An introduce clinical emergency medicine

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An Introduction to Clinical Emergency Medicine Second edition An Introduction to Clinical Emergency Medicine Second edition Edited by S.V Mahadevan, MD Associate Chief, Division of Emergency Medicine Associate Professor of Surgery (Emergency Medicine) Director, Stanford Emergency Medicine International Stanford University School of Medicine, and Emergency Department Medical Director Stanford University Medical Center, Stanford, CA, USA Gus M Garmel, MD Co-Program Director, Stanford/Kaiser Emergency Medicine Residency Clinical Professor (Affiliated) of Surgery (Emergency Medicine) Clerkship Director, Surgery 313D (Emergency Medicine) Stanford University School of Medicine Senior Staff Emergency Physician, The Permanente Medical Group Kaiser Permanente Medical Center, Santa Clara, CA, USA CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Tokyo, Mexico City Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521747769 © Cambridge University Press 2005, 2012 This publication is in copyright Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press Second edition published 2012 First edition published 2005 Printed in the United Kingdom at the University Press, Cambridge A catalogue record for this publication is available from the British Library Library of Congress Cataloguing in Publication data An introduction to clinical emergency medicine / edited by S.V Mahadevan, Gus M Garmel – 2nd ed p cm Includes bibliographical references and index ISBN 978-0-521-74776-9 (pbk.) Emergency medicine – Handbooks, manuals, etc Emergency medicine – Diagnosis I Mahadevan, Swaminatha V II Garmel, Gus M III Title: Clinical emergency medicine [DNLM: Emergency Treatment – methods Emergency Medicine – methods.] RC86.8.I59 2012 616.02’5 – dc22 20120009587 ISBN 978-0-521-74776-9 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use Contributors xi Foreword xvii Foreword to the 1st edition Acknowledgments xxi Preface xxiii Dedication xxv Contents Contents xix Section Principles of Emergency Medicine Approach to the emergency patient Gus M Garmel, MD Airway management 19 S.V Mahadevan, MD and Shannon Sovndal, MD Cardiopulmonary and cerebral resuscitation 41 Brian Lin, MD and Matthew Strehlow, MD Cardiac dysrhythmias 55 Swaminatha V Gurudevan, MD Severe sepsis and septic shock 73 Emanuel P Rivers, MD, MPH, IOM, Anja Kathrin Jaehne, MD and Gilbert Abou Dagher, MD Shock 87 Jairo I Santanilla, MD and Peter M.C DeBlieux, MD Traumatic injuries 95 David Manthey, MD and Kim Askew, MD Emergency medical services 115 Jeffrey M Goodloe, MD and Paul D Biddinger, MD Pain management 127 Eustacia (Jo) Su, MD Section Primary Complaints 10 Abdominal pain 139 S.V Mahadevan, MD Contents v Contents 11 Abnormal behavior 153 Tim Meyers, MD and Gus M Garmel, MD 12 Alcohol-related emergencies 163 John S Rose, MD and Erik G Laurin, MD 13 Allergic reactions and anaphylactic syndromes 177 Steven Go, MD 14 Altered mental status 185 Barry Simon, MD and Flavia Nobay, MD 15 Bleeding 197 Jonathan E Davis, MD 16 Burns 207 David A Wald, DO 17 Chest pain 221 Jeffrey A Tabas, MD and Susan B Promes, MD 18 Constipation 237 Anthony FT Brown, MBChB and Victoria Brazil, MBBS 19 Crying and irritability 245 Lee W Shockley, MD and Katherine Bakes, MD 20 Dental pain 255 Kip Benko, MD 21 Diabetes-related emergencies 271 Christopher RH Newton, MD and Stefanie A Simmons, MD 22 Diarrhea 279 Rawle A Seupaul, MD 23 Dizziness and vertigo 289 Andrew K Chang, MD 24 Ear pain, nosebleed and throat pain (ENT) 24A Ear pain Gregory H Gilbert, MD and S.V Mahadevan, MD vi Contents 301 Nosebleed 313 Gregory H Gilbert, MD 24C Throat pain 321 Alice Chiao, MD and Michelle Huston, MD 25 Extremity trauma 333 Dan Garza, MD and Gregory W Hendey, MD 26 Eye pain, redness and visual loss 357 Janet G Alteveer, MD 27 Fever in adults 375 Gus M Garmel, MD 28 Fever in children 393 Lynne McCullough, MD 29 Gastrointestinal bleeding 405 H Brendan Kelleher, MD and Stuart P Swadron, MD 30 Headache 415 Gino A Farina, MD and Kumar Alagappan, MD 31 Hypertensive urgencies and emergencies 429 Robert Galli, MD and Loretta Jackson-Williams, MD 32 Joint pain 437 Melissa J Lamberson, MD and Douglas W Lowery-North, MD, MSPH 33 Low back pain 449 Mel Herbert, MD, MBBS, BMEDSCI, Mary Lanctot-Herbert, MSN, FNP-C and S.V Mahadevan, MD 34 Pelvic pain 461 Peter G Kumasaka, MD 35 Rash 475 Jamie Collings, MD and Emily Doelger, MD 36 Scrotal pain 491 Jonathan E Davis, MD 37 Seizures 503 Mary Beth Johnson, MD and Stephen R Hayden, MD Contents vii Contents 24B Contents 38 Shortness of breath in adults 515 Sharon E Mace, MD 39 Shortness of breath in children 531 Ghazala Q Sharieff, MD 40 Syncope 545 Amal Mattu, MD 41 Toxicologic emergencies 559 Steven A McLaughlin, MD and Randall Myers, MD 42 Urinary-related complaints 571 Fred A Severyn, MD 43 Vaginal bleeding 583 Pamela L Dyne, MD and Rita Oregon, MD 44 Vomiting 597 Jennifer A Oman, MD, MBA 45 Weakness 607 R Jason Thurman, MD and Alessandro Dellai, MD Section Unique Issues in Emergency Medicine 46 Child abuse, elder abuse, intimate partner violence 631 Carolyn J Sachs, MD, MPH 47 Environmental emergencies 47A Drowning 641 Paul S Auerbach, MD, MS and Ken Zafren, MD 47B Heat illness 646 Ken Zafren, MD 47C Accidental hypothermia 653 Ken Zafren, MD 47D Lightning injuries 660 Ken Zafren, MD 47E Terrestrial venomous bites and stings 665 Robert L Norris, MD 48 Ethics and end-of-life issues Michael A Gisondi, MD viii Contents 673 Index pneumatic anti-shock garment (PASG; military anti-shock trousers [MAST]) 120 pneumatic otoscopy 306–7 pneumonia chest pain 226 common pathogens involved in 541 crying and irritability 249 CURB-65 712 differential diagnosis 522 fever in adults 382 fever in children 399 shortness of breath in adults 526–7 shortness of breath in children 537, 540–1 pneumonitis 536 pneumoperitoneum 148 pneumothorax (PTX) central venous cannulation 726 chest pain 226 differential diagnosis 109, 522 E-FAST 779–81 traumatic injuries 97–9 POC (periorbital cellulitis) 371, 367, 372, 382, 399 POCT (point-of-care testing) 811 point of maximal impulse (PMI) 58–9 point-of-care testing 10 point-of-care testing (POCT) 811 Poker Chip Tool (Pieces of Hurt scale) 128–35 police custody, patients in 13–14 polyarticular arthritis 438–9 polydipsia, defined 272 polymorphic ventricular tachycardia 67–8 polymorphonuclear cells (PMNs) 437 polymyositis general treatment principles 625 weakness 619 polyuria 272 porcine surfactant 644 PORT score for pneumonia 712 positive end-expiratory pressure (PEEP) 91 post-coital headache 420 post-concussive headache 420 post-dural puncture (post-LP) headaches 415, 421, 426 posterior cruciate ligament (PCL) 348 posterior drawer test 348 posterior epistaxis See also nosebleed (epistaxis) defined 313 historical and examination distinctions 314 location of bleeding 314 physical examination 315 postictal paralysis See Todd’s (postictal) paralysis post-LP (post-dural puncture) headaches 415, 421, 426 post-tussive emesis 597 post-void residual 454 potassium alcoholic patients 169 diabetic ketoacidosis 272–3 hyperglycemic hyperosmolar state 275 hypothermia 658 pouch of Douglas 797, 802 povidone-iodine 750–1 PPIs (proton pump inhibitors) 411 P-Q-R-S-T mnemonic PR interval 56 prednisolone 539–40 870 Index prednisone allergic reactions and anaphylactic syndromes 182 asthma 539–40 joint pain 445 pre-eclampsia 432, 434–5 pregnancy testing abdominal pain 147 chest pain 227 diarrhea 282 hypertensive urgencies and emergencies 433 overview 821 pelvic pain 466 seizures 507 shortness of breath in adults 524 syncope 554 traumatic injuries 109 vaginal bleeding 584, 589 vomiting 603 pregnant patients 26 abdominal pain 150 airway management 25 alcohol-related emergencies 174 appendicitis 142 diabetic ketoacidosis 274 fever in adults 389 headaches 427 hypertensive urgencies and emergencies 431, 435 lightning injuries 663 lower back pain 458 pelvic ultrasound 797–802 rash 488 seizures 512 shortness of breath in adults 528 syncope 555 toxicologic emergencies 568 traumatic injuries 113–14 urinary-related complaints 578, 580–1 vaginal bleeding 586 vomiting 602, 605–6 pregnant providers 703 Prehn’s sign 496 preload, defined 88 pre-syncope See also near syncope (pre-syncope) preventable adverse events, defined 691 prickly heat 646 primary (baby) teeth 255, 266, 269, 257 primary headaches See also headaches defined 415 differential diagnosis 419 types of 415 primary hemostasis 197, 203, 199 primary hypothermia 653 primary otalgia 301 primary seizures, defined 503 primary wound closure 745 privacy 3, 6, 685–6 probiotics 285 procainamide 439 procalcitonin (PCT) 824 procedural errors, defined 693 procedural sedation and analgesia (PSA) 759 advance preparations for 765 classifications for risk stratification 760 continuum of depth of sedation 759 chest radiography 230, 554 differential diagnosis 522 echocardiography 790 electrocardiography 552 fever in adults 384 general treatment principles 234–5 Geneva score 714 PERC Rule for 713 predisposing conditions for 517 Pulmonary Embolism Severity Index 713 shortness of breath in adults 528 Simplified Revised Geneva score for 714 syncope 550 Wells Score for 713 Pulmonary Embolism Severity Index (PESI) 713 pulmonary function testing 621 pulmonary system altered mental status 189 burns 210 chest pain 223–4 drowning 643–4 hypertensive urgencies and emergencies 432 pneumonia 712 rapid ultrasound in shock 796 response to lightning injuries 660 seizures 506 shortness of breath in adults 519 shortness of breath in children 534–5 syncope 547–8 toxicologic emergencies 561–2 venomous bites and stings 668 pulp description of 255 fractures of crown involving 260, 264 fractures of crown through 261, 269 pulpitis 262, 268–9 pulse oximetry carbon monoxide toxicity 215 chest pain 223 hypothermia 656 rapid sequence intubation 30–1 shortness of breath in adults 518 shortness of breath in children 534 syncope 548 pulseless electrical activity (PEA) 47 pulsus paradoxus 223 PUM (public utility model) 115 puncture wounds, characteristics of 747 pupils anatomy of 357 eye pain, redness and visual loss 361–3 traumatic injuries 102 PUPPPS (pruritic urticarial papules and plaques of pregnancy syndrome) 488 Purkinje fibers 56 purpura 200, 478–80 Pursuit ACS score 711 PURSUIT score for UA/NSTEMI 711 pustules 479–80 pyelonephritis fever in adults 383 fever in children 399 gastrointestinal symptoms 585 pregnant patients 580–1 Index 871 Index discharge 765 indications for 760 medications for 762 prudent limits and targeted length and depth of 761 reversal agents 764 prochlorperazine headaches 424–5 vomiting 605 progesterone level 466 progestin 592–3 progressive brainstem dysfunction 191 promethazine dizziness 298 vomiting 605 pronator drift 613 proparacaine 364 propofol 761, 763 proptosis 361 prostaglandin E2 (PGE2) 375 prostate rectal examination 495–6 urinary-related complaints 575 prostatitis 383, 580 protected health information (PHI) 685 prothrombin time (PT) alcoholic patients 170 gastrointestinal bleeding 410 nosebleed 316 overview 811 pelvic pain 469 rash 487 shortness of breath in adults 524 vomiting 604 proton pump inhibitors (PPIs) 411 protozoal infections 823 pruritic urticarial papules and plaques of pregnancy syndrome (PUPPPS) 488 pruritus 476, 487 PSA See procedural sedation and analgesia PSA view (parasternal short axis view), echocardiography 785–6, 790, 784–5 pseudogout 442 pseudohyperkalemia 815 pseudohyponatremia 272 pseudomembranes 325 pseudoseizures 512 psoas sign 144 PSQIA (Patient Safety and Quality Improvement Act of 2005) 695 psychiatric evaluation and illness abnormal behavior 155–6 alcohol-related emergencies 174–5 combined with medical illness 16 psychogenic seizures 506 psychogenic unresponsiveness 185 psychophysiologic dizziness (nonspecific dizziness) 290–1, 298 PT See prothrombin time PTT See partial thromboplastin time PTX See pneumothorax public utility model (PUM) 115 pulmonary contusion 109 pulmonary embolism (PE) chest pain 226, 234 Index pyloric stenosis 602 pyridium 579 pyridostigmine 624 pyuria 822 Q QRS complex 56 QT interval 56 qualitative ETCO2 detection devices 31 quantitative ETCO2 detection devices 31 Quincke needles 733 R RA See rheumatoid arthritis rabies 382 raccoon eyes 104 radial artery arterial puncture 727–8 extremity injuries 345–6 radial head subluxation 736 complications 736 indications 736 technique 736 radial nerve 346, 340 radiation, defined 646 radiography abdominal pain 147–9 abnormal behavior 158 abuse 634 accidental hypothermia 656 alcohol-related emergencies 170 allergic reactions and anaphylactic syndromes 180 aortic dissection 231 body stuffers and packers 563 cardiac dysrhythmias 59 chest pain 229–30 constipation 240–1 crying and irritability 252–3 dental pain 263–4 diagnostic testing 240–1 diarrhea 284 dizziness and vertigo 296 drowning 644 ear pain 309 extremity trauma 352 eye pain, redness and visual loss 366–9 fever in adults 386 fever in children 400 gastrointestinal bleeding 410 headache 422–3 heat illness 650 hypertensive urgencies and emergencies 433 joint pain 445 lightning injuries 663 lower back pain 455–6 nosebleed 317 overview 11 pelvic pain 469–70 pulmonary embolism 230 rules to determine need for 10 sciatica 456 scrotal pain 498–9 seizures 509 shortness of breath in adults 521–2 872 Index shortness of breath in children 535 syncope 554 throat pain 328 toxicologic emergencies 563 traumatic injuries 111–12, 716 urinary-related complaints 576–7 vaginal bleeding 590–1 venomous bites and stings 669 vomiting 604 weakness 620–1 radionucleotide-tagged bone scintillography 387 radionuclide imaging 498–9 Ramsay-Hunt syndrome (herpes zoster oticus) 306, 308 range of motion (ROM) 452 ranitidine 182 Ranson’s criteria for pancreatitis 715 RAPD (relative afferent pupillary defect) 362 A Rapid Approach to Ethical Problems 674 rapid plasma reagin (RPR) 823 Rapid Rhino (intranasal balloon catheters) 318 rapid sequence intubation (RSI) 24–31 allergic reactions and anaphylactic syndromes 182 paralysis (with induction) 26 placement 30 positioning 29 possibility of success 24–5 post-intubation management 31 preparation 26 pretreatment medications 27 proof (confirmation of tube placement) 30 protection 29 pulse oximetry 30 steps for 24 rapid streptococcal antigen tests (RSATs) 325, 330 Rapid Ultrasound in Shock (RUSH) 795–6 RAS See reticular activating system rash 475–89 anatomic essentials 475 associated symptoms 477 diagnostic testing 487 differential diagnosis 479–80 disposition 488–9 general treatment principles 487–8 history 475 life-threatening dermatoses 475–6 past medical history 477 pearls, pitfalls and myths 489 physical examination 477–8 red flags 476 scope of problem 475 skin lesions 477–8 special patients 488 throat pain 323 weakness 612 rattlesnake bites 666, 668 See also terrestrial venomous bites and stings Reason Swiss Cheese Model of Error Events 692 reassurance rebound tenderness 143–4 receptive aphasia, defined 607, 613 recombinant human activated protein C distributive shock 90 severe sepsis and septic shock 83 rectal examination 527 retina, anatomy of 358 retinal detachment 366, 368, 371–2 retrograde intubation 34 retropharyngeal abscess ear pain 308 fever in children 399 shortness of breath in children 535, 537, 539 throat pain 327, 329 reverse straight leg raise (RSLR) test (femoral stretch test) 453 Revised Trauma score 715 Rh factor overview 813 pelvic pain 469 vaginal bleeding 590 Rh immunoglobulin (RhIG; Rho-GAM) therapy 114, 472 rheumatic fever dental pain 258 joint pain 442 Jones criteria for diagnosis of 444 rheumatoid arthritis (RA) distribution of pain 440 joints involved 439, 443 RhIG (Rh immunoglobulin; Rho-GAM) therapy 114, 472 rhinorrhea 534 RhoGAM 814 rib fractures geriatric patients 113 pediatric patients 113 RICE (rest, ice, compression, elevation) extremity injuries 354 joint pain 445 right main stem bronchus intubation 31 right upper quadrant (RUQ) view, FAST 769–72 anatomy 770 technique 770–1 ringdown 41 Rinne test 307 Rochester Criteria for febrile infants 717 Rocky Mountain spotted fever 418, 475, 483–4 rocuronium 28 rofecoxib 131–2 ROM (range of motion) 452 Romberg test 293 root, dental 255 roseola infantum (sixth disease) 475, 480 rotator cuff tears 343 rotavirus 283 round ligament pain 468 Rovsing’s sign 144 RPR (rapid plasma reagin) 823 RR See respiratory rate RSATs (rapid streptococcal antigen tests) 325, 330 RSI See rapid sequence intubation RSLR (reverse straight leg raise) femoral stretch test (test) 453 RSV (respiratory syncytial virus) 538, 540 RSVIG (respiratory syncytial virus immune globulin) 527 rubella (German measles) 480 rubor, defined 376 rule of nines 211 rule of palms 212 rules-based cognitive performance 692–3 RUQ view See right upper quadrant view, FAST RUSH (Rapid Ultrasound in Shock) 795–6 Index 873 Index abdominal pain 145 alcohol-related emergencies 166 altered mental status 190 chest pain 225 crying and irritability 248 diarrhea 281 dizziness and vertigo 294 fever in children 397–8 gastrointestinal bleeding 408 lower back pain 452 pelvic pain 466 scrotal pain 495–6 syncope 548 toxicologic emergencies 562 traumatic injuries 105 urinary-related complaints 575 vomiting 600 rectal thermometers 379, 648, 655 reduction of dislocations 733–5 patella 736–7 phalangeal 736 radial head subluxation 736 shoulder 734–5 referred otalgia 302 referred pain abdominal 139 chest 221 pelvic 461 regional nerve block 750 regurgitation, defined 597 relative afferent pupillary defect (RAPD) 362 renal calyces, anatomy of 571 renal colic 574 renal failure cardiac dysrhythmias 58 hypertension 432 renal fascia (Gerota’s fascia) 770 renal pelvis, anatomy of 571 renal system anatomy of 571 response to hypothermia 653–4 resistant bronchospasm 183 respect for autonomy, defined 673 respiratory alkalosis 815 respiratory rate (RR) dizziness and vertigo 292 shortness of breath in adults 518 shortness of breath in children 533 respiratory syncytial virus immune globulin (RSVIG) respiratory syncytial virus (RSV) 538, 540 respiratory system rash 477 response to hypothermia 653 shortness of breath in adults 517 respiratory therapy personnel 26 respiratory transmission, defined 697 rest, ice, compression, elevation See RICE restraint abnormal behavior 158–9 alcoholic patients 170–1 retching, defined 597 reticular activating system (RAS) altered mental status 186 syncope 545 Index S S3 224 S4 224 SA (sinoatrial) node 55 saccade, defined 295 SAD PERSONS mnemonic 160 safe injection practices 698 safety, defined 691 See also patient safety SAGE mnemonic 565 sagittal (longitudinal) plane 768 SAH See subarachnoid hemorrhage Salem sump 728 salicylates heat illness 649–50 toxicologic emergencies 565 Salmonella 283 SALT mnemonic 562, 563 Salter-Harris classification 354 San Francisco Syncope Rule 717 Sandy Beach sign 781 saphenous nerve 340 SARS (severe acute respiratory syndrome), occupational exposure to 699, 703 Save-A-Tooth toothsaver 266 SBI (serious bacterial infection) 395 scabies 483, 487 scald burns 217–18 scales defined 478–9 differential diagnosis 479–80 scaphoid fractures 345 scapholunate dissociation 345 scapula 343 scapular manipulation technique 734 scarlet fever 478, 481 SCh See succinylcholine sciatic nerve 340 sciatica defined 449 pain of 450 radiology 456 SCIWORA (spinal cord injury without radiographic abnormality) 113 sclera anatomy of 357 physical examination 364 scleritis 368, 372 scombroid poisoning 181 scopolamine 298 scorpion stings See also terrestrial venomous bites and stings classical syndromes 667 overview 665 pulmonary examination 668 skin examination 668 treatment of 671 venoms 666 vital signs 668 screen marker, defined 768 scrotal ligament (gubernaculum), anatomy of 491–2 scrotal pain anatomic essentials 491–2 associated symptoms 493–4 diagnostic testing 496, 498 radiologic studies 498–9 874 Index differential diagnosis 497 disposition 500 general treatment principles 499 history 492–3 pearls, pitfalls and myths 500 physical examination 494 red flags 492 scope of problem 491 special patients 491, 499–500 scrotal skin infection 497 scrotal transillumination 496 scrotal tumors 497 scrotum, anatomy of 491 SE See status epilepticus seat belt sign 104 second degree atrioventricular block 61 type I 61–2 type II 62 second degree (deep partial thickness) burns 208, 211 second degree (superficial partial thickness) burns 207–8, 211 secondary headaches See also headaches defined 415 differential diagnosis 420 types of 415 secondary hemostasis 197–9, 203 secondary hypothermia 653 secondary seizures defined 503 etiology of 503 secretory diarrhea, defined 279 sedation 759–66 ASA levels for risk stratification 707 drug selection 761 general treatment principles 759 laceration repair 750 patient assessment and selection 760–1 pearls, pitfalls and myths 766 procedural preparation, monitoring and risk awareness 764–5 recovery and discharge 765 scope of problem 760 special patients 765–6 see-saw respirations (abdominal breathing) 515 segmental fractures 353 seizures 503–13 alcohol-related emergencies 165, 173, 168 anatomic essentials 503 associated symptoms 505 diagnostic testing 507, 509 differential diagnosis 506–7 disposition 512–13 general treatment principles 510–11 history 504–5 lightning injuries 662 past medical history 505 pearls, pitfalls and myths 513 physical examination 510, 505–6 red flags 503–4 scope of problem 503 special patients 511–12 syncope 551 Seldinger guide wire method 723–4 selective serotonin reuptake inhibitors (SSRIs) 154 self-cure composite 265–6 normal values of hemodynamic parameters 94 physical examination 87–8 pitfalls 94 pneumatic anti-shock garment (PASG) 120 pregnant trauma patients 113 scope of problem 87 signs and treatment for classes of 113–14 traumatic injuries 99–100 vasoactive agent intervention 92–4 shortness of breath in adults 515–29 anatomic essentials 515 clinical signs of respiratory distress 518 diagnostic testing 521–2, 524–5 differential diagnosis 519–21 disposition 529 general treatment principles 522, 526–8 history 515–18 past medical history 517–18 pearls, pitfalls and myths 529 physical examination 518–19 red flags 515–16 scope of problem 515 special patients 528 shortness of breath in children 531–43 anatomic essentials 531 diagnostic testing 535–8 differential diagnosis 535–6 disposition 541–2 history 531–3 past medical history 532 pearls, pitfalls and myths 542–3 physical examination 533–5 red flags 531 scope of problem 531 special patients 541 treatment principles 539–41 shoulders anatomy of 333–4 extremity injuries 342–4 reduction of dislocations 733–5 sick sinus syndrome 61 sickle cell disease crying and irritability 250 shortness of breath in children 541 side flash 660 SIG-ME-CAPS mnemonic 154–61 sigmoidoscopy 412 signed-over patients signing out against medical advice 683 silver nitrate sticks 317 silver sulfadiazine cream 216–17 simple interrupted sutures 745, 752–3 Simplified Motor Score in trauma 715 Simplified Revised Geneva score for PE 714 sinoatrial (SA) node 55 sinoatrial block (sinus exit block) 61 sinus bradycardia 61–3 sinus headaches 421 sinus tachycardia 64 sinusitis 308, 382, 710 SIRS (systemic inflammatory response syndrome) 73, 77–84 sitting knee extension test (SKET) 453–4 sixth disease (roseola infantum) 475, 480 skeletal hyperostosis 454 Index 875 Index Sellick’s maneuver 29 Sengstaken-Blakemore tube 411–12 sensitivity, treating patients with 11, 16 sensory conflict theory 298 sentinel bleed 417–18 sepsis See severe sepsis and septic shock septal hematoma 315 septic abortion 468 septic arthritis 383, 399, 443, 445–6 septic embolus with bacterial endocarditis 616 septic miscarriage 583, 588, 593 septic shock See severe sepsis and septic shock septic thrombophlebitis 468 serial evaluation 14–15 serious bacterial infection (SBI) 395 seronegative spondyloarthropathies 443 serotonin syndrome 154 serum chemistries 814 serum sickness 181 severe acute respiratory syndrome (SARS), occupational exposure to 699, 703 severe sepsis and septic shock 718 anatomic essentials 73–4 APACHE-II 720 cardiovascular insufficiency and global tissue hypoxia 75 changes in oxygen content 80 clinical definitions 77–84 crying and irritability 249 diagnostic testing 77 differential diagnosis 78 disposition 83 early hemodynamic optimization 81 fever in adults 382 fever in children 402 general treatment principles 78–83 heat illness 649 history 74 Modified Early Warning Score (MEWS) 719 Mortality in adult ED patients with 718 pearls, pitfalls and myths 83 pediatric patients 84 physical examination 76–84 physiology of systemic oxygen transport and utilization 75 risk stratification 78 scope of problem 73 special patients 83–4 stages of 80–4 sexually transmitted infections (STIs) 821–3 overview 821 syphilis 823 shadow, defined 768 shaken baby syndrome 371, 635 sharps exposures 697 Shigella 283 shingles (herpes zoster) 478, 480 shivering 655 shock 87–94 classification of 89 diagnostic testing 88–9, 789 differential diagnosis 89 general approach to patient 87 general treatment principles 91 history 87 military anti-shock trousers (MAST) 120 Index SKET (sitting knee extension test) 453–4 skill-based cognitive performance 692 skin See also laceration repair abdominal pain 145 abnormal behavior 155–6 alcohol-related emergencies 165–7 allergic reactions and anaphylactic syndromes 178–9 altered mental status 190 anatomy of 475, 745 bleeding 200–1 burns 207 cardiac dysrhythmias 58 chest pain 223 crying and irritability 247, 249 diarrhea 281 fever in adults 381 fever in children 397 gastrointestinal bleeding 408 headaches 418 heat illness 648–9 lightning injuries 661 lower back pain 454 mucocutaneous exposures 697 rash 478–9 seizures 506 shortness of breath in adults 519 throat pain 325 toxicologic emergencies 566, 562 venomous bites and stings 668 vomiting 600 weakness 612 skin abscess 383 skin lesions 477–80, 656 skin ulcer defined 478–9 differential diagnosis 479–80 slapped-cheek rash 397–8 sleep apnea 319 slit lamp examination 733 contraindications 733 equipment 733 eye pain, redness and visual loss 364 indications 733 technique 733 SLR (straight leg raise) test 453 SLUDGE mnemonic 562 SMA (superior mesenteric artery) 791 Smith’s fracture 344 smoke inhalation See inhalation injuries snake bites 666, 668 See also terrestrial venomous bites and stings abdominal examination 668 antidote for 562 bite reflex of dead snake 669 classical syndromes 667 disposition 672 handling snakes 666 overview 665 skin examination 668 treatment of 671 venoms 666 vital signs 668 Snellen eye chart 361 “sniffing” position 29 snoring 21 876 Index SOAP ME mnemonic 26 sobriety, defined 173 social concerns, approach to patient sodium channel blockers antidotes for 562 toxicologic emergencies 562 sodium thiopental 39 soft tissue See compartments, fascial (soft tissue) somatic pain See parietal (somatic) pain somatostatin 411 specimen analysis 825–827 blood cultures 825 cerebrospinal fluid (CSF) 826 sputum testing 826 stool 826 synovial fluid 827 throat swabs 826 viral swabs 825 wound cultures 826 spermatic cord, anatomy of 492 spider bites 665 See also terrestrial venomous bites and stings abdominal examination 668 classical syndromes 667 disposition 671 identification of spider 666–7 overview 665 pulmonary examination 668 skin examination 668 treatment of 671 venoms 666 vital signs 668 spinal cord, anatomy of 449 spinal cord injuries 389, 450, 455, 457, 662 spinal cord injury without radiographic abnormality (SCIWORA) 113 spinal immobilization 119 spinal stenosis 449, 454–5 spiral fractures 353 spleen 771 splenorenal (lienorenal) ligament 771 splinting joint pain 445 teeth 265–6 spondylolisthesis 454 spondylolysis 454 spontaneous bacterial peritonitis 383 sprains (ligamentous injuries) 342 Sprotte needles 733 sputum testing 826 SSRIs (selective serotonin reuptake inhibitors) 154 SSSS (staphylococcal scalded skin syndrome) 213, 478 standard precautions 697–8 stand-up test 344 staphylococcal scalded skin syndrome (SSSS) 213, 478 Staphylococcus aureus 283 staples 754–5 status epilepticus (SE) 510 defined 503–4 heat illness 649 pediatric patients 511 steeple sign 328 STEMI (ST-segment elevation myocardial infarction) 119 sterile pyuria 822 sternoclavicular joint 343 risk scores thrombolytic therapy 622–3 ST-segment elevation myocardial infarction (STEMI) 119 stupor, defined 185 stye (hordeolum) 367, 370 subacute motor weakness 611 subarachnoid hemorrhage (SAH) 423–4 differential diagnosis 421 general treatment principles 424 headaches 415–17 history 418 Hunt and Hess clinical grading scale 425 hypertensive urgencies and emergencies 432 physical examination 418 pregnant patients 427 vomiting 602 weakness 616 subclavian vein cannulation 723–5 subcostal (subxiphoid) view echocardiography 786 FAST 769–70, 775–7 subdural hematoma general treatment principles 425 headaches 422 weakness 615 subluxation, dental 260–1, 265–7, 269 subxiphoid view See subcostal (subxiphoid) view succinylcholine (SCh) 26, 28, 36–7, 39, 624 sucking (open) chest wounds 98 sudden death, defined 675 Sugammadex 28 suicide abnormal behavior 155 abuse 638 burn patients 210 pediatric patients 160 toxicologic emergencies 560, 567–8 sulfa-containing agents acute otitis media 309 urinary-related complaints 578 sulfonamides 580 sulfonylureas 562 sumatriptan 135, 424, 425 superficial (first degree) burns 207 superficial keratitis 368, 370 superficial partial thickness (second degree) burns 207–8, 211 superficial peroneal nerve 340 superior mesenteric artery (SMA) 791 supine hypotension 113, 119 supracondylar fractures 344–5 suprapubic view See pelvis (suprapubic) view, FAST supraventricular tachycardia (SVT) 67, 69 surgical airways cricothyrotomy 34 transtracheal jet ventilation 34–5 sutures 751–2 corner 745, 754 corner suture 754 deep 745, 753 horizontal mattress 745, 753 removal of 756 simple interrupted 745, 752–3 staples 754–5 types and characteristics of 752 Index 877 Index steroids asthma 539–40 bronchiolitis 540 conditions that threaten vision 370 distributive shock 90 headaches 424, 426 laceration repair 747 lower back pain 457 pelvic pain 464 rash 487 throat pain 330 vision change or loss 371 Stevens-Johnson syndrome 213, 484 stim test 828 stimulant laxatives 241 stinging insects (hymenoptera) See also terrestrial venomous bites and stings classical syndromes 667 disposition 671 overview 665 pulmonary examination 668 venoms 666 vital signs 668 STIs (sexually transmitted infections) 821–823 overview 811, 821–823 syphilis 823 stomatitis crying and irritability 249 throat pain 326 stool diabetic ketoacidosis 272 diarrhea 814–15, 826 examinations 826 fever in adults 386 fever in children 400 gastrointestinal bleeding 405 shortness of breath in adults 517 stool ova and parasites diarrhea 282 fever in adults 386 fever in children 400 straddle injuries 633 straight leg raise (SLR) test 453 strains 342 Stratosphere sign 781 strength scale 613 streptokinase 233–4 stridor airway abnormalities and 21 defined 323–4, 534 stroke 551 aspirin 622 clinical syndromes 608 differential diagnosis 615 disposition 626 echocardiography 620 emergent antihypertensive therapies in 623 endovascular mechanical interventional therapies 623–4 heparins 622 hypertension 435, 621 magnetic resonance imaging 620–1 Modified Rankin scale 709 National Institutes of Health Stroke Scale (NIHSS) 614, 709 risk factors for 612 Index SvO2 (venous oxygen saturation) 820–1 SVT (supraventricular tachycardia) 67, 69 swallowing studies 621 swinging flashlight test 362 symmetric arthritis 439–40 sympathomimetics cardiac dysrhythmias 58 heat illness 648 toxidrome 562 syncope 545–56 associated symptoms 547 defined 545 diagnostic testing 551–5 differential diagnosis 549 disposition 555–6 drugs associated with 546 electrocardiography 552 general treatment principles 555 history 546–7 past medical history 547 pathophysiology 545 pearls, pitfalls and myths 556 pelvic pain 463–4 physical examination 547–9 red flags 545 rules to predict short-term serious outcomes 556 San Francisco Syncope Rule 717 scope of problem 545 shortness of breath in adults 517 special patients 555 symptoms similar to lightning injuries 662 vaginal bleeding 586 synovial fluid joint pain 437, 440, 444 knee arthrocentesis 740–1 overview 827 synovial membrane, anatomy of 437 syphilis 383, 478, 823 syringe aspiration device 31 syrup of ipecac 566 system-based error model 4, 693 systemic inflammatory response syndrome (SIRS) 73, 77–84 systemic mastocytosis 181 systolic ejection (flow) 224 T TA (transabdominal) pelvic ultrasound 797–8 tachy-brady syndrome 61 tachycardias See also cardiac dysrhythmias anatomic essentials 56 shortness of breath in adults 518 tachydysrhythmias 63 See also cardiac dysrhythmias accelerated idioventricular rhythm 70 atrial fibrillation 66–7 atrial fibrillation with pre-excitation 70 atrial flutter 67 atrioventricular nodal reentrant tachycardia 65–6 general management of 63 multifocal atrial tachycardia 67 non-paroxysmal junctional tachycardia 66 paroxysmal atrial tachycardia 64 sinus tachycardia 64 supraventricular tachycardia with aberrant conduction torsades de pointes 70 878 Index 69 ventricular tachycardia 67–9 tagged red blood cell imaging 412 talar tilt test 349 tar burns 217 tarsometatarsal joint 350–2 TB See tuberculosis TCAs See tricyclic antidepressants teaching hospitals, ethical issues in 677–8 informed consent 677 overview 677 pearls of wisdom 678 procedures on newly dead 678 research ethics and emergency exception to consent 677–8 teeth 303 See also dental pain airway management and lack of 25–6 anatomy of 255–6 designations of 256 ear pain 303, 307 examination of 258 figure of 256 teething 251 tegmental syndrome (central midbrain syndrome) 608 temperature See also vital signs altered mental status 194 dizziness and vertigo 292 fever in adults 379 shortness of breath in children 534 temporal (giant cell) arteritis 369, 371–2, 422, 425–6 temporomandibular joint (TMJ) 303, 307, 308 tendons extremity trauma 342 laceration repair 747 tenecteplase (TNKase) 233–4 tenesmus 239 tensilon test 621 tension headaches differential diagnosis 419 general treatment principles 424 pain of 415, 417 tension pneumothorax differential diagnosis 109 needle decompression 119 obstructive shock 90 traumatic injuries 97–9 terbutaline 539 terminal illness, defined 674 terrestrial venomous bites and stings 665–72 anatomic essentials 665–6 classical syndromes 667 crying and irritability 250 diagnostic testing 669–70 differential diagnosis 669 disposition 671–2 general treatment principles 670–1 history 667 past medical history 667–8 pearls, pitfalls and myths 672 physical examination 668–9 scope of problem 665 special patients 671 venoms 666 TESPAL (transnasal endoscopic sphenopalatine artery ligation) 319 testicular torsion 495 pearls, pitfalls and myths 331–2 physical examination 323 red flags 321 scope of problem 321 special patients 330–1 throat swabs 826 thrombectomy obstructive shock 90 pulmonary embolism 235 thrombin 318 thrombocytopenia gastrointestinal bleeding 408 lower back pain 451 thromboembolism atrial fibrillation 66 atrial flutter 67 fever in adults 384 thrombolysis acute coronary syndrome 233–4 acute ischemic stroke 622 aspirin 622 head computed tomography 620 indications and contraindications 233, 623 obstructive shock 90 pulmonary embolism 234–5, 528 thrombotic thrombocytopenic purpura (TTP) 202 thumbprint sign 328, 386 thumb-to-index-finger pain measurement 128–35 thyroid 828 thyroid cartilage, description of 20 thyroid disease 58 thyroid function tests (TFTs) cardiac dysrhythmias 59 constipation 240 ear pain 309 thyroid profile 650 thyroid storm 649 thyroid-stimulating hormone (TSH) 59 TIA See transient ischemic attack tibial nerve 340 tick paralysis general treatment principles 625 weakness 619 TIMI risk score 229, 710 tinea cruris 483 tinnitus 291 TIPS (transjugular intrahepatic portosystemic shunt) procedure 411 tissue adhesives 754–5 tissue plasminogen activator (t-PA) 233–4, 435, 622–3 TM See tympanic membrane TMJ (temporomandibular joint) 303, 307–8 TMP-SMX See trimethoprim-sulfamethoxazole (TMP-SMX) TNKase (tenecteplase) 233–4 tobacco use ear pain 304 pelvic pain 464 shortness of breath in adults 518 vaginal bleeding 586 Todd’s (postictal) paralysis seizures 506 weakness 616 tongue, as obstruction in oropharynx 19 tonometers 365 Index Index abdominal pain 146 associated symptoms 493–4 crying and irritability 249 defined 492 differential diagnosis 497–8 importance of identification 491 pain of 492–3 physical examination 494 ultrasonography 498 vomiting 602 tetanus burns 216 corneal abrasions 369 extremity trauma 337 fever in adults 382 laceration repair 746 traumatic injuries 108 venomous bites and stings 667 tetracaine 749 TFTs See thyroid function tests therapeutic hypothermia 50, 653 thermal cauterization dental hemorrhage 267 nosebleed 317 thermoneutral temperature, defined 653 thiamine alcoholic patients 171 altered mental status 193 hypoglycemia 276 toxicologic emergencies 565–6 thiazide diuretics 439 thiopental 27–8 third degree AV block (AV dissociation) 62–3 third degree (full thickness) burns 207–9, 211 Thompson test 349 thoracentesis 741–2 complications 742 contraindications 741 equipment 741 indications 741 technique 741–2 thoracic aortic dissection 789–90 thoracolumbar spine 350 thoracotomy 101 threatened miscarriage (threatened abortion) 583, 588, 593 3, 4-methylenedioxymethamphetamine (MDMA; ecstasy) 647 3-3-2 rule 25 throat (pharynx) anatomy of 321 See also HEENT (head, eye, ear, nose and throat) Modified Centor score 710 rapid sequence intubation 26 sinusitis probability criteria 710 Westley Croup score 710 throat cultures 328, 325 throat pain 321–32 anatomic essentials 321 associated symptoms 322–3 diagnostic testing 325–9 differential diagnosis 325–6 disposition 331 general treatment principles 329 history 321–2 past medical history 323 879 Index tonsillar lymphoid structures 19 tonsillectomy 330 tonsillitis 399 tooth pain (odontalgia) See dental pain torsades de pointes 46, 70 torts defined 688 intentional 689 unintentional 689 torus fractures 353 tourniquets 120 Townes view 263 toxic epidermal necrolysis 213, 484 toxic shock syndrome (TSS) fever in adults 382 rash 482 toxicologic emergencies 559–68 anatomic essentials 559 antidotes for 566 diagnostic testing 563–5 differential diagnosis 562–3 disposition 568 general treatment principles 565–7 history 559–61 hypothermic symptoms 656 pearls, pitfalls and myths 568 physical examination 561 red flags 559–60 scope of problem 559 skin decontamination 566 special patients 567–8 symptoms similar to lightning injuries 662 toxicology screening burns 213 chest pain 227 crying and irritability 252 heat illness 650 hypertensive urgencies and emergencies 433 overview 824 pelvic pain 469 seizures 507 toxicologic emergencies 565 toxidromes common 562 defined 562 t-PA (tissue plasminogen activator) 233–5, 622–3 trabecular meshwork 357 tracheostomies 541 traction splinting 119 traction-countertraction technique 734 tramadol 132 transabdominal (TA) pelvic ultrasound 797–8 transient ischemic attack (TIA) 551 ABCD2 score for 709 carotid duplex scanning 620 differential diagnosis 615 disposition 626 duration of episodes 291 echocardiography 620 general treatment principles 624 hypertension 621 magnetic resonance imaging 620–1 risk factors for 612 880 Index seizures 506 transjugular intrahepatic portosystemic shunt (TIPS) procedure 411 transnasal endoscopic sphenopalatine artery ligation (TESPAL) 319 transtracheal jet ventilation (TTJV) 34–6, 96 transurethral bladder (Foley) catheter 112 transverse fractures 352 transverse myelitis general treatment principles 625 magnetic resonance imaging 621 weakness 617 white blood cell count 620 transverse plane 768 traumatic aortic disruption 109 traumatic injuries 95–114, 715 See also laceration repair alcoholic patients 164, 171 associated symptoms 108 associated with burns 209–10 cervical spine 716 crying and irritability 247 dental 258–62, 264–7 diagnostic testing 108–12 differential diagnosis 108–9 disposition 114 dizziness and vertigo 291 ear pain 304 head 716 history 105–8 joint pain 443 laryngeal 327 lightning injuries 662 Ottawa Ankle Rule 717 Ottawa Foot Rule 717 past medical history 108 peaks of death 95 pearls, pitfalls and myths 114 Pittsburgh & Ottawa Knee Rules 716 primary survey 95–6, 98–101, 103 Revised Trauma score 715 scope of problem 95 scrotal pain 497 secondary survey 103–5 Simplified Motor Score in trauma 715 special patients 112–14 vaginal 585, 589 weakness 616 traumatic subarachnoid hemorrhage 153 travel diarrhea 280, 286 ear pain 304 fever in adults 389 fever in children 395 seizures 505 treadmill tests 10 trepopnea 517 triage mass casualty incidents 120 pain assessment 128 triamcinolone 487 trichomoniasis 471 tricyclic antidepressants (TCAs) antidotes 562 electrocardiography 563–4 U UA See urinalysis (UA) UGIB See gastrointestinal (GI) bleeding; upper gastrointestinal bleeding ulnar artery 345–6 ulnar nerve 340, 346 ultrasonography (US) 767–8 abdominal aortic aneurysm 148, 791–5 abdominal pain 147–9 alcoholic patients 170 appendicitis 148 bedside 10–11 echocardiography 782–91 E-FAST 779–81 embryology 590 equipment 767 FAST 769–78 fever in adults 386–7 hypertensive urgencies and emergencies 433 overview 767 pelvic 469–70, 797–807 peripheral venous cannulation 722 RUSH 795–6 scrotal pain 498 shock 88–90 terminology 767–8 throat pain 328 traumatic injuries 111 urinary-related complaints 577 vaginal bleeding 590–1 vomiting 604 unilateral motor weakness 611 unintentional torts, defined 689 UNLOAD ME mnemonic 527 unstable angina 227 differential diagnosis 226 upper gastrointestinal bleeding (UGIB) See also gastrointestinal (GI) bleeding defined 405 differential diagnosis 409 disposition 413 general treatment principles 411–12 pain of 406 pediatric patients 413 upper respiratory infection fever in adults 380 fever in children 399 shortness of breath in children 537 throat pain 323 uremia 616 ureter, anatomy of 571 ureteral colic abdominal pain 146 pain from 142 vomiting 603 ureterolithiasis 574 urethra anatomy of 571–2 traumatic injuries 105 urethritis 383 urinalysis (UA) 576, 821 abdominal pain 147 alcohol-related emergencies 170 bites and stings 669 chest pain 227 crying and irritability 251 drowning 643 fever in children 400 heat illness 650 hypertensive urgencies and emergencies 433 lower back pain 454–5 pelvic pain 466 scrotal pain 498 traumatic injuries 109 vaginal bleeding 589 vomiting 603 urinary alkalinization 567 Index 881 Index toxicologic emergencies 563 trigeminal neuralgia general treatment principles 426 headaches 422 trimethoprim-sulfamethoxazole (TMP-SMX) diarrhea 285 ear pain 310 urinary-related complaints 578 triquetral fractures 345–6 trismus 323 troponin cardiac dysrhythmias 59 vomiting 603 troponins 818 Trousseau sign 816 TSH (thyroid-stimulating hormone) 59 TSS See toxic shock syndrome TTJV (transtracheal jet ventilation) 34–6, 96 TTP (thrombotic thrombocytopenic purpura) 202 tubal ring, defined 801 tube thoracostomy (chest tube) 737 complications 739 contraindications 737 equipment 737–8 indications 737 technique 738 tuberculosis (TB) occupational exposure to 699, 702 risk scale 714 tubo-ovarian abscess 383, 471 tumor fever 384 tumor headaches 422, 426 tunica albuginea 491 tunica vaginalis, anatomy of 491–2 2:1 atrioventricular block 62 tympanic membrane (TM) ear pain 306 Frenzel maneuver 307 normal 306 otitis media with perforation of 309 pneumatic otoscopy 306–7 tympanic thermometers 379 tympanostomy tube 306 Type I second-degree AV block (Wenckebach phenomenon; Mobitz Type I block) 61–2 Type II second-degree AV block (Mobitz Type II block) 62 typhoid fever 649 Tzanck preparation 487 Index urinary tract infection (UTI) abdominal pain 147 abnormal behavior 159 crying and irritability 249 geriatric patients 580 male patients 580 overview 571 pediatric patients 575–6, 581, 579 pelvic pain 469 pregnant patients 581 treatment of 577–9 vaginal bleeding 589, 586 urinary-related complaints 571–82 anatomic essentials 571–2 anatomy 571 associated symptoms 574 diagnostic testing 575–7 differential diagnosis 575 disposition 581 general treatment principles 577–80 history 572–4 pearls, pitfalls and myths 581–2 physical examination 574–5 pregnant patients 578 red flags 572–7 scope of problem 571 special patients 580–1 urination alcohol-related emergencies 165 diabetic ketoacidosis 272 pelvic pain 463–4 scrotal pain 494 shortness of breath in children 532 urine culture fever in children 400 urinary-related complaints 576 urticaria 179 US See ultrasonography uterine fibroids 467–8 uterine perforation 468 uterus abnormal uterine bleeding 583, 586, 588, 592–4 vaginal bleeding 587 UTI See urinary tract infection uvulitis 327 V vaginal bleeding (VB) 583–94 anatomic essentials 583–4 associated symptoms 585–6 diagnostic testing 589–91 differential diagnosis 588–9 disposition 593–4 general treatment principles 591–3 history 584–6 menstrual cycle 584 past medical history 586 pearls, pitfalls and myths 594 physical examination 587 red flags 584–5 scope of problem 583 vaginitis 589 vaginosis 471 valcyclovir 488 882 Index valdecoxib 132 valgus stress test elbows 344 knees 349 vallecula, description of 20 valproate 510 valvular heart disease 57 vancomycin diarrhea 285 neutropenia and fever 389 scrotal pain 499 vancomycin-resistant Enterococcus (VRE) 389 varicella (chicken pox) occupational exposure to 699, 703 rash 480 varicella zoster immune globulin (VZIG) 703 varicoceles 495, 497 varus stress test 349 VAS (Visual Analog Scale) 128–35 vas deferens, anatomy of 492 vascular system See also cardiovascular system delayed blood flow 337 laceration repair 746–7 physical examination 342 vasculitis 497 vasoactive agents, See also names of specific vasoactive agents dose ranges of vasoactive agents in adults 92 medications and initial dose 92–4 receptor affinity and hemodynamic effects 92 shock 92–3 vasoconstrictive agents 317 vasomotor (vasovagal) syncope 506, 546, 551 vasopressin lower gastrointestinal bleeding 412 sepsis 80–1 shock 93 upper gastrointestinal bleeding 411 ventricular fibrillation and pulseless VT 46 vasopressors, See also names of specific vasopressors allergic reactions and anaphylactic syndromes 183 cardiogenic shock 90 sepsis 80–2 shock 92–3 vasovagal (vasomotor) syncope 506, 546, 551 VB See vaginal bleeding (VB) VBG (venous blood gases) analysis 819 VDRL (venereal disease research laboratory) 823 vecuronium 31, 39, 28 vehicular accidents See also traumatic injuries arrival on scene 117 history 106–7 seat belt sign 104 side impact 106 vena caval filters 234 venereal disease research laboratory (VDRL) 823 venomous bites and stings See terrestrial venomous bites and stings venous blood gases (VBG) analysis 819 venous oxygen saturation (SvO2) 820–1 ventilation See airway management ventilation/perfusion (V/Q) scans 525 ventral midbrain syndrome (Weber syndrome) 609 ventricular fibrillation (VF) See cardiopulmonary resuscitation (CPR) cardiac dysrhythmias 58 chest pain 223 in children by age 396 constipation 239 crying and irritability 247 dental pain 258 diarrhea 281 dizziness and vertigo 292 drowning 642–3 ear pain 304–5 extremity injuries 341 eye pain, redness and visual loss 360 fever in adults 379 fever in children 395 gastrointestinal bleeding 407–8 heat illness 648 hypertensive urgencies and emergencies 431 important joint pain 439 lightning injuries 661 lower back pain 452 normal body temperature 375 nosebleed 315 overview pelvic pain 464 rash 478 scrotal pain 494 seizures 505 shock 87–8 shortness of breath in adults 518 shortness of breath in children 533 syncope 548 throat pain 324 toxicologic emergencies 561 traumatic injuries 99–100 urinary-related complaints 574 vaginal bleeding 587 venomous bites and stings 668 vomiting 599 weakness 612 vitamin A toxicity 250 vitamin K 197–8, 413, 813 vitreous hemorrhage 369 vitreous humor 358 volume management See fluid (volume) management volvulus abdominal pain 146 crying and irritability 249 vomiting 603 vomiting 597–606 alcohol-related emergencies 165 antiemetic medications for 605 associated symptoms 246, 598–9 constipation 239 defined 597 diabetic ketoacidosis 272 diagnostic testing 603–4 differential diagnosis 600 disposition 604, 606 drowning 642 gastrointestinal bleeding 405, 407 general treatment principles 604 heat illness 647 history 598 Index Index ventricular repolarization 56 ventricular tachycardia (VT) 46, 67 See also cardiopulmonary resuscitation (CPR) venturi mask 91 vertebral artery dissection general treatment principles 426 headaches 422 vertebrobasilar insufficiency 291 vertigo See also dizziness and vertigo overview 289 patient description of 291 peripheral and central causes of 289 vomiting 598, 603 vesicles defined 477–8 differential diagnosis 479–80 vestibular neuritis duration of episodes 291 viral illness 291 vestibular suppressants 298 VF (ventricular fibrillation) See cardiopulmonary resuscitation (CPR) Vibrio cholerae 283 Vibrio parahemolyticus 283 Vibrio vulnificus 283 video laryngoscopy 34 Vincent’s angina 327 violation producing behaviors (VPBs) 692 violent crimes 117 violent patients 14 viral arthritis 443 viral conjunctivitis 368, 370 viral exanthems antibiotics 488 pediatric patients 488 respiratory symptoms 477 viral swabs 825 virtues, defined 673 visceral pain abdominal 139 chest 221 pelvic 461 vision See eye pain, redness and visual loss visual acuity 360–1 gross visual acuity testing 361 hypertensive urgencies and emergencies 430 near chart 361 ophthalmoscope 361 overview 360 pinhole testing 361 Snellen eye chart 361 Visual Analog Scale (VAS) 128–35 visual fields 363 visual hallucinations 165 visual pathway defects 363 vital signs abdominal pain 142–3 abnormal behavior 155 accidental hypothermia 655 alcohol-related emergencies 166 allergic reactions and anaphylactic syndromes 179 altered mental status 186 bleeding 201 burns 210 883 Index vomiting (cont.) nosebleed 314 past medical history 599 pathophysiology 597 pearls, pitfalls and myths 606 pelvic pain 463–4 physical examination 599 red flags 598 scope of problem 597 shortness of breath in adults 517 special patients 604–5 vaginal bleeding 585 weakness 611 von Willebrand’s disease 202 VPBs (violation producing behaviors) 692 V/Q (ventilation/perfusion) scans 525 VT (ventricular tachycardia) 46, 67 See also cardiopulmonary resuscitation (CPR) VVIR pacemakers 57 VZIG (varicella zoster immune globulin) 703 W Wallenburg syndrome (lateral medullary syndrome) 608 warfarin 813 bleeding 198, 204 extremity injuries 340 interactions 12 lower back pain 451 vaginal bleeding 586 water rescue, defined 641 Watson’s test 345 WBC count See white blood cell count WBI (whole bowel irrigation) 567 weakness 607–26 anatomic essentials 607–9 associated symptoms 611–12 diagnostic testing 619–20 differential diagnosis 615, 617 disposition 625–6 general treatment principles 621–5 heat illness 647 history 609–11 past medical history 612 pearls, pitfalls and myths 626 physical examination 612–13 red flags 610 scope of problem 607 special patients 625 weapons brought to ED 14 gunshot wounds 103, 107 See also traumatic injuries Weber syndrome (ventral midbrain syndrome) 609 Weber test 307 weight loss constipation 238–9 shortness of breath in adults 517 884 Index vaginal bleeding 586 Wells Score for PE 713 Wells Simplified Clinical Model for Assessment of DVT 714 Wenckebach phenomenon (Type I second-degree AV block) 61 Wernicke’s encephalopathy alcoholic patients 164, 171 altered mental status 193 Westermark sign 230 Westley Croup score 710 wheals (hives) defined 477–8 differential diagnosis 479–80 wheezing, defined 535 Whitacre needles 733 white blood cell (WBC) count abdominal pain 147 fever in adults 384 fever in children 401 joint pain 441, 444 pelvic pain 469 scrotal pain 498 seizures 507 shortness of breath in adults 524 throat pain 325 transverse myelitis 620 urinary-related complaints 576 whole bowel irrigation (WBI) 567 wide-complex tachydysrhythmias 64 withdrawal, alcohol 171–3 Wolff-Parkinson-White syndrome 551–2 Woodruff’s plexus 313 Wood’s lamp 487 wound care cultures 826 emergency medical services systems 120 irrigation and cleaning 751 laceration repair 755–6 preparation 748–51 wound taping (butterfly closure) 755 Wright Stain (fecal leukocytes) 282 wrists anatomy of 333, 335 extremity trauma 344–6 X xanthochromia 424 X-rays See radiography xylocaine 329 Y Yersinia enterocolitica yolk sac 591, 799 Z ziprasidone 159 ~StormRG~ 283 ... Permanente, San Francisco San Francisco, CA Michelle Lin, MD Associate Professor of Emergency Medicine University of California, San Francisco San Francisco General Hospital and Trauma Center San... medicine – Handbooks, manuals, etc Emergency medicine – Diagnosis I Mahadevan, Swaminatha V II Garmel, Gus M III Title: Clinical emergency medicine [DNLM: Emergency Treatment – methods Emergency Medicine. .. An Introduction to Clinical Emergency Medicine Second edition An Introduction to Clinical Emergency Medicine Second edition Edited by S.V Mahadevan, MD Associate Chief, Division of Emergency
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