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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…

Death and dying

Essentials 1 Death and management of the dying process is core business for emergency medicine. 2 Death in the emergency department can be either sudden and unexpected or the natural and expected evolution of a disease process. 3 Emergency physicians have a responsibility to understand the principles of a ‘good death’ and to manage departmental deaths in alignment with these principles. 4 Communication skills for discussing…

Pharmacological management of the aroused patient

Essentials 1 Benzodiazepines and antipsychotics, often used most effectively in combination, are the first-line drugs for sedation of the aroused patient. 2 As much information as possible should be collected before the patient is sedated. 3 The risks involved in administering sedative drugs need to be considered, particularly at higher doses. 4 Dose adjustments are necessary in the older or medically compromised patient. Acknowledgements The chapter…

Psychosis

Essentials 1 In the age of community mental health treatment, emergency departments have become major sites for the assessment of patients with psychosis. 2 An important responsibility of the emergency department clinician is to exclude delirium and ‘organic’ causes of psychotic symptoms, including intoxication with illicit substances. 3 Key risks associated with acute psychosis include self-harm/suicide, aggression, misadventure and homelessness. Disposition decisions, including community referral or…

Deliberate self-harm/suicide

Essentials 1 Deliberate self-harm is a frequent presentation to emergency departments and is a symptom of diverse underlying problems, be they biological, social or psychological. 2 Patients with deliberate self-harm form a heterogeneous group, most of whom do not have ongoing suicidal behaviour. 3 Assessment of suicide risk following deliberate self-harm is to inform treatment and to identify risks amenable to intervention and protective factors. It…

Distinguishing medical from psychiatric causes of mental disorder presentations

Essentials 1 Morbidity and health costs are reduced by distinction of medical from psychiatric causes of mental disorder presentations to emergency departments. 2 Always ask if any medical condition exists in addition to the psychiatric complaints. This will identify most medical causes of mental disorder. 3 Missed medical diagnosis is most commonly associated with failure to undertake an adequate medical history, mental state examination and physical…

Mental state assessment

Essentials 1 The number of patients presenting to the emergency department (ED) with mental health problems is increasing. 2 Regardless of diagnosis and presentation, an initial assessment must be performed within the first few minutes of an individual’s arrival in the ED, taking into account the risk of Suicide and self-harm Violence or other forms of assault Absconding 3 The role of organic illness presenting as…

Emergency delivery and complications

Essentials 1 Perform a rapid assessment of any pregnant patient arriving in labour at the emergency department to decide the most appropriate site for management. 2 Emergency department staff must be prepared to provide newborn resuscitation following an emergency delivery. Preparedness for newborn resuscitation requires preparation of a suitable area with ability to provide radiant heat, special equipment and trained dedicated personnel as well as a…

Pre-eclampsia and eclampsia

Essentials 1 Pre-eclampsia is hypertension with organ-system dysfunction unique to the second half of pregnancy. 2 Maternal and foetal demise are inevitable and can only be stopped by pregnancy termination. 3 Early diagnosis is crucial as the rate of deterioration is unpredictable. 4 Eclampsia is a seizure complicating pre-eclampsia and leads to high maternal and foetal morbidity and mortality. Introduction Pre-eclampsia is a hypertensive disorder unique…

Bleeding after the first trimester of pregnancy

Essentials 1 Up to 5% of pregnant women will have significant bleeding after 20 weeks’ gestation. 2 Resuscitation of the mother followed by ultrasound localization of the placenta are the priorities of management for patients with heavy vaginal bleeding after 20 weeks’ gestation. 3 Secondary postpartum haemorrhage is commonly caused by endometritis or retained products of conception. Introduction Pregnancy is measured in trimesters from the first…

Ectopic pregnancy and bleeding in early pregnancy

Essentials 1 Approximately 25% of all clinically diagnosed pregnancies are associated with bleeding in the first 12 weeks, of which approximately 50% of cases will be due to a failed pregnancy. 2 Ectopic pregnancy occurs at a rate of around 11:1000 diagnosed pregnancies. 3 The management of ectopic pregnancy and failed pregnancy may be surgical, medical or conservative. Introduction Bleeding in early pregnancy is a common…

Abnormal vaginal bleeding in the non-pregnant patient

Essentials 1 Start the assessment of any patient with vaginal bleeding by excluding pregnancy. 2 Locate the anatomical site of bleeding and assess the severity looking for signs of hypovolemia and shock. 3 Familiarize yourself with the PALM-COEIN classification system. 4 Consider coagulopathy as a cause of heavy uterine bleeding in all patients, especially adolescents. Introduction Vaginal bleeding is often divided into two major categories: bleeding…

Pelvic inflammatory disease

Essentials 1 Pelvic inflammatory disease (PID) is infection and/or inflammation of the upper genital tract. 2 The clinical features cover a spectrum of presentations that depend on the extent of infection and/or inflammation, the anatomical structures involved and the specific micro-organisms. 3 Chlamydia trachomatis is the most common pathogen identified in sexually transmitted PID. Other pathogens include Neisseria gonorrhoeae and mixed anaerobes. 4 The sequelae of…

Pelvic pain

Essentials 1 History, abdominal and age-appropriate pelvic examination guide diagnosis. 2 History and examination can be supplemented, but not replaced, with appropriate investigations. 3 A normal pelvic examination should not preclude gynaecological referral, even in the absence of other findings. 4 The possibility of pregnancy must be considered in all patients of reproductive age with abdominal or pelvic pain under the following well-iterated tenets: All female…

Ear, nose and throat emergencies

Essentials 1 Make sure that the ear-nose-throat (ENT) supplies in your emergency department are well stocked and maintained. 2 Develop agreed pathways/protocols with your local ENT department for common and serious presentations. 3 A foreign body in the ear requires atraumatic removal with appropriate equipment and a cooperative patient. Refer to ENT if you anticipate difficulty. 4 Exclude a perilymphatic fistula in blunt and penetrating ear…