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Approach to the poisoned patient

Essentials 1 Self-poisoning is a manifestation of an underlying psychiatric, drug and alcohol, or social disorder. 2 A wide range of clinical manifestations of toxicity may be observed following drug overdose. 3 An accurate risk assessment predicts the likely clinical course and informs planning for subsequent investigation, management and disposition. 4 The mainstay of management is timely institution of an appropriate level of supportive care. 5…

Altitude illness

Essentials 1 The high-altitude syndromes—acute mountain sickness (AMS), high-altitude cerebral oedema (HACE) and high-altitude pulmonary oedema (HAPE)—are all clinical diagnoses, where management may need to be undertaken without access to diagnostic testing. 2 AMS and HACE represent stages along a continuum owing to cerebral vasodilatation and cerebral oedema, while in HAPE the oedema manifests in the lungs. 3 Descent is the single best treatment for AMS,…

Electric shock and lightning injury

Essentials 1 Death from electric shock is due to ventricular fibrillation, the lethal arrhythmia occurring at the time of the exposure. Routine admission for ECG monitoring is unnecessary. 2 Most deaths are caused by low-voltage (<1000 V) exposures. 3 The amount of current passing through the body is determined mainly by tissue resistance, which is dramatically reduced by moisture. 4 Electrical injury resembles a crush injury…

Drowning

Essentials 1 The incidence of non-fatal drownings requiring medical assessment to fatal drownings is around 2 to 20 times greater than fatal drowning. 2 The highest rates of drowning occur in children from 1 to 4 years of age and young adult males. In adults that die, many are intoxicated. 3 A total of 10% to 20% of fatal drownings have minimal aspiration with asphyxia probably…

Radiation incidents

Essentials 1 Radiation accidents are rare but require well-planned protocols for successful management. The principal challenge will be managing large numbers of people who have concerns about their exposure to radiation, or contamination with radioactive material as a result of an incident. 2 The management of life-threatening illness or injury always takes precedence over the radiation aspects of the patient’s condition. 3 Removing the patient’s clothing…

Dysbarism

Essentials 1 Dysbarism is the term given to medical complications of exposure to gases at higher than normal atmospheric pressure. It includes barotrauma and decompression illness. 2 An understanding of the pathophysiology of dysbarism requires an understanding of the gas laws. 3 Barotrauma occurs as a consequence of excessive expansion or contraction of gas within enclosed body cavities. It principally affects the middle ear, the sinuses…

Hypothermia

Essentials 1 Hypothermia is categorized into mild (32°C to 35°C), moderate (29°C to 32°C) and severe (<29°C) on the basis of a rectal or other core temperature reading. 2 Moderate-to-severe hypothermia produces progressive delirium and coma, hypotension, bradycardia and failure of thermogenesis. 3 The electrocardiograph will often show slow atrial fibrillation and an extra positive deflection in the QRS (the J or Osborn wave) in leads…

Heat-related illness

Essentials 1 Exercise-associated collapse is the most common heat- and exercise-related illness. It is due to an impaired compensation for the drop in blood pressure that occurs when muscle pumping ceases and venous return drops at the cessation of exercise. It responds rapidly to supine posture followed by rest and oral fluids. No other medical interventions are usually required. 2 Heatstroke is a true medical emergency,…

Magnetic resonance imaging in emergency medicine

Essentials 1 Magnetic resonance imaging (MRI) is becoming more readily available in Australian hospitals and is becoming part of many imaging diagnostic algorithms. 2 The most common indication for MRI in the emergency department (ED) is suspected acute spinal cord pathology. 3 MRI is well suited to imaging soft tissues, particularly the central nervous system, musculoskeletal tissues and abdominal organs. 4 Lack of ionizing radiation makes…

Computed tomography scanning in emergency medicine

Essentials 1 Computed tomography (CT) scans are a major diagnostic modality in emergency medicine. 2 Emergency physicians are ordering CTs more frequently than previously for a variety of reasons. 3 Artefacts are occasionally encountered in CT scans, and clinicians should be familiar with these artefacts. 4 Contrast media reactions and carcinogenic effects of radiation are recognized potential adverse effects of CT scanning. Introduction Computed tomography (CT)…

Emergency department ultrasound

Essentials 1 Ultrasound examination, interpretation and clinical correlation should be available in a timely manner 24 hours a day for emergency department patients. 2 Emergency physicians providing emergency ultrasound services should possess appropriate training and hands-on experience to perform and interpret limited bedside ultrasound imaging. 3 Ultrasound imaging by emergency physicians is useful for at least the following indications: major trauma, undifferentiated shock, respiratory distress, pain…

Emergency department procedural sedation

Essentials Emergency physicians and nurses should all be trained to provide effective procedural sedation in the emergency department (ED). Plan and prepare yourself, and assess the risk-benefit of each individual procedure. Assess the timing and nature of recent oral intake, medications, available staff to assist, other simultaneous activity in the ED and patient comorbidities. Determine the safe limit of targeted depth and duration of the sedation.…

Local anaesthesia

Essentials 1 Local anaesthetic infiltration and nerve blocks may be used as a supplement to oral, inhaled or parenteral analgesia. 2 Also, they may be the primary method of achieving analgesia, particularly where pain is localized to a digit or within a peripheral nerve distribution region. 3 Local anaesthetic toxicity may occur with inadvertent bolus intravenous injection or by exceeding the recommended maximum safe dose. Neurological…

General pain management

Essentials 1 Acute pain is the most common symptom in the emergency setting. 2 Pain is a complex, multidimensional, subjective phenomenon. 3 Effective pain management involves both accurate assessment and timely treatment. 4 Patient self-reporting is the most reliable indicator of the presence and intensity of pain. 5 Both pharmacological and non-pharmacological techniques should be employed for the treatment of acute pain. Effective pain relief should…

Organ and tissue donation

Essentials 1 Organ donation should be considered for all patients where death is expected. Suitability for donation should be discussed with an organ donation specialist. 2 A substantial numbers of missed potential organ and tissue donors can be identified in emergency departments (EDs) and intensive care units (ICUs). 3 Clinical triggers have been introduced in Australian EDs to assist with the early identification of potential donors.…

End-of-life decision making and palliative care

Essentials 1 An emergency department attendance represents an opportunity to set goals for care during the attendance and beyond. 2 End-of-life discussions and advance care planning assist early decision making about treatment goals and end-of-life care. 3 Knowledge of the law assists decision making at the end of life. 4 Not all dying patients require the skill set of a palliative care specialist, but every dying…

The challenging patient

Essentials 1 Many patients characterized as ‘challenging’ share common characteristics, including complex and chronic medical disease, mental illness, marginalization, poverty, high levels of drug and alcohol use and lack of social supports, safety and security. 2 An understanding of the issues that contribute to the challenging nature of some patients may help the practitioner to develop a management approach characterized by sound knowledge, clear and achievable…

Alcohol-related illness

Essentials 1 Acute alcohol intoxication and withdrawal are responsible for many emergency department attendances and carry significant morbidity and mortality. 2 Chronic gastrointestinal and hepatic disease, mental illness, central nervous system disease and immunosuppression are common in alcohol-dependent persons, with complications that increase the morbidity and mortality further. 3 Wernicke encephalopathy is an uncommon but serious illness related to vitamin B1 deficiency. Treatment requires high-dose parenteral…

Family violence

Essentials 1 Family violence encompasses physical, sexual, financial and psychological abuse. 2 All forms of family violence are inter-related in a complex way. Victims of violence may suffer many forms of abuse over their lives. 3 Between 30% and 50% of women and approximately 15% of men experience family violence over their lifetimes. 4 Family violence occurs across all socioeconomic, religious and cultural groups. 5 There…

Sexual assault

Essentials 1 Sexual assault is defined as an act of a sexual nature carried out against a person’s will. 2 There is widespread under-reporting of this criminal offence. 3 The complex medical, legal and psychological sequelae mandate a team-based approach for victims involving doctors, police and counsellors in a collaborative effort. 4 Management by a sympathetic non-judgemental physician can help the victim to regain control. 5…