uncal herniation syndrome.	558
14. What is central herniation syndrome?	558
15. How does cingulate herniation occur?	558
16. Explain posterior fossa herniation.	558
17. What is the ED treatment for increased ICP?	558
18. Is there any role for therapeutic hypothermia in patients with TBI?	559
19. If a patient has a normal CT scan after head trauma, is it completely safe to discharge him or her home?	559
20. What are the indications for a repeat head CT scan?	560
References	560
Questions	560.e1
85 Traumatic Ophthalmologic Emergencies	561
Abstract	561.e1
Keywords:	561.e1
1. Name the two most time-critical emergencies in ophthalmology.	561
2. What is the treatment for a chemical burn of the eye?	561
3. How do I know when I have irrigated the eye enough?	561
4. What is the significance of pain from an eye injury that is not relieved with topical anesthesia?	561
5. List nine potential injuries that must be considered in a patient sustaining a blunt injury to the eye.	561
6. What is the most common eye injury seen in the ED?	561
7. How is corneal abrasion diagnosed?	561
8. What is the treatment for a corneal abrasion?	561
9. What is the role of an eye patch in treatment of corneal abrasions?	562
10. How does a corneal abrasion from a contact lens differ from other causes of corneal trauma?	562
11. What is the most common location of an ocular foreign body?	562
12. What is the proper treatment for a corneal foreign body?	562
13. What is an anterior hyphema?	562
14. How is an anterior hyphema treated?	562
15. What physical findings lead to the suspicion of a blow-out fracture?	562
16. What is traumatic mydriasis?	562
17. Why is a history of hammering metal on metal important in a patient with an eye complaint?	563
18. Which eyelid lacerations should be repaired by an ophthalmologist or plastic surgeon?	563
19. When should penetration of the globe be suspected?	563
20. List traumatic ophthalmologic injuries that require immediate ophthalmologic consultation.	563
21. Name two ophthalmologic injuries that require urgent ophthalmologic consultation (within 12 to 24 hours).	563
22. What is solar keratitis?	563
23. What is the significance of a retroorbital hematoma?	563
24. What is the cause of a dilated pupil that fails to constrict with topical pilocarpine?	563
Bibliography	564
Questions	564.e1
86 Neck Trauma	565
Abstract	565.e1
Keywords:	565.e1
1. Why is neck trauma a complicated topic?	565
2. What common findings indicate significant neck injury?	565
3. What are the most urgent concerns in the initial management of neck trauma?	565
4. What is the preferred method to secure the airway?	565
5. What are the indications for cervical spine immobilization in neck trauma?	565
6. What are the three anatomic zones of the neck?	565
7. Why is the neck divided into three zones?	566
8. What is the main controversy regarding management of penetrating neck trauma.	566
9. What is the current algorithm for the workup of penetrating neck trauma?	566
10. What are the hard and soft signs of penetrating neck trauma?	566
11. Can CTA replace conventional angiography for detection of vascular injuries in penetrating neck injuries?	567
12. Which diagnostic studies are important in suspected laryngeal injuries?	567
13. Which diagnostic studies are important in suspected esophageal injuries?	567
14. What are the signs and symptoms of blunt carotid or vertebral artery trauma?	568
15. What are the indications for imaging to evaluate for vascular injury in patients with blunt cervical trauma?	568
16. What diagnostic testing is preferred in the detection of blunt vascular injuries?	568
17. Is there any role for Doppler ultrasound in blunt vascular trauma?	568
18. How about MRI? Can it be used to identify blunt vascular injury?	568
19. What is the appropriate management of blunt vascular injuries?	568
Bibliography	569
Questions	569.e1
87 Chest Trauma	570
Abstract	570.e1
Keywords:	570.e1
1. What is the initial approach to the patient with chest trauma?	570
2. What is the proper way to examine the chest during the trauma survey?	570
3. What are the immediate threats to life after thoracic trauma, and how are they identified?	570
4. Which major organs may be injured in blunt or penetrating chest trauma?	570
5. What is a pneumothorax, and what may commonly cause it?	571
6. What are the signs and symptoms of a pneumothorax?	571
7. How is a pneumothorax diagnosed?	571
8. How do I treat a pneumothorax?	571
9. What is a tension pneumothorax?	571
10. What are the possible signs and symptoms of a tension pneumothorax?	571
11. How should a tension pneumothorax be diagnosed?	571
12. How is a tension pneumothorax treated?	571
13. What is an open pneumothorax, and how is it diagnosed?	572
14. How should an open pneumothorax be treated?	572
15. What is a hemothorax, and how is it diagnosed?	572
16. What is the treatment of hemothorax?	572
17. What should I do if my chest tube does not completely drain the hemothorax?	572
18. What is a massive hemothorax?	572
19. How much ongoing blood loss out of the chest tube is an indication for operative exploration?	572
20. What other fluids may fill the pleural space after trauma?	572
21. What is the best management of an asymptomatic, hemodynamically stable patient after penetrating thoracic trauma with no pneumothorax or hemothorax on initial chest radiography?	572
22. What is a pulmonary contusion, and how is it diagnosed?	573
23. How is a pulmonary contusion managed?	573
24. What are the signs and symptoms of an intrathoracic tracheobronchial tree injury?	573
25. How are tracheobronchial tree injuries diagnosed and treated?	573
26. What are the signs and symptoms of cardiac tamponade?	573
27. How can cardiac tamponade be diagnosed?	573
28. How is cardiac tamponade treated?	573
29. What is blunt cardiac injury (BCI)?	574
30. What is the appropriate management for suspected BCI?	574
31. When should a penetrating cardiac injury be suspected, and how is it diagnosed?	574
32. How does the management of a suspected transmediastinal gunshot wound differ in a hemodynamically stable patient from the management of an unstable patient?	574
33. What is blunt aortic injury, and how does it occur?	574
34. At which anatomic location is the aorta most commonly injured after blunt trauma?	574
35. How do blunt aortic injuries present, and how are they diagnosed?	574
36. Which modalities are used to diagnose blunt aortic injury, and what are the radiographic findings?	575
37. How are blunt aortic injuries treated?	575
38. How do penetrating injuries to the great vessels present?	575
39. How are great vessel injuries evaluated, and what is the treatment?	575
40. What are the goals of ED resuscitative thoracotomy?	575
41. What are the contraindications for ED resuscitative thoracotomy?	575
42. Which is the more common mechanism for thoracic esophageal injury: blunt or penetrating?	575
43. What are the signs and symptoms of esophageal injury and rupture?	575
44. How should a suspected thoracic esophageal injury be investigated?	576
45. What is the treatment of esophageal injury?	576
46. Why are diaphragm injuries important to recognize?	576
47. How is a diaphragm injury diagnosed?	576
48. What are the manifestations of a chyle leak resulting from blunt thoracic trauma, and how do I confirm the diagnosis?	576
49. What are the signs and symptoms of rib fractures, and how are they diagnosed?	576
50. Name the potential complications after rib fractures.	576
51. How are rib fractures treated?	576
52. What are the risk factors for increased morbidity and mortality from rib fractures?	576
53. What is a flail chest?	576
54. What is the treatment of choice for flail chest?	577
55. What injuries are associated with a posterior sternoclavicular dissociation and scapular fracture?	577
56. What is the significance of a sternal fracture, and how is it diagnosed?	577
57. What is the imaging modality of choice for suspected thoracic spinal injuries?	577
58. What is neurogenic shock, and how does it manifest?	577
59. How does thoracic trauma in children differ from thoracic trauma in adults?	577
Bibliography	577
Questions	578.e1
88 Abdominal Trauma	579
Abstract	579.e1
Keywords:	579.e1
1. What is ABCDE, and why is it relevant to the evaluation of significant abdominal trauma?	579
2. Discuss the key aspects of the secondary survey in the evaluation of abdominal trauma.	579
3. What are some of the biomechanical principles in blunt and penetrating trauma?	579
4. What are the most commonly injured abdominal organs?	580
5. What is a seat belt sign?	580
6. Lower rib fractures are typically associated with what intraabdominal injuries?	580
7. What is a Chance fracture?	580
8. What abdominal injuries are associated with pelvic fractures?	580
9. In the setting of trauma, what is the significance of gross hematuria?	581
10. Describe the incidence of diaphragmatic rupture in trauma and how it can be diagnosed on a chest radiograph.	581
11. Does a normal serum amylase test exclude pancreatic injury?	582
12. What is the initial imaging modality of choice to evaluate for evidence of abdominal trauma?	582
13. What are the four locations evaluated during FAST, and in which order should they be evaluated?	582
14. What is the role of CT scanning?	582
15. What is the role of DPL?	582
16. How are DPL results interpreted?	582
17. What are the unique concerns in a pregnant patient with abdominal trauma?	583
18. What are the general principles of trauma in the elderly population?	583
19. In the management of abdominal trauma, are children really just small adults?	583
Bibliography	584
Questions	585.e1
89 Pelvic Fractures and Genitourinary Trauma	586
Abstract	586.e1
Keywords:	586.e1
1. Why are pelvic fractures so deadly?	586
2. What is the approach to the patient with a pelvic fracture?	586
3. How do I examine the patient with a pelvic fracture?	586
4. How are pelvic fractures classified?	586
5. What are the sources of bleeding from major pelvic fractures?	588
6. Name three goals of mechanical pelvic stabilization.	588
7. Discuss four methods of acute pelvic stabilization.	588
8. When should patients with pelvic trauma undergo laparotomy?	588
9. How often are rectal injuries associated with pelvic injuries, and how are they managed?	588
10. What is the role of pelvic packing for pelvic trauma?	588
11. What types of injuries are associated with genitourinary trauma?	589
12. What is considered a true genitourinary emergency?	589
13. What clinical signs may indicate injury to the kidney?	589
14. What is the general management strategy for renal injury?	589
15. What diagnostic tools can be used to evaluate renal trauma?	589
16. When should ureteral trauma be suspected?	589
17. What are the associated clinical findings with bladder injury?	589
18. How should bladder injury be evaluated?	589
19. When should urethral injury be suspected?	590
20. How is a retrograde urethrogram performed?	590
21. What is the diagnostic approach to asymptomatic microhematuria in the patient with blunt trauma?	590
22. What is a penile fracture?	590
23. What is the role of ultrasound in the evaluation of testicular trauma?	590
Bibliography	590
Questions	591.e1
90 Trauma in Pregnancy	592
Abstract	592.e1
Keywords:	592.e1
1. What is the most important concept I need to remember from this chapter?	592
2. How common is trauma in pregnancy?	592
3. Is physical or sexual abuse often seen in pregnant patients?	592
4. Given the impact of domestic violence, what can be done in the ED?	592
5. What are the implications of MVC mechanisms of injury for pregnant patients?	592
6. How do physiologic changes in pregnancy affect the evaluation of the trauma victim?	592
7. How do physiologic changes of pregnancy affect laboratory values?	593
8. Are serious maternal injuries required for fetal injury to be present?	593
9. Name the most common causes of fetal death.	593
10. How does placental abruption occur?	593
11. What are the findings of abruption after trauma?	593
12. How often does ultrasound detect placental abruption?	593
13. Are radiologic investigations harmful to the fetus?	593
14. How should these patients be managed in the field?	593
15. What are the priorities for ED management?	594
16. How do I begin to evaluate the fetus?	594
17. What is fetomaternal hemorrhage (FMH)?	594
18. How is FMH managed?	594
19. When is emergency cesarean section indicated?	594
20. When should perimortem cesarean section be performed?	594
21. Which pregnant patients with abdominal trauma require admission for fetal monitoring?	594
Bibliography	595
Questions	595.e1
91 Pediatric Trauma	596
Abstract	596.e1
Keywords:	596.e1
1. Which children get injured? How do they do it?	596
2. Are children just little adults?	596
3. What are some of the anatomic differences?	596
4. How does prioritization of the resuscitation ABCs (airway, breathing, and circulation) differ between children and adults?	596
5. Which factors affect the patency of a child’s airway?	597
6. Which factors affect endotracheal intubation of a child?	597
7. What are my options if I cannot endotracheally intubate the patient’s airway?	597
8. How do I recognize shock in a pediatric patient?	597
9. Name the preferred sites for venous access.	597
10. What are some considerations regarding an IO line?	598
11. What is a child’s normal blood volume?	598
12. How should I resuscitate a pediatric trauma patient?	598
13. Why are children prone to head trauma?	598
14. Which kinds of head injuries do children get?	598
15. Which children need cranial imaging after head trauma?	598
16. How do I recognize a concussion in a child?	599
17. How do cervical spine injures in children differ from those in adults?	599
18. What is SCIWORA?	599
19. What is pseudosubluxation of the cervical spine, and how common is it?	599
20. What is the most common upper extremity fracture in children?	599
21. What are other examples of fractures that are more common in children than adults?	599
22. How common are rib fractures in children?	600
23. How common are mediastinal (great vessel) injuries in children?	600
24. What are predictors of pediatric intraabdominal injuries?	600
25. Compare and contrast the primary diagnostic modalities for evaluating children for abdominal trauma.	600
26. What is a handlebar injury?	600
27. What is the lap belt syndrome?	600
28. How much of a problem is nonaccidental trauma?	601
29. What are some examples of specific childhood fractures and fracture patterns that are highly suspicious for nonaccidental trauma?	601
Bibliography	601
Questions	602.e1
92 Musculoskeletal Trauma and Hand Injuries	603
Abstract	603.e1
Keywords:	603.e1
General Principles	603
1. What are immediate treatment priorities in open fractures?	603
2. What percentage of polytrauma patients have unrecognized fractures at time of admission?	603
3. What is compartment syndrome?	603
4. What causes compartment syndrome?	603
5. What are the clinical signs and symptoms of ACS?	604
6. What are the most common sites for compartment syndrome?	604
7. How do I treat compartment syndrome?	604
8. Describe the joint fluid analysis consistent with septic arthritis.	604
9. How do I diagnose a traumatic arthrotomy (open joint)?	605
10. When should I order radiographs, and how many should I order?	605
Hand and Forearm Injuries	605
11. What is the incidence of hand injuries seen in EDs?	605
12. List the essential elements of the history in hand injuries.	605
13. List the elements of a complete hand examination.	605
14. What is the best method to control bleeding in lacerations of hand and forearm?	605
15. What is the normal posture of the hand at rest, and what is the tenodesis test?	605
16. Does dorsal hand swelling always signify a dorsal hand injury or infection?	605
17. What is the Allen test, and how is it performed?	606
18. How is function of the flexor digitorum superficialis (FDS) tendon tested?	606
19. How do I test the extrinsic extensor tendons?	606
20. Can extensor function to a finger be intact despite complete laceration of the extensor digitorum communis (EDC) to that finger?	606
21. How do I test sensory nerve function?	606
22. Describe the sensory distributions of the median, ulnar, and radial nerves	606
23. How is the motor function for the median, ulnar, and radial nerves tested?	606
24. Name the carpal bones, including the most commonly dislocated carpal bone?	606
25. Which is the most commonly fractured carpal bone?	607
26. How much deformity can be tolerated in metacarpal fractures?	607
27. What are Rolando and Bennett fractures?	607
28. What is the appropriate treatment for a patient with pain in the snuffbox of the wrist and normal radiographs after a traumatic event to the wrist?	607
29. What is the difference between a “nightstick” fracture and a Monteggia fracture?	609
30. What nerve can be injured in a Monteggia fracture?	609
31. Why are high-pressure injections serious hand injuries?	609
32. List Kanavel’s four cardinal signs of flexor tenosynovitis.	609
33. What is a paronychia, and how is it treated?	609
34. How is whitlow different from a paronychia?	610
35. What is a felon, and how is it treated?	610
36. What is a jersey finger, and how is it treated?	610
37. What is a mallet finger, and how is it treated?	610
38. Describe a subungual hematoma. How is it treated?	610
39. What is a gamekeeper’s thumb, and how is it diagnosed?	610
40. What is a boxer’s fracture?	610
41. What is a fight bite?	610
42. Name six hand emergencies.	611
43. Name indications and contraindications for a microvascular replantation	611
44. How should an amputated part be handled and stored for transport?	611
45. What should be done with a devascularized but still partially attached digit?	611
Shoulder and Upper Arm Injuries	612
46. How can I detect anterior and posterior shoulder dislocations on radiographic film?	612
47. What is the incidence and what are common causes of posterior shoulder dislocations?	612
48. What percentage of patients with anterior shoulder dislocations experience recurrent dislocations?	612
49. What are potential complications of anterior shoulder dislocations?	612
50. How is a rotator cuff tear diagnosed?	612
51. What is the most common neurologic deficit seen with humeral shaft fractures?	612
52. What about clavicle fractures?	612
53. How are clavicle fractures treated?	612
54. What is a shoulder separation, and how does it occur?	613
55. How is an AC separation treated?	613
Lower Extremity and Pelvic Fractures	613
56. Name major complications seen in pelvic fractures.	613
57. What is the mortality rate in patients with open pelvic fracture?	613
58. What is the incidence and injury mechanism in posterior hip dislocation?	613
59. What complications can be seen in posterior hip dislocations?	613
60. How are posterior hip dislocations clinically differentiated from femoral neck fractures?	613
61. How much blood loss can be expected from a femoral shaft fracture?	613
62. How are femoral shaft fractures best stabilized in the ED?	613
63. Why can patients with pathologic conditions of the hip experience knee pain?	613
64. Name the most common injury associated with traumatic hemarthrosis of the knee joint.	614
65. Name the most commonly injured ligament seen in an inversion-type ankle sprain.	614
66. Describe the treatment for ankle sprains.	614
67. What is a locked knee, and what are the most common causes?	614
68. What is the most common direction of a knee dislocation?	614
69. What direction is associated with irreducible knee dislocations?	614
70. How is the ABI calculated?	614
71. What injuries are often associated with calcaneal fractures?	614
Pediatric Orthopedics	615
72. What is a torus or buckle fracture?	615
73. What is a greenstick fracture?	615
74. What is the Salter-Harris classification?	615
75. Which vascular complication is associated with pediatric supracondylar humerus fractures?	615
76. Describe the neurologic complications associated with pediatric supracondylar humerus fractures.	615
77. What is a nursemaid’s or pulled elbow, and what is its management?	616
78. Describe the potential implications of long bone fractures in a small child.	616
79. What is the Waddell triad?	616
80. Which nontraumatic hip disorders cause a limp in a child?	616
81. What are the early radiographic findings of an SCFE?	616
82. What is the ED management of a child with injury and tenderness over an open epiphysis but a normal radiograph?	616
Bibliography	617
Questions	617.e1
93 Burns	618
Abstract	618.e1
Keywords:	618.e1
1. Immediately after a thermal injury, what first aid should be offered?	618
2. How is the burn patient evaluated on arrival?	618
3. What should I do if there is both trauma and burns?	618
4. What factors are important in assessment of the burn patient’s airway?	618
5. List the criteria for transfer to a burn center.	618
6. What informs my decision to intubate the airway of a burn patient?	619
7. What dangers might be encountered with airway intubation of the burn patient?	619
8. Can succinylcholine be used safely in intubation of the burn patient?	619
9. How is the burn depth categorized?	619
10. What do superficial burns look like?	619
11. Describe superficial partial-thickness burns.	619
12. What are deep partial-thickness burns?	619
13. Describe full-thickness burns.	620
14. Why are circumferential full-thickness burns important to recognize?	620
15. Why, when, and where are thoracic escharotomies done?	620
16. How does %TBSA impact patient care? How is it calculated?	620
17. How is %TBSA useful in planning fluid resuscitation in burn patients?	620
18. Calculate a fluid regiment using the Parkland formula in a 70-kg adult suffering 20% TBSA burns.	620
19. Are there any pitfalls with using the Parkland formula?	620
20. What is burn shock?	621
21. What are three mechanisms by which smoke inhalation can cause injury?	621
22. What are three ways smoke from a fire causes death by asphyxiation?	621
23. What should I look for in a patient with CO exposure?	622
24. How is CO poisoning treated?	622
25. How do I manage patients with cyanide toxicity?	622
26. What are characteristics of patients whose burns can be managed in the outpatient setting?	622
27. What are the elements of an outpatient management plan for the burn patient?	623
28. What about tetanus prophylaxis?	623
29. How are children who suffer burns different from adults?	623
30. What characteristics of burns suggest nonaccidental trauma?	623
31. In pediatric patients, what specific concerns should be considered in household electrical injuries?	623
32. What about the child who bites an electrical cord and sustains a burn at the oral commissure?	623
33. What are the special considerations in elderly adults suffering burns?	623
34. Are there any issues in treating elderly adults who sustain burns?	623
35. What is special about treating facial burns?	624
36. What are general principles in managing patients suffering chemical burns?	624
Bibliography	624
Questions	624.e1
94 Wound Management	625
Abstract	625.e1
Keywords:	625.e1
1. Why is wound management important?	625
2. What is the difference between functional and cosmetic closure?	625
3. How do I remember what steps to take when repairing a wound?	625
4. Which factors increase the visibility of scars and compromise wound healing, and how are they minimized?	625
5. What aspects of history should be obtained in a patient with a traumatic wound?	625
6. What are the most important aspects of the physical examination?	625
7. What is the most important step I can take to prevent infection?	626
8. Which anesthetic agent should be used for local anesthesia?	626
9. What causes the pain of local anesthetic infiltration, and how can it be prevented?	627
10. What is the toxic dosage of lidocaine and bupivacaine?	627
11. Describe the presentation of lidocaine toxicity.	627
12. What can I use to anesthetize a patient who is allergic to amide and ester anesthetics?	627
13. What are the contraindications to epinephrine as an adjunct to lidocaine and bupivacaine?	627
14. What is LET?	628
15. What are the contraindications to LET?	628
16. When should regional anesthesia be used?	628
17. When do I use procedural sedation?	628
18. What is a contaminated wound?	628
19. List factors that contribute to wound infection.	628
20. Is a dirty wound the same as a contaminated wound?	628
21. What causes tattooing?	628
22. How is road rash managed?	628
23. When is obtaining a radiograph appropriate?	628
24. Which types of foreign bodies found in wounds are visible on radiographs?	628
25. What is the best method for hair removal?	629
26. Define the three different types of wound closure.	629
27. Which wounds should be closed primarily	629
28. When should delayed primary closure be used?	629
29. How is a wound prepared for delayed primary closure?	629
30. When should secondary closure be used?	629
31. What is the most important step when closing a lip laceration through the vermilion border?	629
32. When are surgical staples indicated?	629
33. What is surgical glue, and how is it used?	629
34. How do I remove tissue adhesive?	630
35. Summarize the advantages and disadvantages of the available techniques for wound closure.	630
36. Which sutures are used for specific locations, how is the wound repaired, and when do I remove the sutures?	630
37. How are bites treated?	630
38. What should be included in all follow-up instructions?	630
39. How do I remember the direction of the lines of skin tension?	630
40. Are there any controversies in wound care?	630
Bibliography	633
Questions	634.e1
XVII Behavioral Emergencies	635
95 Acute Psychosis	635
Abstract	635.e1
Keywords:	635.e1
1. What is psychosis?	635
2. What are delusions?	635
3. What are hallucinations?	635
4. How does a patient in a psychotic state typically appear upon arrival at the ED?	635
5. How should priorities be set when I first encounter a psychotic patient?	635
6. Why is it important to control psychotic behavior immediately?	635
7. Are there behavioral controls that can be used immediately for the psychotic patient?	635
8. What options can be exercised if the patient becomes increasingly disorganized, agitated, and violent?	635
9. How do I obtain a history for a psychotic patient?	636
10. What historical information is important?	636
11. How should my physical examination be tailored for a psychotic patient?	636
12. What is the difference between organic and functional psychosis?	636
13. Summarize the key points to consider in the differentiation of organic from functional psychosis.	636
14. List the possible causes of alcohol-related organic psychosis.	636
15. Is there a brief, self-limited, and nonorganic psychosis?	636
16. Summarize the potentially reversible causes of psychosis.	636
17. Name the life-threatening causes of acute psychosis.	637
18. List pharmacologic agents that can cause acute psychosis.	637
19. Is laboratory screening necessary in the workup of an acute psychotic patient?	638
20. Are there any other clinical rules of thumb in the workup of the acute psychotic patient?	638
21. When should hospitalization be recommended?	638
22. How do I treat the acutely psychotic patient in the ED?	638
Acknowledgment	638
Bibliography	638
Questions	639.e1
96 Depression, Suicide, and Posttraumatic Stress Disorder	640
Abstract	640.e1
Keywords:	640.e1
Depression	640
1. What are the symptoms of depression?	640
2. Why is depression considered a mood disorder?	640
3. What is the difference between primary and secondary depression?	640
4. List medical conditions that might cause secondary depression.	640
5. List medications that might cause secondary depression.	641
6. Why should the clinician always inquire about alcohol use when evaluating depression?	641
7. When should I suspect depression when a patient presents with what seems to be a medical complaint?	641
8. Are psychotic features ever a manifestation of depression?	641
9. Name therapies available for treatment of depression.	641
10. What antidepressant medications are used to treat depression?	641
11. What are some psychotropic-related emergencies or precautions?	642
12. When should the emergency physician prescribe antidepressant therapy?	642
13. What is the most serious complication of depression?	642
14. Which patients should be hospitalized for depression?	642
Suicide	642
15. What is the proper approach to a patient who has attempted suicide?	642
16. Describe suicide precautions.	642
17. Are accidents ever suicide attempts?	643
18. What psychiatric disorders are associated with attempted suicide?	643
19. How do I evaluate the risk of a subsequent suicide in someone who attempted suicide?	643
20. How does age relate to suicide risk?	643
21. What role does gender play?	643
22. What is the relationship of marital status to risk of successful suicide?	643
23. What about other social support?	643
24. Is there a relationship between physical illness and suicide risk?	644
25. Does a history of prior suicide attempts signify increased risk?	644
26. What is the relationship of family history to suicide risk?	644
27. How does the risk of the suicide attempt and the likelihood of rescue affect a suicide evaluation?	644
28. What is secondary gain as it applies to suicide attempt?	644
29. What is the value of assessing the suicidal patient’s attitude and affect?	644
30. Why is it important to inquire about a specific plan?	644
31. What is the SAD PERSONS Scale?	644
32. In general, which suicidal patients should be hospitalized?	645
Posttraumatic Stress Disorder	646
33. What are the clinical features of posttraumatic stress disorder (PTSD)?	646
34. What kind of traumatic events can cause PTSD?	646
35. What is meant by intrusive thoughts or events?	646
36. What kinds of avoidance behavior are noted?	646
37. What are negative alterations in cognition and mood associated with PTSD?	646
38. What kinds of alterations in arousal are noted?	646
39. What are special considerations in the ED evaluation of patients with suspected PTSD?	646
40. What are treatment consideration in PTSD?	646
Bibliography	646
Questions	646.e1
97 Management of the Violent Patient	647
Abstract	647.e1
Keywords:	647.e1
1. Is violence a problem in the ED?	647
2. Why does a patient become violent in the first place?	647
3. What can hospitals do to decrease the risk of violence?	647
4. What can be done to preempt a violent episode?	648
5. What is the initial approach a physician can take to control an agitated or violent patient?	648
6. What if that doesn’t work?	648
7. What do I need to remember when physically restraining a patient?	649
8. Am I legally allowed to restrain someone?	649
9. What medications are recommended for emergency treatment of agitation?	649
10. I normally use haloperidol; what if two doses of haloperidol have not calmed the patient?	651
11. What about the pediatric patient?	651
12. Summarize the main side effects to watch for with these drugs.	651
13. Give a quick reference on dosing and administration.	651
14. How should restrained patients be monitored?	651
15. Does the ED staff need any treatment?	652
Acknowledgment	652
Bibliography	652
Questions	652.e1
98 Intimate Partner Violence	653
Abstract	653.e1
Keywords:	653.e1
1. Is intimate partner violence (IPV) more of a law enforcement issue than it is a health issue?	653
2. Define domestic violence.	653
3. What are the risk factors for IPV?	653
4. Are men ever victims of partner abuse?	653
5. If IPV is so common, why have none of my patients experienced it?	653
6. What is the result of a missed diagnosis of IPV?	653
7. State some of the reasons why physicians choose not to inquire about IPV.	653
8. Why are victims of partner abuse reluctant to disclose the abuse to health care providers, even if asked?	653
9. What are some of the structural and system barriers that might prevent a victim from disclosing abuse?	654
10. What clues to IPV might be evident in a patient’s history?	654
11. What clues may be present on physical examination in a victim of IPV?	654
12. How can I increase my recognition of partner abuse?	654
13. What questions about partner violence can I ask a woman without injuries?	654
14. What about screening all women for IPV?	654
15. What comments or questions are inappropriate when discussing IPV with women?	654
16. What do I do if my patient has an injury caused by her partner?	655
17. Summarize some important points to remember when documenting IPV.	655
18. Do I have any legal responsibilities?	655
19. Why is she going home to her batterer, and why does she just not leave him?	655
20. What can we do about IPV?	655
Acknowledgment	655
Bibliography	655
Questions	656.e1
XVIII EMS and Disaster Management	657
99 EMS Medical Oversight	657
Abstract	657.e1
Keywords:	657.e1
1. What is medical oversight?	657
2. Why is medical oversight of prehospital personnel and care important?	657
3. How is medical oversight provided?	657
4. Is being an EMS medical director an administrative role?	657
5. Who are the key stakeholders in an EMS system?	657
6. In what conditions has EMS been demonstrated to have proven benefit?	657
7. In what other, difficult-to-study ways might EMS be beneficial?	658
8. What are some key controversies in current EMS practice?	658
9. What are the common performance benchmarks of an EMS system?	658
10. Who are the members of the EMS workforce?	658
11. What skills can be performed by prehospital providers at different levels of training?	658
12. How important is physician involvement in education and training for prehospital personnel?	659
13. What are the different models of EMS systems?	659
14. What are the strengths and weaknesses of fire department–based EMS?	659
15. What are the strengths and weaknesses of third-service EMS?	659
16. What are the strengths and weaknesses of private sector EMS?	659
17. What are the strengths and weaknesses of hospital-based EMS?	659
Bibliography	659
Questions	659.e1
100 Disaster Management	660
Abstract	660.e1
Keywords:	660.e1
1. Define the term disaster.	660
2. What is the difference between a mass casualty incident (MCI) and a disaster?	660
3. Are all disasters MCIs?	660
4. How is an MCI different from a mass gathering?	660
5. Why is there a need for disaster planning?	660
6. Define the all-hazards approach to disaster planning.	661
7. What are the four phases of a disaster response?	661
8. What is an incident command system (ICS)?	661
9. What is the National Incident Management System (NIMS)?	661
10. Does ICS have to be used for every incident?	661
11. Describe each of the five key functions in ICS?	661
12. What is the weakest link in a response to an incident?	662
13. How does triage occur at a scene?	662
14. How is triage applied in a disaster situation?	662
15. Are there any exceptions to this rule of prioritizing patients in the red category over those in the black category?	662
16. What triage system is most commonly used in the United States?	662
17. Tell me more about START.	662
18. What is the difference between START and SALT triage systems?	664
19. Which one is better, START or SALT?	665
20. How does transport occur for victims in an MCI?	665
21. When do patients need to be transported to the hospital emergently (i.e., lights and sirens [L&S])?	665
22. What about spinal immobilization for patients?	665
23. Can doctors and nurses be helpful on scene for an MCI?	665
24. What is critical incident stress management (CISM)?	665
Bibliography	666
Questions	666.e1
101 Weapons of Mass Destruction	667
Abstract	667.e1
Keywords:	667.e1
1. Why is it important for emergency physicians (EPs) to be familiar with weapons of mass destruction (WMDs)?	667
2. We hear about terrorism all the time. Are we ready to respond?	667
3. Do we have hazardous materials (HAZMAT) teams to deal with nuclear, biologic, and chemical (NBC) attacks?	667
4. What else is unique about a terrorist attack?	667
5. What makes a good chemical or biologic weapon (in a terrorist’s mind)?	667
6. What should EPs do to prepare and protect themselves?	667
7. Describe the levels of PPE.	668
Radiation	668
8. What are the basic physics of radiation?	668
9. What are the units of radiation?	668
10. Describe the different types of radiation and their shielding requirements.	668
11. What are the types of radiation injury?	668
12. What are the different types of attacks?	669
13. Describe the three acute radiation syndromes (ARSs).	669
14. Describe the four stages of ARS.	670
15. All these numbers are great, but what is the bottom line?	670
16. How is the absolute lymphocyte count helpful in evaluating ARS?	670
17. What treatment options are available for radiation exposure?	670
18. When should treatment with KI tablets be considered?	670
19. What is the most appropriate course of action for a patient with radiologic exposure and associated major trauma?	671
Chemical Weapons	671
20. List the characteristics of chemical weapons.	671
21. What are the different classes of chemical weapons?	671
22. Describe the pathophysiology and clinical symptoms caused by nerve agents.	671
23. What is the easiest way to remember the effects of nerve agents?	671
24. How deadly are nerve agents?	673
25. What is the treatment for nerve agent toxicity?	673
Biologic Agents	674
26. What is bioterrorism?	674
27. Have terrorists really used biologic agents?	674
28. Does the manufacturing of biologic agents require a lot of money and sophisticated equipment?	674
29. How are biologic attacks different from exposure to radiation or chemical agents?	674
30. How does the CDC categorize biologic agents?	674
31. What are the general descriptive characteristics of biologic agents?	674
32. Give me the basics about anthrax.	675
33. What are the signs and symptoms of anthrax?	675
34. How should I treat anthrax?	675
35. What other sources are available to learn more about biologic weapons?	675
36. How should I protect myself when I am caring for patients exposed to biologic weapons?	675
37. How will I know if a biologic attack has occurred?	675
38. What should I do if I suspect an attack has occurred?	676
Explosives	676
39. With all these other highly effective and lethal terrorist weapons, are people really still using explosives?	676
40. Describe the five blast injury categories after explosions.	676
41. Is there a quick screening method to triage victims of blast injuries?	677
42. What is blast lung?	677
Decontamination	677
43. What should I know about decontamination?	677
44. How do I decontaminate victims of chemical exposure?	677
45. How do I decontaminate a patient who has been exposed to radioactive material?	677
46. How are victims of biologic agent exposure decontaminated?	678
Bibliography	678
Questions	679.e1
102 Tactical Medicine	680
Abstract	680.e1
Keywords:	680.e1
1. What is tactical medicine?	680
2. What has driven the development of TEMS as an area of practice?	680
3. Provide some specific examples of these incidents.	680
4. How does practice of this subspecialty fit within emergency medicine?	680
5. What are the main entities or recognized bodies providing recommendations on the practice and scope of TEMS medicine?	680
6. What does SWAT stand for?	680
7. What is the role of SWAT, and why does it create a need for tactical medicine?	680
8. In what areas of tactical medicine can emergency physicians have input and participation?	681
9. What are the goals of TEMS?	681
10. What is the difference between cover and concealment?	681
11. What are the zones of tactical operations, and how are they defined?	681
12. What is “barricaded care,” or remote patient care?	681
13. What comprises the tactical/military primary assessment, and how does it differ from the traditional primary assessment?	681
14. What are the priorities in providing care in a tactical environment?	682
15. What are the phases of tactical medical care, how are they defined, and what care is provided in each phase?	682
16. How does hemorrhage control in the tactical or combat environment differ from that of civilian care?	682
17. What are desirable features of a tactical/combat tourniquet?	682
18. How can I tell when a tourniquet is appropriately applied?	682
19. In the tactical environment, what are the advantage(s) and limitations of using a tourniquet over other hemorrhage control techniques?	682
20. What is the maximum time a tourniquet can be left in place without injury or loss of the limb?	682
21. Where should a tourniquet be placed?	683
22. What are the side effects of the failure to adequately tighten a tourniquet?	683
23. What are the features of recommended hemostatic agents for use in the tactical environment?	683
24. What areas of the body are amenable to wound packing in a tactical environment?	683
25. What are the different types of hemostatic agents currently used in tactical care?	683
26. What is the basic airway adjunct of choice in the tactical environment?	683
27. What is the advanced airway intervention of choice in the tactical or combat environment?	683
28. What is the intervention of choice for managing tension pneumothorax in the field?	684
29. Why is it important to manage a sucking chest wound, and what is the device of choice?	684
30. Why is it essential to manage hypothermia in the tactical environment?	684
31. What is the leading cause of combat death?	684
32. What are the most common areas of the body injured during combat?	684
Bibliography	684
Questions	685.e1
Index	686
A	686
B	691
C	693
D	697
E	699
F	702
G	703
H	704
I	708
J	709
K	709
L	710
M	711
N	713
O	714
P	715
Q	719
R	719
S	721
T	725
U	727
V	728
W	729
X	729
Y	729
Z	729
Clinical Key Ad	IBC1

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