SECTION 1 Selected Diagnosic and Therapeutic Techniques of Emergency Medicine
Dignostic Techniques
Chapter 1 Emergency Ultrasound ………………… 2 PERSPECTIVE ……………………………………… 2 APPLIED ULTRASOUND PHYSICS AND INSTRUMENTATION ………………………… 2 EQUIPMENT AND SAFETY ……………………… 3 INTEGRATION INTO EMERGENCY MEDICINE PRACTICE ………………………………………… 11
Chapter 2 Monitoring the Emergency Patient … 12 PERSPECTIVE …………………………………… 12 NONINVASIVE BLOOD PRESSURE MEASUREMENT …………………………… 12 PULSE OXIMETRY ……………………………… 13 END-TIDAL CARBON DIOXIDE MONITORING ……………………………… 13 CEREBRAL FUNCTION MONITORING ……… 16 MONITOR ALARMS AND LIMITS …………… 16
Therapeutic Techniques
Chapter 3 Airway …………………………………… 17 PERSPECTIVE …………………………………… 17 PATHOPHYSIOLOGY …………………………… 17 CLINICAL FEATURES …………………………… 17 MANAGEMENT ………………………………… 21 THERAPEUTIC MODALITIES ………………… 23 PRINCIPLES OF MECHANICAL VENTILATION … 28 MANAGEMENT ………………………………… 31
Chapter 5 Adult Resuscitation …………………… 36 PERSPECTIVE …………………………………… 36 PRINCIPLES OF DISEASE ……………………… 36 CLINICAL FEATURES AND MANAGEMENT … 37
Chapter 6 Brain Resuscitation …………………… 43 PERSPECTIVE …………………………………… 43 PATHOPHYSIOLOGY …………………………… 43 MANAGEMENT ………………………………… 43 CLINICAL OUTCOMES ………………………… 48
Chapter 7 Implantable Cardiac Devices………… 49 PERSPECTIVE …………………………………… 49 INDICATIONS FOR PERMANENT PACEMAKERS AND ANTIARRHYTHMIA DEVICES ……… 49 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS …………………………… 57
Chapter 8 Blood and Blood Components ……… 62 PERSPECTIVE …………………………………… 62 PATHOPHYSIOLOGIC PRINCIPLES ………… 62 MANAGEMENT ………………………………… 64 OUTCOMES ……………………………………… 65
SECTION 2 Medical Emergencies
Cardiac Emergencies
Chapter 9 Chest Pain ……………………………… 68
PERSPECTIVE …………………………………… 68
Chapter 4 Mechanical Ventilation and Noninvasive DIAGNOSTIC APPROACH……………………… 68
Ventilatory Support …………………… 28 DIAGNOSTIC TABLE …………………………… 74
PERSPECTIVE …………………………………… 28 MANAGEMENT AND DISPOSITION ………… 76
Chapter 10 Acute Coronary Syndrome ………… 80
PERSPECTIVE …………………………………… 80 EPIDEMIOLOGY ………………………………… 80 SPECTRUM OF DISEASE………………………… 80 PATHOPHYSIOLOGY …………………………… 81 CLINICAL FEATURES …………………………… 81 DIAGNOSTIC INVESTIGATIONS ……………… 82 EMERGENCY DEPARTMENT BASED CHEST
PAIN CENTERS ……………………………… 96 MANAGEMENT OF ACUTE CORONARY SYNDROME…………………………………… 97
Chapter 11 Aortic Dissection ……………………… 102 PERSPECTIVE …………………………………… 102 PRINCIPLES OF DISEASE ……………………… 102 CLINICAL FEATURES …………………………… 104 DIAGNOSTIC STRATEGIES …………………… 105 DIFFERENTIAL CONSIDERATIONS ………… 107 MANAGEMENT ………………………………… 107 DISPOSITION……………………………………… 109
Chapter 12 Pericardial and Myocardial Disease … 110 PERICARDIAL DISEASE (PERICARDITIS) ……… 110 PERSPECTIVE …………………………………… 110 ETIOLOGY ………………………………………… 110 EPIDEMIOLOGY ………………………………… 110 PRINCIPLES OF DISEASE ……………………… 111 PATHOPHYSIOLOGY …………………………… 111 IDIOPATHIC PERICARDITIS …………………… 111 UREMIC PERICARDIAL DISEASE …………… 112 POST-MYOCARDIAL INFARCTION PERICARDITIS ………………………………… 113 POSTINJURY PERICARDITIS …………………… 113 NEOPLASTIC PERICARDIAL DISEASE ……… 114 PERICARDIAL DISEASE RELATED TO CONNECTIVE TISSUE DISORDERS …………… 114 MISCELLANEOUS INFECTIOUS CAUSES OF PERICARDITIS ………………………………… 114 PERICARDIAL EFFUSION ……………………… 115 CARDIAC TAMPONADE ……………………… 115 PURULENT PERICARDITIS …………………… 116 CONSTRICTIVE PERICARDITIS ……………… 117 MYOCARDIAL DISEASES (MYOCARDITIS) …… 117 PERSPECTIVE …………………………………… 117
PRINCIPLES OF DISEASE AND PATHOPHYSI-
OLOGY ………………………………………… 118 CLINICAL FEATURES …………………………… 118 DIAGNOSTIC STRATEGIES …………………… 118 DIFFERENTIAL DIAGNOSIS …………………… 119 MANAGEMENT ………………………………… 119 DISPOSITION……………………………………… 119
CARDIOMYOPATHIES AND SPECIFIC HEART MUSCLE DISEASE ……………………………… 119 DILATED CARDIOMYOPATHY ……………… 120 HYPERTROPHIC CARDIOMYOPATHY ……… 121 RESTRICTIVE CARDIOMYOPATHY ………… 122 PERIPARTUM CARDIOMYOPATHY ………… 123 SPECIFIC HEART MUSCLE DISEASES………… 123
Chapter 13 Hypertension…………………………… 125 PERSPECTIVE …………………………………… 125 PRINCIPLES OF DISEASE ……………………… 125 CLINICAL FEATURES …………………………… 127 DIAGNOSTIC STRATEGIES …………………… 128 CONSIDERATION OF DIFFERENTIAL DIAGNOSES…………………………………… 129 MANAGEMENT ………………………………… 129 DISPOSITION……………………………………… 129
Chapter 14 Dysrhythmias ………………………… 130
CARDIAC CELLULAR ELECTROPHYSI-
OLOGY ……………………………………… 130 ANATOMY AND CONDUCTION……………… 131 MECHANISMS OF DYSRHYTHMIA
FORMATION ……………………………… 132 APPROACH TO DYSRHYTHMIA RECOGNITION AND MANAGEMENT ……………………… 133 SPECIFIC DYSRHYTHMIAS …………………… 135
Chapter 15 Heart Failure ………………………… 148 EPIDEMIOLOGY ………………………………… 148 CELLULAR MECHANISMS …………………… 149 CARDIAC PHYSIOLOGY ……………………… 150 PRIMARY DISEASE PROCESSES RESULTING IN HEART FAILURE ……………………………… 151 COMPENSATORY MECHANISMS IN HEART FAILURE ……………………………………… 152 CLASSIFICATION OF HEART FAILURE ……… 153 CLINICAL EVALUATION OF PATIENTS WITH
EPIDEMIOLOGY AND ETIOLOGY …………… 118 SUSPECTED HEART FAILURE……………… 154
TREATMENT OF ACUTE HEART FAILURE … 156 SUMMARY ………………………………………… 161
Pulmonary Emergencies Chapter 16 Dyspnea ………………………………… 162
PERSPECTIVE …………………………………… 162 DIAGNOSTIC APPROACH……………………… 163 DIFFERENTIAL DIAGNOSIS …………………… 168
Chapter 17 Hemoptysis …………………………… 172 PERSPECTIVE …………………………………… 172 DIAGNOSTIC APPROACH……………………… 173 DIAGNOSTIC ALGORITHM …………………… 174 DISPOSITION……………………………………… 175
Chapter 18 Asthma ………………………………… 176 PERSPECTIVE …………………………………… 176 EPIDEMIOLOGY ………………………………… 176 PRINCIPLES OF DISEASE ……………………… 177 CLINICAL FEATURES …………………………… 179 DIAGNOSTIC STRATEGIES …………………… 180 DIFFERENTIAL CONSIDERATIONS (Box 18-2) …………………………………182 MANAGEMENT OF ACUTE EXACERBATIONS… 182 DISPOSITION……………………………………… 188
Chapter 19 Pneumonia……………………………… 190
PERSPECTIVE …………………………………… 190 PRINCIPLES OF DISEASE ……………………… 190 CLINICAL FEATURES …………………………… 192 DIAGNOSTIC STRATEGIES …………………… 194 DIFFERENTIAL DIAGNOSIS
CONSIDERATIONS ………………………… 197 MANAGEMENT ………………………………… 197 DISPOSITION……………………………………… 200 ACUTE RESPIRATORY DISTRESS
SYNDROME …………………………………201
Chapter 20 Pulmonary Embolism and Deep Vein Thrombosis …………………………… 203 PERSPECTIVE …………………………………… 203 DEEP VEIN THROMBOSIS ……………………… 203 PULMONARY EMBOLISM ……………………… 205
Chapter 21 Nontraumatic Pleural Problems …… 213 SPONTANEOUS PNEUMOTHORAX ………… 213 PLEURAL INFLAMMATION AND EFFUSION …………………………………… 218
Gastrointestinal Emergencies Chapter 22 Acute Pancreatitis …………………… 224
BACKGROUND…………………………………… 224 PERSPECTIVE …………………………………… 225 PRINCIPLES OF DISEASE ……………………… 225 CLINICAL FEATURES …………………………… 227 DIAGNOSTIC STRATEGIES …………………… 229 PROGNOSIS ……………………………………… 231 RADIOGRAPHIC STUDIES……………………… 232 DIFFERENTIAL CONSIDERATIONS ………… 232 MANAGEMENT ………………………………… 233 DISPOSITION……………………………………… 234
Chapter 23 Gastrointestinal Bleeding …………… 235 PERSPECTIVE …………………………………… 235 DIAGNOSTIC APPROACH……………………… 235 DIAGNOSTIC ALGORITHM …………………… 238 EMPIRICAL MANAGEMENT ………………… 238 DEFINITIVE MANAGEMENT ………………… 240 DISPOSITION……………………………………… 241
Renal Emergency Chapter 24 Acute Kidney Injury ………………… 242
PRINCIPLES OF DISEASE ……………………… 242 CLINICAL FEATURES …………………………… 245 DIAGNOSTIC STRATEGY ……………………… 245 MANAGEMENT ………………………………… 246 DISPOSITION……………………………………… 246
Hematologic Emergency Chapter 25 Disorders of Hemostasis …………… 248
PERSPECTIVE …………………………………… 248 PATHOPHYSIOLOGY …………………………… 248 CLINICAL FEATURES …………………………… 250 DIFFERENTIAL DIAGNOSIS AND
MANAGEMENT ……………………………… 252 DISPOSITION……………………………………… 258
Metabolic Emergencies Chapter 26 Diabetic Emergency ………………… 259
DIABETES MELLITUS …………………………… 259 HYPOGLYCEMIA ………………………………… 260 DIABETIC KETOACIDOSIS……………………… 261 HYPERGLYCEMIC HYPEROSMOLAR STATE … 265 CONTROL OF DIABETES ……………………… 266
Chapter 27 Electrolyte Disorders ………………… 268 PERSPECTIVE …………………………………… 268 HYPERKALEMIA ………………………………… 268 HYPOKALEMIA ………………………………… 271 HYPERNATREMIA ……………………………… 273 HYPONATREMIA………………………………… 274 HYPERCALCEMIA ……………………………… 278 HYPOCALCEMIA ………………………………… 279 HYPERMAGNESEMIA…………………………… 281 HYPOMAGNESEMIA …………………………… 282 HYPERPHOSPHATEMIA ……………………… 283 HYPOPHOSPHATEMIA ………………………… 284
Chapter 28 Acid-Base Disorders ………………… 286 PERSPECTIVE …………………………………… 286 PRINCIPLES OF DISEASE ……………………… 286 DIAGNOSTIC STRATEGIES …………………… 287 RESPIRATORY ACIDOSIS ……………………… 288 RESPIRATORY ALKALOSIS …………………… 289 METABOLIC ACIDOSIS ………………………… 290 METABOLIC ALKALOSIS ……………………… 292 MIXED DISORDERS ……………………………… 293
Neurologic Emergencies Chapter 29 Acute Meningitis ……………………… 294
DEFINITION ……………………………………… 294 PRINCIPLES OF DISEASE ……………………… 294 CLINICAL FEATURES …………………………… 296 DIAGNOSTIC STRATEGIES …………………… 297 DIFFERENTIAL CONSIDERATIONS ………… 301 MANAGEMENT ………………………………… 301 DISPOSITION……………………………………… 303
Chapter 30 Headache ……………………………… 304 PERSPECTIVE …………………………………… 304 DIAGNOSTIC APPROACH……………………… 304 DIFFERENTIAL CONSIDERATIONS ………… 308 SPECIAL MANAGEMENT ……………………… 309 PRIMARY HEADACHE DISORDERS ………… 309 SECONDARY HEADACHE DISORDERS……… 314 OTHER HEADACHE DISORDERS AND FACIAL PAIN …………………………………………… 319
Chapter 31 Syncope ………………………………… 320
PERSPECTIVE …………………………………… 320 DIAGNOSTIC APPROACH……………………… 320 DIAGNOSTIC ALGORITHM …………………… 324 EMPIRICAL MANAGEMENT ………………… 326
Chapter 32 Depressed Consciousness and Coma…… 328 PERSPECTIVE …………………………………… 328 CLINICAL EVALUATION ……………………… 329 EMPIRICAL MANAGEMENT ………………… 335
Chapter 33 Seizure ………………………………… 336 PERSPECTIVE …………………………………… 336 DIAGNOSTIC APPROACH……………………… 337 MANAGEMENT ………………………………… 342 DISPOSITION……………………………………… 342
Chapter 34 Stroke …………………………………… 343 PERSPECTIVE …………………………………… 343 PRINCIPLES OF DISEASE ……………………… 345 CLINICAL FEATURES …………………………… 346 DIFFERENTIAL CONSIDERATIONS ………… 350 DIAGNOSTIC STRATEGIES …………………… 351 STROKE MANAGEMENT ……………………… 352 DISPOSITION……………………………………… 356
SECTION 3 Surgical Emergencies
Chapter 35 Acute abdominal pain ……………… 358 PERSPECTIVE …………………………………… 358 DIAGNOSTIC APPROACH……………………… 363 DIFFERENTIAL DIAGNOSIS …………………… 368 EMPIRICAL MANAGEMENT ………………… 368 DISPOSITION……………………………………… 369
Chapter 36 Abdominal Aortic Aneurysm ……… 371 PERSPECTIVE …………………………………… 371 PRINCIPLES OF DISEASE ……………………… 372 CLINICAL FEATURES …………………………… 372 DIAGNOSTIC STRATEGIES …………………… 375 DIFFERENTIAL CONSIDERATIONS ………… 377 MANAGEMENT ………………………………… 377 LATE COMPLICATIONS OF REPAIR ………… 380 DISPOSITION……………………………………… 380
Chapter 37 Acute Disorders of the Small Intestine … 381
SMALL BOWEL OBSTRUCTION ……………… 381 ACUTE MESENTERIC ISCHEMIA……………… 385
Chapter 38 Wound Management Principles …… 389 PERSPECTIVE …………………………………… 389 PRINCIPLES OF DISEASE ……………………… 389 CLINICAL FEATURES AND DIAGNOSTIC STRATEGIES …………………………………… 391 MANAGEMENT ………………………………… 393 DISPOSITION……………………………………… 407 SUMMARY ………………………………………… 408
Chapter 39 Multiple Trauma ……………………… 410 INTRODUCTION ………………………………… 410 PRINCIPLES OF DISEASE ……………………… 410 MANAGEMENT ………………………………… 410 DISPOSITION……………………………………… 415
Chapter 40 Injury Prevention and Control …… 416 PERSPECTIVE …………………………………… 416 PRINCIPLES OF THE DISEASE OF INJURY … 416 METHODS OF PREVENTION ………………… 418 INJURY CONTROL IN MEDICAL PRACTICE … 419
SECTION 4 Enviroment Emergencies
Chapter 41 Heat Illness …………………………… 422 PERSPECTIVE …………………………………… 422 PRINCIPLES OF DISEASE ……………………… 422 PATHOPHYSIOLOGY …………………………… 423 MINOR HEAT ILLNESS ………………………… 424 HEAT EXHAUSTION …………………………… 425 HEATSTROKE …………………………………… 426
Chapter 42 High-Altitude Medicine……………… 429 EPIDEMIOLOGY ………………………………… 429 DEFINITIONS …………………………………… 429 ENVIRONMENTAL CONSIDERATIONS …… 430 ACCLIMATIZATION …………………………… 430 PATHOPHYSIOLOGY …………………………… 431 ACUTE MOUNTAIN SICKNESS ……………… 433 HIGH-ALTITUDE PULMONARY EDEMA …… 434 HIGH-ALTITUDE CEREBRAL EDEMA ……… 436 HIGH-ALTITUDE RETINAL HEMORRHAGE … 436 ALTITUDE AND UNDERLYING MEDICAL CONDITIONS ………………………………… 437
Chapter 43 Drowning ……………………………… 440
PERSPECTIVE …………………………………… 440 PRINCIPLES OF DISEASE ……………………… 440 CLINICAL FEATURES …………………………… 441 DIFFERENTIAL CONSIDERATIONS ………… 442 DIAGNOSTIC STUDIES ………………………… 442 MANAGEMENT ………………………………… 442 DISPOSITION……………………………………… 443
Chapter 44 Electrical and Lightning Injuries … 444 PERSPECTIVE …………………………………… 444 PRINCIPLES OF DISEASE ……………………… 444 CLINICAL FEATURES …………………………… 448 COMPLICATIONS ……………………………… 450 DIFFERENTIAL CONSIDERATIONS ………… 450 MANAGEMENT ………………………………… 451 DISPOSITION……………………………………… 452
SECTION 5 Toxicology Emergencies
Chapter 45 General Approach to the Poisoned Patient…………………………………… 454 PERSPECTIVE …………………………………… 454 INITIAL APPROACH TO THE POISONED PATIENT ……………………………………… 454 TOXIC SYNDROMES AND ANTIDOTES……… 455 TOXICOLOGY LABORATORY ………………… 459 DECONTAMINATION ………………………… 459 DISPOSITION AND CONSULTATION ……… 460
Chapter 46 Opioids ………………………………… 461 PERSPECTIVE …………………………………… 461 PRINCIPLES OF DISEASE ……………………… 461 CLINICAL FEATURES …………………………… 462 DIAGNOSTIC STRATEGIES …………………… 463 DIFFERENTIAL CONSIDERATIONS ………… 464 MANAGEMENT ………………………………… 464 DISPOSITION……………………………………… 465
Chapter 47 Organophosphorus-poison ………… 466 PERSPECTIVE …………………………………… 466 PRINCIPLES OF DISEASE ……………………… 466 CLINICAL FEATURES …………………………… 467 DIAGNOSTIC STRATEGIES …………………… 468 DIFFERENTIAL DIAGNOSIS …………………… 468 MANAGEMENT ………………………………… 468
DISPOSITION……………………………………… 469
Chapter 48 Sedative Hypnotics Poisoning ……… 470 BARBITURATES ………………………………… 470 BENZODIAZEPINES …………………………… 472
Chapter 49 Toxic Alcohols ………………………… 476 METHANOL ……………………………………… 476 ETHYLENE GLYCOL …………………………… 479 ISOPROPYL ALCOHOL ………………………… 484
SECTION 6 Toxinlogy Emergency
Chapter 50 Venomous Snake Bite ……………… 488 PERSPECTIVE …………………………………… 488 PRINCIPLES OF DISEASE ……………………… 490 CLINICAL FEATURES …………………………… 491 MANAGEMENT ………………………………… 491 DISPOSITION……………………………………… 496
SECTION 7 Other Emergencies
Chapter 51 Shock Syndrome ……………………… 498 PERSPECTIVE …………………………………… 498 CLINICAL FEATURES ………………………… 500 MANAGEMENT ………………………………… 502
Chapter 52 Sepsis Syndromes …………………… 505 PERSPECTIVE …………………………………… 505 PRINCIPLES OF DISEASE ……………………… 506 CLINICAL FEATURES …………………………… 508 DIAGNOSTIC STRATEGIES …………………… 509 DIFFERENTIAL CONSIDERATIONS ………… 510 MANAGEMENT ………………………………… 510
SECTION 8 Pharmacotherapy of selected emergencies
Chapter 53 Antihypertensive medications ……… 516 PERSPECTIVE …………………………………… 516 ACUTE BLOOD PRESSURE CONTROL ……… 517 CHRONIC ANTIHYPERTENSIVE THERAPY … 521
Chapter 54 Antiarrhythmic Agents ……………… 525 CLASSIFICATION OF ANTIDYSRHYTHMIC DRUGS ………………………………………… 525
Chapter 55 Drug Therapy in Pregnancy………… 529 PERSPECTIVE …………………………………… 529 PRINCIPLES OF DISEASE ……………………… 530 DRUG THERAPY DURING PREGNANCY …… 531
REFERENCES ………………………………………………………………………………………………………………… 553