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Diabetes mellitus and hypoglycaemia: an overview

Essentials 1 Type I diabetes is characterized by pancreatic beta cell destruction with an absolute insulin deficiency, usually but not exclusively associated with autoimmune damage. 2 Type II diabetes results from a progressive insulin secretory deficiency on the background of insulin resistance. 3 Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) are both life-threatening acute complications of diabetes mellitus. 4 The aim of excellent long-term blood…

Renal colic

Essentials 1 The lifetime risk of developing kidney stones is 1 in 10 for men and 1 in 35 for women. 2 Approximately 75% of all stones are calcium based. 3 Management usually comprises adequate analgesia and hydration. 4 Computed tomography or intravenous pyelography establishes the diagnosis and evaluates the possibility of obstruction. 5 Most stones (90%) are passed spontaneously within 1 month. 6 Obstruction, infection…

The acute scrotum

Essentials 1 Torsion is the most time-critical diagnosis in acute scrotal pain. 2 Early surgery is mandatory if the diagnosis is strongly suspected. No investigation should delay surgery. 3 Colour Doppler ultrasound is helpful and is best used when testicular ischaemia must be excluded in an inflammatory mass or in an older patient. 4 Torsion of an appendage can be diagnosed clinically by finding a small…

Tropical infectious diseases

Essentials 1 Tropical diseases are a major cause of morbidity and mortality worldwide. 2 Due to climate change and increasing population mobility (migration and travel), health practitioners in non-tropical areas will increasingly have to diagnose and treat tropical diseases. 3 A significant proportion of northern Australia has a tropical climate and several tropical diseases occur in this area. Vigilant public health surveillance, case tracking and vector…

Needlestick injuries and related blood and body fluid exposures

Essentials 1 Avoiding blood and other body fluid exposure remains the primary means of preventing occupationally acquired blood-borne virus infections. 2 The risks of acquiring infection after occupational exposure to blood-borne viruses are human immunodeficiency virus (HIV) 0.3%, hepatitis B virus (HBV) 12% to 30%, hepatitis C virus (HCV) 1.8%. 3 HBV immunization is an integral part of workplace safety. 4 Effective post-exposure prophylaxis (PEP) is…

Antibiotics in the emergency department

Essentials 1 Patients with infections and infectious diseases commonly present to emergency departments. 2 There are also changing patterns of infectious disease, largely due to immunosuppression from chemotherapy, continuing development of bacterial resistance, HIV-associated infections and new and emerging infections. 3 Many bacteria are becoming increasingly resistant to available antimicrobials, with some resistant to multiple agents including many community-acquired infections. 4 The growing world trade in…

Sexually transmitted infections

Essentials 1 Sexually transmitted infections (STIs) are among the commonest infections worldwide and account for a significant number of emergency department (ED) visits per year. ED staff should be competent to screen, diagnose and treat STIs and to notify and improve future sexual health through advice and referral. 2 Emergency physicians should aim to provide effective, confidential, non-judgemental and culturally appropriate care. The sexual history, where…

Human immunodeficiency virus and acquired immune deficiency syndrome

Essentials 1 Patients with previously undiagnosed human immunodeficiency virus (HIV) infection may present to the emergency department at any time during the course of infection, from early (seroconversion) to late acquired immune deficiency syndrome ([AIDS]-defining illness) stages. 2 Patients with previously diagnosed HIV infection may present with complications of anti-retroviral therapy or, if therapy has failed or is not taken, with a range of HIV-related clinical…

Hepatitis

Essentials 1 Acute and chronic viral hepatitis is of global public health importance. 2 Definitive diagnosis may be delayed in the emergency setting. 3 Supportive care is fundamental in the acute management of hepatitis. 4 Prevention of viral hepatitis is possible via the introduction of public health programmes that include appropriate education regarding high-risk practices. Introduction Hepatitis is a non-specific clinicopathological term that encompasses all disorders…

Skin and soft-tissue infections

Essentials 1 The time-honoured principles of soft tissue infection management and judicious evidence-based use of antibiotics remain the basis of treatment and the prevention of further complications. 2 These infections are common and range from mild to rapidly progressive and life threatening; early clinical recognition and treatment are paramount in reducing morbidity and mortality. 3 Deep soft tissue infections have high morbidity and mortality and, unless…

Urinary tract infections

Essentials 1 Urinary tract infection (UTI) is the most common bacterial infection. 2 By age 32, 50% of women will report at least one UTI. 3 Sexual activity is the most important risk factor in young women. 4 Most UTIs are caused by Escherichia coli , but Staphylococcus saprophyticus is responsible for up to 15% of infections in young, sexually active women. 5 There is a…

Septic arthritis

Essentials 1 Early diagnosis and treatment are critical for the prevention of irreversible joint destruction. 2 Diagnosis is based on clinical features and synovial fluid examination; imaging techniques have a role in difficult cases. 3 Staphylococcus aureus, Streptococcus and Neisseria gonorrhoeae are the most frequent pathogens in adults and older children. Methicillin-resistant staphylococcus aureus (MRSA) is an emerging problem, particularly among intravenous drug users. Fungal, mixed…

Meningitis

Essentials 1 Bacterial meningitis can be a rapidly progressive and fatal illness. A high level of suspicion is necessary, as well as rapid diagnosis and treatment. 2 Eighty-five percent of cases have headache, fever, meningism and mental obtundation, but these are often absent or diminished in very young or old patients, those partially treated with oral antibiotics and those with some form of immunocompromise. 3 Treatment…

Approach to undifferentiated fever in adults

Essentials 1 Over one-third of patients who have fever for more than 2 to 3 days with no localizing symptoms and signs are likely to have a bacterial infection; half of these will be in the respiratory or urinary tracts. 2 An unexplained fever in a person over the age of 50 should be regarded as due to a bacterial infection until proved otherwise. 3 An…

Weakness

Essentials 1 The differential diagnosis of weakness in the emergency department (ED) is very broad. Careful history taking and examination with targeted investigations will help to identify most of the important causes. 2 Causes of weakness must be distinguished as neuromuscular or non-neuromuscular. 3 Most patients presenting to the ED with a complaint of weakness have a non-neuromuscular cause for their symptoms. 4 Guillain-Barré syndrome is…

Syncope and vertigo

Essentials 1 It is important to distinguish between syncope and true vertigo. 2 The most common cause of syncope is neurally mediated syncope. 3 A detailed history and physical examination are more useful than extensive investigations. 4 It is essential to identify high-risk patients for the serious potential cardiac causes of syncope so that appropriate treatment can be given. 5 A key diagnostic step is to…

Seizures

Essentials 1 Approximately 9% of the population will have at least one seizure in their lifetimes but only 1% to 3% will develop epilepsy. 2 The management of an acute episode is directed at rapid control of seizures, identification of precipitating factors and prevention/correction of complications. 3 Benzodiazepines and phenytoin are the principal anticonvulsant agents for acute seizures. 4 Management of drug-related seizures (including those related…

Altered conscious state

Essentials 1 For clinical purposes, the ability of the individual to respond appropriately to environmental stimuli provides a quantifiable definition of consciousness. 2 The causes of altered conscious state can be divided pathophysiologically into structural and metabolic insults. 3 A thorough history and examination is the key to guiding investigation choice and identifying the cause of the primary insult. Management is directed towards resuscitation, specific correction…

Subarachnoid haemorrhage

Essentials 1 The diagnosis of subarachnoid haemorrhage (SAH) requires a high index of suspicion. 2 Up to a third of patients with SAH experience a warning leak—the sentinel haemorrhage—in the hours to days prior to the major bleed. 3 Risk of re-bleeding is maximal in first 2 to 12 hours and is associated with a poor prognosis and high mortality. 4 Severe sudden headache is the…