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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…

Dental emergencies

Essentials 1 An avulsed tooth reimplanted within 30 minutes has a 90% chance of survival. 2 Dental caries is the most common cause of dental emergency attendance. 3 Dental caries requires analgesia in the emergency department and referral to a dentist for definitive care. Antibiotics are not required unless the caries is complicated by abscess. Anatomy The tooth consists of the crown, which is exposed, and…

Ocular emergencies

Essentials 1 Always test and record visual acuity: use pinhole if usual spectacles are not available. 2 Chloramphenicol eyedrops are not a universal panacea. 3 Pain: sharp/scratchy = anterior (cornea or conjunctiva); aching = intraocular (intraocular pressure or inflammation) Trauma 1 Computed tomography scan/x-ray where bony or globe penetration injury is suspected. 2 Remove prolapsed ocular tissue or protruding foreign bodies only in an operating theatre…

Emergency dermatology

Essentials 1 Emergency dermatology presentations may be divided into potentially life-threatening dermatoses, vesiculo-bullous conditions, petechial and purpuric rashes, and inflammatory dermatoses such as eczema, urticaria and psoriasis. 2 Potentially life-threatening presentations include Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN), Sweet syndrome, drug rash with eosinophilia and systemic symptoms (DRESS) and erythroderma. 3 Petechial or purpuric rashes may represent cutaneous or systemic vasculitis, or coagulopathy; investigations are targeted…

Musculoskeletal and soft-tissue emergencies

Essentials 1 The mechanism of injury and biomechanics predict the soft-tissue damage caused. 2 Soft-tissue injuries can be as debilitating and painful as fractures in the same area, and may take longer to heal. 3 The so-called ‘minor injury’ can be associated with significant and prolonged morbidity that could be permanent if managed incorrectly. Adopting a careful, consistent approach that considers potential pitfalls is important to…

Polyarthritis

Essentials 1 Polyarthritis is a common adult rheumatological presentation with a wide differential diagnosis. 2 Recording articular and extra-articular involvement facilitates decision making, particularly with regards to patient admission. 3 Joint aspiration is paramount for both diagnosis and excluding a septic arthritis. 4 Early rheumatological consultation is essential to ensure appropriate and timely diagnosis and treatment for inflammatory arthritis to prevent joint damage and maintain joint…