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Textbook of Adult Emergency Medicine E-Book

Textbook of Adult Emergency Medicine E-Book

Peter Cameron | George Jelinek | Anne-Maree Kelly | Lindsay Murray | Anthony F. T. Brown

(2011)

Additional Information

Abstract

A major postgraduate textbook in emergency medicine, covering all the major topics that present to the trainee doctor in the emergency department.

  • A comprehensive textbook of adult emergency medicine for trainee doctors - covers all the problems likely to present to a trainee in the emergency department.
  • Chapters are short and concise, with key point boxes (called "Essentials") at the beginning.
  • Also has boxes featuring controversial areas of treatment.
  • Practical and clinically orientated.
  • Major changes to resuscitation guidelines.
  • Complete rewriting of ENT section.
  • Significant updating of following topics - acute coronary syndrome management, trauma, sepsis management, imaging, arrhythmias.
  • Expansion of administration section - especially patient safety.
  • Changes to drug overdose sections in toxicology section.

Table of Contents

Section Title Page Action Price
Front Cover Cover
Textbook of Adult Emergency Medicine iii
Copyright iv
Preface to the first edition v
Preface to the third edition vi
Contributors vii
Contents xiii
Section 1: Resuscitation 1
1.1 Basic life support 1
Introduction 1
Development of protocols 1
Initial evaluation: DR ABCD approach 2
Management 3
Defibrillation 4
BLS summary 4
References 5
1.2 Advanced life support 5
Introduction 5
Aetiology and incidence of cardiac arrest 5
Advanced life support guidelines and algorithms 6
Initiation of ALS 6
Attachment of the defibrillator/monitor and rhythm recogniton 6
Defibrillation 7
The CPR 'Code Blue' process 9
Other ALS interventions 9
Drug therapy in ALS 10
Haemodynamic monitoring during CPR 12
When to discontinue ALS 12
Prognosis for survival after cardiac arrest 12
Uniform reporting in cardiac arrest research 13
References 13
1.3 Ethics of resuscitation 14
Introduction 14
Application of the principles of Beauchamp and Childress to resuscitation medicine 15
Futility 16
Consent, withholding and withdrawing resuscitation 17
'Not For Resuscitation' (NFR) orders 17
Practising resuscitation procedures on the newly dead 18
Conclusions 19
References 19
Section 2: Critical care 20
2.1 Airway and ventilation management 20
Introduction 20
Non-invasive ventilation 20
Endotracheal intubation 21
The difficult intubation 23
Laryngeal mask airway 24
Intubating laryngeal mask airway 24
Fibreoptic bronchoscope-assisted intubation 24
Retrograde intubation 24
Blind nasotracheal intubation 25
Cricothyroidotomy 25
Tracheostomy 25
Mechanical ventilation 25
Extubation in the emergency department 26
References 26
2.2 Oxygen therapy 27
Introduction 27
Physiology of oxygen 27
Oxygen delivery systems 29
Variable performance systems 29
Fixed-performance systems 30
100% oxygen delivery systems 31
Helium and oxygen mixtures 33
Measurement of oxygenation 33
Paediatric considerations in oxygen therapy 33
Transfer of patients on oxygen therapy 34
Oxygen therapy in specific circumstances 34
Complications of oxygen therapy 36
Special delivery systems 36
References 37
2.3 Haemodynamic monitoring 38
Introduction 38
Historical background 38
Overview of cardiovascular physiology 39
Role of haemodynamic monitoring in the emergency department 39
Clinical assessment 39
Blood pressure monitoring 40
Other non-invasive monitoring methods for cardiac output 40
Invasive devices 41
Conclusion 43
Future developments 43
References 43
2.4 Shock overview 45
Introduction 45
Aetiology and epidemiology 45
Pathophysiology 46
Clinical features in the initial diagnosis of shock 46
Initial emergency management of the shocked patient 47
Guidance for interventions and treatments 48
Interventions in shock 49
The effects of shock on other interventions 52
The management of specific shock syndromes 52
Conclusion 55
References 56
2.5 Sepsis and septic shock 57
Introduction 57
Aetiology and pathophysiology 57
Clinical features 57
Clinical investigations 58
Treatment 58
References 60
2.6 Arterial blood gases 61
Introduction 61
Normal values 61
Definitions and conventions 61
Venous gas correlation 61
Arterial blood gas specimen collection 61
Arterial blood gas interpretation 62
Rules for complex acid-base disorders 63
Clinical use of blood gases in the seriously ill patient 63
Detection of non-clinically suspected serious disease 64
References 64
2.7 Cerebral resuscitation after cardiac arrest 65
Introduction 65
Definition 65
Pathophysiology of cerebral ischaemia 65
Reperfusion injury 65
Cerebral haemodynamics after reperfusion 66
Pharmacological interventions 66
Therapeutic hypothermia 66
Other interventions 67
Outcome prediction 67
Summary 67
References 67
Section 3: Trauma 68
3.1 Trauma overview 68
Introduction 68
Initial management 69
Clinical presentation 71
Monitoring 72
Management 72
Hypotensive resuscitation 72
Next steps 73
Trauma audit 73
Trauma in developing countries 74
References 74
Further reading 74
3.2 Neurotrauma 75
Introduction 75
Pathogenesis 75
Epidemiology 76
Prevention 76
Clinical features 76
Clinical investigation 77
Treatment 77
Disposition 79
Prognosis 79
References 79
3.3 Spinal trauma 80
Introduction 80
Pathophysiology 80
Neurological injuries 81
Autonomic nervous system effects of spinal cord damage 82
Spinal shock10,15-17 83
Vertebral injury2,10,13-20 83
Spinal cord injury management 85
Documentation conventions 87
Unconscious patients 89
Referral-disposition 91
Other treatments 91
Clearing the spine 91
Immobilization 92
References 92
Further reading 93
3.4 Facial trauma 94
Introduction 94
History 94
Examination 94
Radiographic examination 95
Immediate management in the emergency department 95
Specific injuries 96
Penetrating injuries to the face 97
Conclusion 98
References 98
3.5 Abdominal trauma 99
Introduction 99
Primary and secondary surveys 99
Penetrating injuries 101
Disposition 102
Future directions 102
References 103
3.6 Chest trauma 104
Introduction 104
Chest wall injury 104
Pleural injury 105
Lung injury 106
Tracheobronchial injury 106
Mediastinal injury 106
Vertebral column and spinal cord injury 107
Indications for emergency thoracotomy33 107
Conclusion 108
References 109
3.7 Limb trauma 109
Introduction 109
Presentation 110
Investigations 110
Management 111
Disposition 112
Hyperbaric oxygen therapy 113
Complications 113
Acute limb compartment syndrome 114
Fat embolism syndrome 114
Crush syndrome 114
Immobilization 115
References 115
3.8 Radiology in major trauma 116
Emergency department reception 116
Hazards of radiation 116
The trauma series 117
Specific regional radiology 117
Chest trauma 124
Abdomen/pelvis 127
Extremities 129
Conclusion 129
References 130
3.9 Trauma in pregnancy 131
Introduction 131
Anatomical and physiological changes in pregnancy 131
Epidemiology 131
Specific injuries 132
Presentation 132
Investigations 132
Management 133
Disposition 133
Prognosis 133
Prevention 133
References 134
3.10 Wound care and repair 134
Introduction 135
Clinical presentation 135
Wound cleansing 135
Tetanus prophylaxis 137
Wound-healing mechanisms 137
Suture types 137
Needles 138
Basic suture technique 139
Special sites and situations 142
Special suture techniques 142
The 'dog-ea' 143
Wound drainage 144
Dressings 144
Immobilization 145
Disposal/removal 145
References 148
3.11 Burns 149
Introduction 149
Pathophysiology 149
Classification 149
Thermal Burns 149
Presentation 149
Investigations 151
Management 151
Burn shock 152
Inhalation injury 152
Disposition 152
Chemical Burns 153
General principles 153
Disposition 153
References 153
Section 4: Orthopaedic emergencies 154
4.1 Injuries of the shoulder 154
Fractures of the clavicle 154
Acromioclavicular joint injuries 155
Sternoclavicular subluxation and dislocation 155
Fractures of the scapula 155
Rotator cuff injuries 155
Dislocation of the shoulder 156
Further reading 157
4.2 Fractures of the humerus 157
Introduction 157
Fractures of the proximal humerus 157
Fractures of the shaft of humerus 159
Fractures of the distal humerus 160
References 161
Further reading 161
4.3 Dislocations of the elbow 161
Introduction 161
Clinical assessment 161
Investigations 162
Management 162
Disposition 162
References 163
Further reading 163
4.4 Fractures of the forearm and carpal bones 163
Radial head fractures 163
Shaft fractures 164
Fractures of the distal radius and ulna 165
Carpal fractures and dislocations 167
Further reading 168
4.5 Hand injuries 168
Introduction 168
Clinical features 168
Investigations 169
Treatment 170
Fingertip injuries 170
Digital nerve injuries 171
Nailbed injuries 171
Terminalization 171
Distal interphalangeal joint injuries 171
Middle phalangeal injuries 171
Proximal interphalangeal joint injuries 171
Proximal phalangeal injuries 172
Metacarpophalangeal joint injuries 172
Metacarpal injuries 172
Dorsal hand injuries 172
Palmar hand injuries 172
Disposition 172
Prognosis 173
Prevention 173
References 173
Further reading 173
4.6 Pelvic injuries 174
Anatomy 174
Classification of pelvic fractures 174
Clinical assessment 175
Injuries associated with pelvic fractures 175
Management of unstable pelvic fracture 176
Open pelvic fractures 176
Stable fractures of the pelvis 176
Acetabular fractures 177
Further reading 177
4.7 Hip injuries 178
Anatomy 178
Classification of hip fractures 178
Hip dislocation 181
Further reading 182
4.8 Femur injuries 182
Femoral shaft fracture 182
Further reading 183
4.9 Knee injuries 184
Anatomy 184
Clinical assessment 184
Fractures around the knee joint 185
Dislocations around the knee joint 187
Soft tissue injuries 188
Further reading 190
4.10 Tibia and fibula injuries 190
Anatomy 190
Fractures of the tibia 190
Fractures of the fibula 192
References 193
Further reading 193
4.11 Ankle joint injuries 193
Anatomy 193
Clinical assessment 193
Ankle fracture classification 194
Fracture management 194
Pilon fractures 195
Maisonneuve fracture 195
Ankle dislocations 195
Soft tissue injuries 195
References 196
Further reading 196
4.12 Foot injuries 197
Anatomy 197
Clinical assessment 197
Hindfoot injuries 198
Midfoot fractures 199
Forefoot fractures 200
References 201
Further reading 201
Section 5: Cardiovascular 202
5.1 Chest pain 202
Introduction 202
Epidemiology 202
Differential diagnosis 203
Clinical features 203
Clinical investigation 204
Treatment 206
Prognosis 207
Likely developments over the next 5-10 years 207
Further reading 207
5.2 Acute coronary syndromes 208
Introduction 208
Aetiology, pathogenesis and pathology 208
Epidemiology 209
Prevention 209
Clinical features 209
Differential diagnosis 210
Clinical investigation 210
Criteria for diagnosis 211
Treatment 211
Disposition 213
Complications 213
Prognosis 213
Likely developments over the next 5-10 years 214
Further reading 214
5.3 Assessment and management of acute pulmonary oedema 215
Introduction 215
Pathophysiology 215
Clinical assessment 215
Investigation 216
Management 216
References 218
5.4 Arrhythmias 219
Introduction 219
Pathophysiology and pathogenesis 219
Principles of assessment and management 220
Further reading 231
5.5 Pulmonary embolism 232
Introduction 232
History 232
Examination 233
Investigations 233
Management 236
Specific treatments in unstable patients 237
Prognosis 237
Disposition 237
Conclusion 237
References 238
5.6 Pericarditis, cardiac tamponade and myocarditis 239
Pericarditis 239
Introduction 239
Clinical features 239
Investigations 239
Making the diagnosis 240
Management 241
Disposition 241
Non-Traumatic Cardiac Tamponade 241
Introduction 241
Clinical features 241
Differential diagnosis 242
Investigations 242
Treatment 242
Disposition 243
Myocarditis 243
Introduction 243
Clinical features 243
Investigations 244
Treatment and disposition 244
Prognosis 245
Further reading 245
5.7 Heart valve emergencies 246
Introduction 246
Infective endocarditis 246
Acute aortic incompetence 250
Acute deterioration in chronic aortic incompetence 250
Acute deterioration in critical aortic stenosis 251
Acute deterioration in mitral stenosis 251
Acute mitral incompetence 252
Acute deterioration in chronic mitral incompetence 252
Prosthetic valve complications 253
Further reading 253
5.8 Peripheral vascular disease 254
Arterial Disease 254
Introduction 254
Chronic arterial ischaemia 254
Acute arterial ischaemia of the lower limb 255
Acute arterial ischaemia of the upper limb 256
Venous Disease: Lower Limb 256
Introduction 256
Venous insufficiency and varicose veins 256
Superficial venous thrombosis 256
Deep venous thrombosis 257
Venous Disease: Upper Limb 258
Introduction 258
Likely developments over the next 5-10 years 258
Further reading 258
5.9 Hypertension 259
Introduction 259
Hypertensive emergencies 259
Hypertensive urgency 262
Developments in the next 5-10 years 262
Further reading 262
5.10 Aortic dissection 263
Introduction 263
Epidemiology 263
Pathophysiology 263
Classification 264
Clinical features 264
Investigation 265
Differential diagnosis 266
Treatment 266
Prognosis 267
Disposition 268
References 268
5.11 Aneurysms 269
Introduction 269
Aetiology, genetics, pathogenesis and pathology 269
Central aneurysms 269
Cerebral aneurysms 271
Peripheral aneurysms 271
Likely developments over the next 5-10 years 272
References 272
Section 6: Respiratory 314
6.1 Upper respiratory tract 273
Introduction 273
Triage and initial evaluation 273
Upper airway obstruction 274
Investigation 274
Management 275
Trauma 275
Thermal injury 276
Investigations 276
Infections 276
Further reading 278
6.2 Asthma 279
Introduction 279
Epidemiology 279
Pathophysiology 279
Clinical assessment 280
Investigation 280
Management 280
Disposition 282
Further reading 282
6.3 Community-acquired pneumonia 283
Introduction 283
Pathogenesis and aetiology 283
Epidemiology 285
Prevention 285
Clinical features 285
Differential diagnosis 286
Complications 286
Investigation 286
Treatment 290
Likely developments over the next 5-10 years 292
Acknowledgements 293
Further reading 293
6.4 Influenza and emerging respiratory infections 293
Introduction 293
Influenza 294
History 294
Clinical features 295
Assessment 296
Treatment 296
Prevention 296
Avian influenza 297
Organizational issues 297
Further reading 297
6.5 Chronic obstructive pulmonary disease 298
Introduction 298
Aetiology, genetics, pathogenesis and pathology 298
Epidemiology 298
Clinical features 298
Clinical investigations 299
Treatment 300
Prognosis 302
Further reading 303
6.6 Pneumothorax 303
Introduction 303
Clinical features 304
Differential diagnosis 304
Investigations 304
Management 304
Prognosis 306
Disposition 306
Further reading 306
6.7 Pleural effusion 307
Introduction 307
Pathophysiology 307
Aetiology 307
Classification 307
Clinical features 307
Investigations 308
Management 309
Complications 310
Disposition 310
Summary 310
References 310
Further reading 310
6.8 Haemoptysis 311
Introduction 311
Aetiology 311
Clinical features 311
Clinical investigations 311
Treatment 312
Massive haemoptysis 312
References 313
Section 7: Digestive 314
7.1 Dysphagia 314
Introduction 314
Aetiology 314
Clinical features 314
Clinical investigation 315
Treatment 315
Other issues 315
References 315
7.2 Approach to abdominal pain 316
Introduction 316
Epidemiology 316
Pathophysiology and differential diagnosis 316
Causes of diffuse abdominal pain 317
Clinical features 318
Investigations 320
Pitfalls 322
Diagnosis versus disposition 323
General management 323
Disposition 323
Non-specific abdominal pain (NSAP) 324
Discharge advice 324
Developments in the next 5-10 years 324
References 324
7.3 Bowel obstruction 325
Introduction 325
Aetiology and pathophysiology 325
Clinical features 325
Investigations 326
Management 326
Disposition 327
Further reading 327
7.4 Hernia 327
Introduction 327
Inguinal hernia 328
Femoral hernia 328
Umbilical hernia 328
Epigastric hernia 328
Other herniae 328
Complications 328
Treatment 328
References 329
7.5 Gastroenteritis 329
Introduction 329
Pathophysiology and microbiology 330
Clinical presentation 330
Clinical examination 330
Diarrhoea in certain circumstances 331
Differential diagnosis 331
Investigations 331
Treatment 332
References 333
7.6 Haematemesis and melaena 334
Introduction 334
Epidemiology, aetiology and differential dignosis 334
Prevention 334
Definitions 334
Clinical features 334
Clinical investigation 335
Treatment 335
Specific therapy 336
Other issues 338
Likely developments over the next 5-10 years 338
References 339
7.7 Peptic ulcer disease and gastritis 339
Introduction 339
Pathophysiology 339
Clinical features 340
Investigations 340
Management 341
Complications 342
Disposition 343
Further reading 343
7.8 Biliary tract disease 344
Introduction 344
Gallstones 344
Cholelithiasis 345
Acute cholecystitis 345
Acalculous cholecystitis 346
Choledocholithiasis 346
Cholangitis 346
Further reading 347
7.9 Pancreatitis 347
Acute pancreatitis 347
Likely developments over the next 5-10 years 348
Chronic pancreatitis 349
References 350
7.10 Acute appendicitis 350
Introduction 350
Presentation 350
Differential diagnosis 351
Investigation 351
Treatment 352
Acute appendicitis in Pregnancy 353
Likely developments over the next 5-10 years 353
Further reading 353
7.11 Inflammatory bowel disease 353
Introduction 353
Aetiology, genetics, pathogenesis and pathology 353
Epidemiology 354
Clinical Features 354
Clinical investigation 354
Management 354
Disposition 355
References 356
7.12 Acute liver failure 356
Introduction 356
Aetiology, pathogenesis and pathology 356
Epidemiology 356
Prevention 357
Clinical features 357
Differential diagnosis 357
Clinical investigations 357
Criteria for diagnosis 358
Treatment 358
Prognosis 360
Likely developments over the next 5-10 years 361
Further reading 361
7.13 Rectal bleeding 361
Introduction 361
Aetiology 362
History 362
Examination 362
Investigations 362
Treatment 363
Conclusion 363
Further reading 364
7.14 Perianal conditions 364
Pilonidal disease 364
Anorectal abscesses 364
Anal fistula 365
Haemorrhoids 365
Anal fissure 366
Pruritus ani 367
Proctalgia fugax 367
Injuries to the perianal region 367
Other anorectal conditions 367
References 367
Section 8: Neurology 368
8.1 Headache 368
Introduction 368
Pathophysiology 368
Assessment 369
Investigation 369
Tension headache 370
Migraine 370
Trigeminal neuralgia 371
Further reading 372
8.2 Stroke and transient ischaemic attacks 372
Introduction 372
Pathophysiology 372
Prevention 373
Ischaemic stroke syndromes 374
Pre-hospital care 375
Clinical evaluation in the ED 375
Differential diagnosis 376
Complications of stroke 376
Investigations 376
Treatment 378
Intracerebral haemorrhage (ICH) 379
References 380
Further reading 381
8.3 Subarachnoid haemorrhage 381
Introduction 381
Pathology and epidemiology 381
Clinical features 382
Investigations 382
Complications 384
Management 384
Prognosis 385
Incidental unruptured aneurysms 385
Conclusion 385
Further reading 386
8.4 Altered conscious state 386
Introduction 386
Pathophysiology 386
Differential diagnoses 387
Clinical assessment 387
Investigations 389
Management 390
Disposition 391
Prognosis 391
Further reading 391
8.5 Seizures 392
Introduction 392
First seizures 393
Status epilepticus 394
Non-convulsive seizures 395
Pseudoseizures 395
Alcohol-related seizures 396
Drug-related seizures 396
Post-traumatic seizures 396
Seizures and pregnancy 396
Future directions 397
References 397
8.6 Syncope and vertigo 398
Introduction 398
Syncope 398
Vertigo 400
References 401
Section 9: Infectious diseases 402
9.1 Approach to undifferentiated fever in adults 402
Introduction 402
Approach 403
Clinical investigation 406
Disposition 406
Future research directions 407
References 407
Further reading 407
9.2 Meningitis 408
Introduction 408
Classification 408
Aetiology 408
Epidemiology 408
Pathogenesis 409
Presentation 409
Examination 410
Investigations 410
Differential diagnosis 411
Management 411
Disposition 412
Prognosis 412
Prevention 412
References 413
9.3 Septic arthritis 414
Introduction 414
Presentation 414
Investigation 414
Differential diagnosis 415
Management 415
Disposition 415
Prognosis 415
Prevention 415
References 415
9.4 Osteomyelitis 416
Introduction 416
Presentation 416
Investigations 416
Differential diagnosis 416
Management 417
Disposition 417
Prognosis 417
Prevention 417
References 417
9.5 Urinary tract infection 418
Introduction 418
Epidemiology 418
Aetiology 418
Pathogenesis 419
Presentation 420
Investigations 420
Imaging 421
Management 422
Disposition 424
Prognosis 424
References 424
Further reading 425
9.6 Skin and soft-tissue infections 426
Introduction 426
Aetiology 426
Examination 426
Investigations 427
Management 427
Disposition 428
Superficial skin infections 428
Cellulitis 429
Abscesses 429
Deep soft-tissue infections 429
Toxic complications of wound infections 430
Special infections 431
References 433
9.7 Hepatitis 434
Introduction 434
Clinical presentations of viral hepatitis 434
Hepatitis A virus 434
Hepatitis B virus 435
Hepatitis C virus 436
Hepatitis D virus 436
Hepatitis E virus 437
Hepatitis G virus 437
Non-hepatotrophic viruses 437
Non-viral hepatitis 437
Future directions 438
References 438
9.8 HIV/AIDS 438
Introduction 438
Epidemiology 439
Pathogenesis 439
Classification and natural history 439
Presentation 439
Investigation 442
Management 443
Disposition 445
Prognosis 445
Prevention 445
References 446
9.9 Antibiotics in the emergency department 446
Principles of antimicrobial therapy 446
Antibiotic resistance 447
Prophylactic use of antibiotics 447
Penicillins 449
Cephalosporins 450
Macrolides 451
Tetracycline 452
Aminoglycosides 452
Metronidazole 452
Co-trimoxazole 453
Quinolones 453
Nitrofurantoin 454
Antiviral drugs 454
Antiretroviral drugs 454
Outpatient parenteral antibiotic therapy 454
Other issues 455
Likely developments over the next 5-10 years 455
References 456
9.10 Needlestick injuries and related blood and body fluid exposures 456
Introduction 456
General issues 457
Hepatitis B 457
Hepatitis C 457
Human immunodeficiency virus 458
Exposures that occur in the community 459
Illustrative cases 459
References 460
Further reading 460
Section 10: Genitourinary 461
10.1 Acute kidney injury 461
Introduction 462
Aetiology and pathogenesis 462
Epidemiology 464
Prevention 464
Clinical features 465
Differential diagnosis 467
Criteria for diagnosis 468
Treatment 469
Prognosis 472
References 472
10.2 The acute scrotum 473
Torsion of the Spermatic Cord (Testicle) 473
Aetiology 473
Pathology 473
Clinical presentation 473
Differential diagnosis of acute testicular pain 473
Traps in the clinical diagnosis 474
Investigations 474
Treatment 474
Prognosis 474
Torsion of a testicular appendage 475
Acute Epididymo-Orchitis 475
Introduction 475
Aetiology 475
Clinical presentation 475
Investigations 475
Differential diagnosis 475
Treatment 475
Complications 475
Blunt traumatic injury to the testicle 475
References 476
10.3 Renal colic 477
Introduction 477
Pathophysiology of pain 477
Presentation 477
Radiological examination 478
Management 479
Precautions 479
Conclusion 480
References 480
Section 11: Endocrine 481
11.1 Diabetes mellitus and hypoglycaemia: an overview 481
Diabetes Mellitus 481
Classification system and diagnostic criteria 481
Aetiology 481
Emergency presentations of a high blood sugar 481
General management of diabetes mellitus 482
Diabetic Hypoglycaemia 482
Clinical features 482
Management of hypoglycaemic coma 482
References 483
11.2 Diabetic ketoacidosis and hyperosmolar, hyperglycaemic non-ketotic state 483
Introduction 484
Aetiology, genetics, pathogenesis and pathology 484
Epidemiology 484
Clinical features 484
DKA differential diagnosis 484
Clinical investigations in DKA 484
Criteria for diagnosis 484
Treatment of DKA 484
Treatment of HHNS 486
Prognosis 486
Miscellaneous issues 486
References 486
11.3 Thyroid and adrenal emergencies 487
Introduction 487
Thyrotoxicosis 487
Aetiology, genetics, pathogenesis and pathology 487
Epidemiology 487
Clinical features 487
Clinical investigation and criteria for diagnosis1-3 488
Treatment 488
Thyroid storm 488
Apathetic hyperthyroidism 489
Hypothyroidism 489
Aetiology, genetics, pathogenesis and pathology 489
Epidemiology 489
Clinical features 489
Clinical investigation and criteria for diagnosis 490
Treatment 490
Myxoedema coma 490
Hypoadrenal States 490
Aetiology, genetics, pathogenesis and pathology 490
Clinical features 491
Differential diagnosis 491
Clinical investigation 491
Criteria for diagnosis 3 491
Treatment 491
Prognosis 492
Response to severe illness 492
Hyperadrenal States 492
Aetiology, pathogenesis and epidemiology 492
Clinical features 492
Clinical investigation and criteria for diagnosis 492
Treatment 492
References 493
Further reading 493
Section 12: Metabolic 494
12.1 Acid-base disorders 494
Introduction 494
Acid-base homeostasis 494
Acidosis 494
Alkalosis 496
References 497
12.2 Electrolyte disturbances 497
Hyponatraemia 497
Introduction 497
Pathophysiology 497
Aetiology and classification 498
Clinical features 498
Syndrome of inappropriate ADH secretion 499
Clinical investigation 499
Treatment 499
Hypernatraemia 500
Introduction 500
Aetiology and classification 501
Clinical features 501
Treatment 501
Hypokalaemia 501
Introduction 501
Pathophysiology 501
Section 13: Haematology 508
13.1 Anaemia 508
Introduction 508
Anaemia Secondary to Haemorrhage 508
Aetiology 508
Clinical features 508
Clinical investigations 509
Treatment 510
Chronic haemorrhage 510
Disposition 510
Anaemia Secondary to Decreased Red Cell Production 510
Megaloblastic anaemia 510
Anaemia of chronic disorders 511
Other causes of decreased red cell production 511
Anaemia Secondary to Decreased Red Cell Survival: The Haemolytic Anaemias 511
Hereditary spherocytosis 512
Glucose-6-phosphate dehydrogenase deficiency 512
Sickle cell anaemia 512
Thalassaemias 513
Acquired haemolytic anaemias 513
Microangiopathic haemolytic anaemia 513
Haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura 513
HELLP syndrome 514
Disseminated intravascular coagulation 514
Paroxysmal noctural haemoglobinuria 514
Other causes of haemolysis 514
Further reading 514
13.2 Neutropenia 515
Introduction 515
Pathophysiology and aetiology 515
Clinical features 516
Clinical investigation 516
Treatment 516
Disposition 516
Prognosis 517
References 517
13.3 Thrombocytopenia 517
Introduction 517
Aetiology 517
Artifactual thrombocytopenia 517
Immune-related thrombocytopenia 518
Non-immune platelet destruction 518
Massive blood transfusion and thrombocytopenia 519
Hypersplenism 519
Clinical features 519
Clinical investigation 520
Treatment 520
Disposition 520
References 520
13.4 Haemophilia 521
Introduction 521
Pathophysiology 521
Clinical features 521
Clinical investigation 522
Treatment 522
Disposition 523
von Willebrand disease 523
Useful contacts 524
Further reading 525
13.5 Blood and blood products 525
Introduction 525
Packed red blood cells 526
Precautions when cross-matching and transfusing blood 528
Adverse reactions to transfusion 528
Management of transfusion reactions 530
Platelets 530
Fresh frozen plasma 530
Cryoprecipitate 530
Massive transfusion 531
References 531
Section 14: Rheumatology and Musculoskeletal 532
14.1 Rheumatological emergencies 532
Introduction 532
Rheumatoid Arthritis 532
Emergencies in RA - Articular Manifestations 532
Acute monoarthritis 532
Cervical spine involvement 533
Section 15: Dermatology 559
15.1 Emergency dermatology 559
Introduction 559
Potentially Life-Threatening Dermatoses 559
Toxic epidermal necrolysis and Stevens-Johnson syndrome 559
Investigations 560
Management 560
Erythroderma 561
Complications of erythroderma 561
Investigations 561
Management 561
Other bullous and vesicular conditions 561
Pemphigus vulgaris 562
Bullous pemphigoid 562
Petechial and Purpuric Rashes 562
Petechiae, bruising and ecchymoses 562
Cutaneous vasculitis 562
Pruritic (Itchy) Dermatoses 563
Scabies 564
Eczema and Psoriasis 565
Eczema 565
Psoriasis 566
Other Dermatoses 566
Skin cancer 566
Herpes zoster 566
Non-accidental injury and neglect 566
Further reading 567
Section 16: Eyes 568
16.1 Ocular emergencies 568
Introduction 568
Ocular Trauma 569
History 569
Examination 569
Investigation 569
Management of specific injuries 569
Prevention 570
Acute Inflammatory Conditions 570
Acute primary angle-closure (glaucoma) 570
Acute iritis 571
Acute infectious keratitis 571
Acute Visual Failure 572
Introduction 572
Clinical assessment 572
Central retinal artery occlusion 572
Central (branch) retinal vein occlusion 573
Anterior ischaemic optic neuropathy 574
Retinal detachment 574
Vitreous haemorrhage 574
Age-related macular degeneration 574
Optic neuritis 575
References 575
Further reading 575
Section 17: Dental 576
17.1 Dental emergencies 576
Anatomy 576
Dental caries 576
Periodontal emergencies 576
Alveolar osteitis (dry socket) 577
Postdental extraction bleeding 577
Traumatic dental emergencies 577
Dentoalveolar trauma in children 577
Dental fractures 577
Temporomandibular dislocation 578
Dental infection and abscess (odontogenic infection) 578
References 578
Section 18: Ent 579
18.1 Ears, nose and throat 579
The Ear 579
Introduction 579
Foreign body 579
Trauma 580
Infection 580
The Nose 581
Foreign body 581
Trauma 581
Sinusitis 581
Epistaxis 582
Summary 582
The Throat 582
Foreign body 582
Infection 583
References 584
Section 19: Obstetrics and Gynaecology 585
19.1 Emergency delivery 585
Introduction 585
The setting 585
History 586
Examination 586
Management 587
Procedure post delivery 589
Disposition 589
Complications of delivery 589
Resuscitation of the neonate 590
Acknowledgements 592
References 592
Further reading 592
19.2 Ectopic pregnancy and bleeding in early pregnancy 592
Introduction 592
History 593
Examination 593
Investigations 593
Management 594
Ectopic pregnancy 594
Failed pregnancy (miscarriage) 594
Prognosis 594
Disposition 594
References 595
19.3 Bleeding after the first trimester of pregnancy 595
Introduction 595
Antepartum Haemorrhage 595
Differential diagnosis 595
History 596
Examination 596
Investigations 596
Management 596
Prognosis 597
Disposition 597
Secondary Post-Partum Haemorrhage 597
Introduction 597
Differential diagnosis 597
History 597
Examination 597
Investigations 597
Treatment 597
References 597
19.4 Abnormal vaginal bleeding in the non-pregnant patient 598
Introduction 598
Causes of abnormal vaginal bleeding 598
History 598
Physical examination 599
Investigations 599
Management 599
Disposition 600
Conclusions 600
References 600
19.5 Pelvic inflammatory disease 601
Introduction 601
Epidemiology 601
Presentation 601
Investigations 602
Differential diagnosis 602
Management 602
Disposition 602
Prognosis 602
References 602
19.6 Pelvic pain 603
Introduction 603
Classification 603
History 603
Examination 604
Laboratory investigations 604
Imaging 605
Differential diagnosis 605
Conclusion 607
Further Reading 608
19.7 Pre-eclampsia and eclampsia 608
Introduction 608
Aetiology, genetics and pathogenesis of pre-eclampsia 608
Epidemiology 609
Clinical features of pre-eclampsia and eclampsia 609
Differential diagnosis 610
Clinical investigation 610
Treatment 611
Prognosis of pre-eclampsia and eclampsia 612
Likely developments in the next 5-10 years 612
References 612
Section 20: Psychiatric Emergencies 613
20.1 Mental state assessment 613
Epidemiology 613
Introduction to the mental state examination 614
Aims of mental health assessment 615
The formal psychiatric interview 615
Conclusion 618
References 618
20.2 Distinguishing medical from psychiatric causes of mental disorder presentations 619
Introduction 619
General approach 619
Triage 620
The interview environment 621
History 621
Collateral history 621
Examination 621
Investigations 623
Diagnostic formulation 623
Conclusion 624
References 624
20.3 Deliberate self-harm/suicide 625
Introduction 625
Incidence 625
Aetiology 625
Patient characteristics 626
Assessment 627
Definitive treatment and disposition 628
Consequences 629
Prevention 630
Conclusion 630
References 630
20.4 Depression 631
Introduction 631
Epidemiology 632
Aetiology 632
Prevention 633
Clinical features 633
Differential diagnosis 636
Assessment 638
Treatment 639
References 641
20.5 Psychosis 641
Introduction 641
Classification 642
Epidemiology and prognosis 642
Aetiology and prevention 642
Clinical features 642
Assessment 645
Treatment 647
References 648
20.6 Pharmacological management of the aroused patient 649
Introduction 649
General principles of rapid tranquillization 650
References 652
Section 21: Challenging Situations 653
21.1 Death and dying 653
Introduction 653
The death process 654
Dying persons 654
Breaking bad news 654
Viewing the body 655
Legal issues 656
Euthanasia 656
Death certificates 656
Organ donation 656
Bereavement counselling 656
Subsequent issues 656
An ED protocol 657
Professional issues 657
References 658
Further reading 658
21.2 Sexual assault 658
Introduction 658
Definitions 658
Epidemiology 659
Rape myths and barriers to care 659
Medical care for the victim 659
The forensic examination 661
Psychological impact of a sexual assault 662
Sexual assault in special circumstances 662
Conclusion 663
References 663
21.3 Domestic violence 664
Definition 664
Incidence 664
Predictors of domestic violence 665
Outcomes 665
Social 666
Barriers to detection and reporting of domestic violence 667
Screening 667
Management 667
Conclusion 668
References 669
21.4 Alcohol-related illness 670
Introduction 670
Epidemiology 670
Pharmacology 670
Chronic alcohol-related illness 671
Important illnesses to be excluded that mimic alcohol intoxication 675
Treatment of alcohol-related illness 676
Assessment of alcohol misuse 677
Pharmacotherapy for alcohol use disorder 678
Likely developments over the next 5-10 years 678
References 678
21.5 The challenging patient 680
The Homeless Patient 680
Definition and epidemiology 680
Clinical features 681
Management 681
The Prisoner 681
Definition and epidemiology 681
Clinical features 682
Management 682
The Behaviourally Disturbed and Violent Patient 683
Aetiology and epidemiology 683
Prevention 683
Clinical features 683
Legal and ethical considerations 684
Management 684
Violence 686
The Frequent Attender 687
Definition and epidiemiology 687
Clinical features 687
Management 687
The Patient With Drug-Seeking Behaviour 688
Definition and aetiology 688
Clinical features 688
Management 688
The Very Important Person 689
Definition 689
Management 689
References 690
Section 22: Pain relief 692
22.1 General pain management 692
Introduction 692
Physiology 692
Assessment of pain and pain scales 693
General principles 693
Specific agents 693
Other analgesic agents 696
Pain relief in pregnancy 696
Non-pharmacological therapies 696
Special pain situations and non-analgesic agents 696
Chronic pain 696
The acute abdomen 697
Likely developments over the next 5-10 years 697
References 697
22.2 Local anaesthesia 698
Local anaesthesia 698
Topical agents 699
Specific nerve blocks 699
Intravenous regional anaesthesia or Bier's block 701
References 703
22.3 Procedural sedation and analgesia 704
Introduction and rationale 704
Underlying principles 704
Pre-procedure risk assessment 705
Choice of agent 706
Preparation and monitoring 708
Post-procedure considerations 709
Likely developments in the next 5-10 years106 709
References 710
Section 23: Ultrasound 712
23.1 Emergency department ultrasound 712
Background 712
Basic physics of ultrasound 712
Transducers 713
The scope of emergency department ultrasound 713
Abdominal aortic aneurysm 715
Early pregnancy 716
RUQ/Gallbladder 717
Renal ultrasound 717
Deep vein thrombosis 718
Emergency echocardiography 719
Ultrasound guided vascular access 720
Miscellaneous applications 720
Training and credentialing 721
References 722
Section 24: Academic Emergency Medicine 724
24.1 Research methodology 724
Introduction 724
Initiating the research project 724
Assembling the research team 725
Development of the study protocol 725
Study design 726
Concepts of methodology 727
Sampling study subjects 728
Data-collection instruments 728
Bias and confounding 729
Principles of clinical research statistics 730
Databases and principles of data management 731
Research ethics 731
References 732
24.2 Writing for publication 733
Introduction 733
Manuscript preparation 733
Manuscript submission 734
Feedback from journals 735
Post acceptance issues 735
Scientific misconduct 735
Further reading 735
24.3 Principles of medical education 735
Introduction 735
Adult learning principles 736
Learner-centred education 736
What makes a good ED teacher? 737
Types of teaching in the ED 738
Feedback to learners 740
Conclusion 740
Likely developments over the next 5-10 years 740
References 741
24.4 Undergraduate teaching in emergency medicine 741
Introduction 741
Overview of undergraduate medical education in Australia 742
The importance of medical student teaching 742
Curriculum development 742
Different ways to teach emergency medicine 743
Assessment principles 745
Likely developments over the next 5-10 years 745
References 746
24.5 Postgraduate emergency medicine teaching and simulation 746
Introduction 746
Current training pathways in postgraduate emergency medicine 747
Challenges for contemporary emergency medicine education 747
Curricular trends 747
Innovation in teaching and learning 747
Learning technology 748
Simulation-based learning for emergency medicine 748
Assessment and performance appraisal 749
Faculty development in emergency medicine 749
Non-vocational teaching in emergency medicine 750
References 750
Section 25: Emergency medicine and the law 751
25.1 Mental health and the law: the Australasian and UK perspectives 751
Introduction 751
Variations in practice 752
Mental health legislation in Australasia 753
References 760
Further reading 760
25.2 The coroner: the Australasian and UK perspectives 760
Australasia 761
Introduction 761
Legislation 761
Reportable deaths 762
A coronial investigation 762
Expert opinion 763
A coronial inquest 763
Coronial findings 764
UK 764
Introduction 765
History of the coroner 765
Structure of the coroner system in the UK 765
How to report a death 766
Handling the body 766
Documentation 766
Information for families 766
Postmortems 766
Preparing a statement for the coroner 767
Inquest 767
References 767
25.3 Consent and competence - the Australasian and UK perspectives 768
Consent 768
Competence 769
Patients who might not be able to consent 769
References 771
Further reading 771
25.4 Privacy and confidentiality 771
Introduction 772
Physical privacy 772
Healthcare providers 772
Mandatory reporting 772
Police 772
Forensic issues 773
Patient health information 773
Legislation 773
National privacy principles 773
NPP10 774
New Zealand 774
Implementation 774
Communications 774
Medicolegal reports 775
Research and quality assurance 775
Complaints and non-compliance 775
Retrospectivity 775
State, territory and New Zealand privacy laws 775
Section 26: Emergency Medical Systems 776
26.1 Pre-hospital emergency medicine 776
Introduction 776
Dispatch 776
Clinical skills 777
Trauma care 777
Cardiac care 778
Other medical emergencies 779
References 779
26.2 Retrieval 780
Introduction 781
Principles of transport 781
Organization structure and staffing 781
Modes of transport 781
Preparation for transport 782
Common problems in transit 782
Special problems associated with travelling at altitude 783
Decisions on flight safety 784
Future directions 784
References 784
26.3 Medical issues in disasters 785
Introduction 785
Definitions and classification 785
Epidemiology 786
Socioeconomic impact 787
Disaster management/emergency management 787
Disaster planning 788
Disaster response activities 788
Urban search and rescue 791
Mental health 791
Mass gatherings 791
Public health issues in disasters 791
Conclusion 792
References 792
26.4 Triage 793
Introduction 793
Civilian triage developments 793
Process of triage 793
Australasian triage development 794
The Australasian triage scale 794
Other triage scales 794
Use beyond waiting time 794
Structure and function of a triage system 795
Pre-hospital triage 795
References 796
26.5 Refugee health 796
Introduction 796
Responsibility for refugee care 797
Refugee camps 797
Emergency phase 797
Post-emergency phase 798
Permanent solutions 798
Past problems 798
Innovations in refugee care 799
Attributes of a refugee doctor 799
Further reading 799
26.6 Emergency department observation wards 800
Introduction 800
OW policies and protocols 800
Efficiency of patient care 801
Staffing 801
Audit and feedback 802
Overall impact of observation wards 802
Short-stay medicine 802
References 802
26.7 Emergency department overcrowding and access block 803
Introduction 803
Theoretical basis of overcrowding 803
Definition of overcrowding 803
Causes of overcrowding 804
Results of overcrowding 804
Strategies to deal with overcrowding 804
Conclusions 804
References 805
26.8 Patient safety 806
Introduction 807
Specific emergency department factors that may compromise patient safety 807
Common safety problems encountered in emergency departments 807
Improving safety in the emergency department 808
Conclusion 808
References 809
26.9 The medical emergency team 809
Introduction and definitions 809
Epidemiology and principles underlying the MET 809
How MET services and RRS work 810
Clinical features of MET patients 810
Management of MET call patients 811
Other issues - the MET and the ED 811
Controversies 812
Likely future developments 812
References 812
Section 27: Administration 814
27.1 Emergency department staffing 814
General principles 814
Calculating clinical workload 815
Medical staff 815
Ancillary staff 815
Optimizing work practices 815
References 816
27.2 Emergency department layout 816
Introduction 816
Design considerations 816
Size and composition of the emergency department 817
Clinical areas 817
Clinical support areas 819
Non-clinical areas 819
Likely developments over the next 5-10 years 820
Further reading 820
27.3 Quality assurance/quality improvement 821
Introduction 821
History 821
Definitions 821
Continuous quality improvement 821
National bodies 822
Quality in the ED 822
Common measures of clinical performance or outcome 822
Likely developments over the next 5-10 years 823
References 823
27.4 Business planning 823
Introduction 823
Types of plans 824
The business plan 824
Planning process 824
Private EDS 826
Business plan implementation and monitoring 826
27.5 Accreditation, specialist training and recognition in Austral 826
Specialist recognition and registration 827
Specialist training in emergency medicine 827
Accreditation 828
References 832
27.6 Specialist training and recognition in emergency medicine in 833
Introduction 833
Regulation of training 833
Modernizing medical careers 834
Training in EM in the UK 834
Conclusion 835
27.7 Complaints 835
Introduction 835
Reasons 836
Pressure for litigation and compensation 837
Responding to complaints 838
Resolution 839
Prevention 839
References 840
27.8 Clinical risk management in the emergency department 840
Introduction 840
The extent of the problem 841
Incidents, errors, adverse events and adverse outcomes 843
Cause and effect 843
Practical application of CRM strategies 843
Indicators/benchmarks 845
Indicators and audit 845
Future directions 847
References 847
Section 28: Environmental 848
28.1 Heat-related illness 848
Introduction 848
Epidemiology and pathophysiology 848
Prevention 849
Clinical features 849
Clinical investigation 850
Treatment 850
Prognosis and disposition 851
References 851
28.2 Hypothermia 852
Introduction 852
Epidemiology and pathophysiology 852
Clinical features 852
Clinical investigation 853
Treatment 853
Prognosis and disposition 854
References 855
28.3 Dysbarism 856
Introduction 856
Diving physics and physiology 856
Barotrauma 857
Decompression illness 859
Other issues 863
Important phone numbers 863
References 864
28.4 Radiation incidents 865
Introduction 865
Radiation sources and incidents 865
Measuring radioactivity 866
Pathophysiology 866
Chronic radiation exposure 867
Acute radiation exposure 867
Occult radiation exposure 869
Contamination with radioactive material 869
Internal contamination 871
References 872
Further reading 872
28.5 Drowning 872
Introduction 873
Epidemiology 873
Prevention 873
Definitions and terminology 873
Pathophysiology 873
Clinical features and organ-specific effects 874
Treatment 874
Clinical investigation 875
Prognosis 876
Disposition 876
References 876
28.6 Electric shock and lightning injury 877
Electric Shock 877
Introduction and epidemiology 877
Physics of electricity and pathophysiology of electrical Injury 877
Prevention 878
Clinical features 878
Electric shock in pregnancy 879
Treatment 879
Prognosis 879
Disposition 879
The Taser 879
Lightning Injury 880
Introduction and epidemiology 880
Physics 880
Clinical features 880
Treatment 881
Prognosis and disposition 881
References 881
28.7 Anaphylaxis 882
Introduction 882
Definition 882
Aetiology 883
Epidemiology 884
Pathophysiology 884
Clinical features 885
Differential diagnosis 886
Clinical investigation 886
Treatment 886
Disposition 888
Discharge policy 888
References 889
28.8 Altitude illness 889
Introduction 890
Epidemiology and pathophysiology 890
Prevention 890
Clinical features 890
Treatment 891
References 892
Section 29: Toxicology 893
29.1 Approach to the poisoned patient 893
Introduction 893
Pathophysiology and clinical features 894
Assessment 895
Treatment 896
Differential diagnosis 898
Clinical investigation 898
Disposition 899
References 899
29.2 Cardiovascular drugs 900
Calcium Channel Blockers and beta-Blockers 900
Introduction 900
Pharmacokinetics 900
Pathophysiology 900
Clinical features 901
Clinical investigation 902
Treatment 902
Disposition 903
Digoxin 903
Introduction 903
Pharmacokinetics 903
Pathophysiology 903
Clinical features 903
Clinical investigation 903
Treatment 903
Disposition 904
Clonidine 904
Introduction 904
Pharmacokinetics 904
Pathophysiology 904
Clinical features 905
Investigations 905
Treatment 905
Disposition 905
References 905
29.3 Central nervous system drugs 906
Introduction 906
Benzodiazepines 906
Pharmacology 906
Clinical features 907
Treatment 907
Clinical investigation 907
Non-Benzodiazepine Sedative-Hypnotics 907
Pharmacology 907
Clinical features 908
Treatment 908
Antipsychotic Drugs 908
Pharmacology 908
Clinical features 909
Section 30: Toxinology 984
30.1 Snakebite 984
Introduction 984
Epidemiology 984
Prevention 985
Clinical features and toxinology 985
Treatment 986
Clinical investigation 988
Disposition 989
References 989
30.2 Spider bite 989
Introduction 989
Redback spider (Latrodectus hasselti) 990
Steatoda species (Cupboard or button spiders) 991
Funnel web spider (Atrax and Hadronyche Species) 991
Mouse spiders (Missulena spp.) 992
Other Australasian spiders 992
Necrotic arachnidism 992
An approach to the patient with spider bite 992
References 993
30.3 Marine envenoming and poisoning 993
Introduction 993
Jellyfish envenoming 993
Sea snake envenoming 994
Blue-ringed octopus envenoming 995
Cone-shell envenoming 995
Stonefish envenoming 995
Management of other venomous fish stings 995
Stingray injury 996
Ciguatera poisoning 996
Scombroid poisoning 996
Paralytic shellfish poisoning 996
Tetrodotoxin poisoning 996
References 996