Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Monoarthritis

Essentials 1 Presenting features alone, including absence of fever, do not reliably exclude a septic arthritis, especially in older people and those who are immunosuppressed. 2 Synovial aspirate in appropriate pathology transport media should be performed prior to commencing antibiotics when septic arthritis is being considered. 3 Acute monoarthritis affecting a prosthetic joint or the hip should not be aspirated in the emergency department. It requires…

Rheumatological emergencies

Essentials 1 Rheumatological emergencies relate to the disease, extra-articular manifestations of the disease or toxicity from treatment. 2 Infection must be considered and promptly treated in patients on antirheumatic and immunosuppressive medication, including those on biological therapies. Introduction Rheumatological conditions are common and encompass (1) inflammatory diseases, such as rheumatoid arthritis (RA); (2) connective tissue diseases, such as systemic lupus erythematosus (SLE); and (3) mechanical/musculoskeletal conditions.…

Blood and blood products

Essentials 1 The decision to transfuse packed red cells should ultimately be based on the knowledge that the patient’s oxygen carrying capacity has dropped to an unacceptably low level. 2 The administration of blood products carries substantial risk. The emergency physician should always ensure that potential benefits outweigh potential risks and communicate these risks and benefits in order to obtain informed consent where possible. 3 Rigorous…

Haemophilia

Essentials 1 Haemophilia is a disorder that should be managed by the emergency physician in consultation with the nearest haemophilia centre. 2 Patients should carry their treatment regimen cards with them. If they do not, they should be encouraged to do so. Introduction Haemophilia is a group of congenital disorders of blood coagulation that arise as a result of a deficiency of clotting factor proteins, which…

Thrombocytopaenia

Essentials 1 A low platelet count detected on automated blood count should always be confirmed by examination of the blood film prior to further investigation or treatment. 2 The cause of isolated thrombocytopaenia can often be determined by a careful history and physical examination in addition to assessment of the full blood count (FBC) and blood film. 3 Platelet transfusion is unnecessary in the management of…

Neutropaenia

Essentials 1 The risk of infection increases significantly as the absolute neutrophil count drops below 1.0 × 10 9 2 Life-threatening neutropaenia is most likely due to impaired haematopoiesis. 3 A detailed medication history is vital to the ‘workup’ of neutropaenia. 4 Fever in the presence of severe neutropaenia constitutes a true emergency that mandates rapid assessment and aggressive management to prevent progression to overwhelming…

Anaemia

Essentials 1 Anaemia is a condition in which the absolute number of red cells in the circulation is abnormally low. 2 Anaemia is not a diagnosis: it is a finding, which should prompt a search for an underlying cause. 3 The anaemic patient is doing at least one of three things: not producing enough red cells, destroying them too quickly or bleeding. 4 Bleeding is the…

Electrolyte disturbances

Essentials 1 Sodium disorders are relatively common in hospitalized patients and elderly people. 2 The brain is most at risk from acute hyponatraemia because the osmotically expanded intracellular volume may induce increased intracranial pressure (hyponatraemic encephalopathy). 3 Treatment of hyponatraemia needs to be carefully individualized because of the risk of osmotic myelinolysis. 4 Hypernatraemia has a high in-hospital mortality rate, which often reflects severe associated medical…

Acid–base disorders

Essentials 1 Acid–base homeostasis is one of the most tightly regulated systems within the body. It is maintained by buffering, respiratory and renal mechanisms. 2 Most acid–base disturbances are complex and require a systematic approach to determine underlying processes. 3 High-anion-gap metabolic acidosis and respiratory acidosis are both common in emergency medicine and should direct the clinician to determine and treat the aetiology. 4 Administration of…

Thyroid and adrenal emergencies

Essentials 1 The thyroid and adrenal emergencies that pose an acute threat to life are thyroid storm, myxoedema coma and acute adrenal insufficiency. Diagnosis of these conditions requires a high index of suspicion and treatment frequently must be initiated on clinical rather than laboratory diagnosis. 2 Common features of thyroid storm are fever, alteration in mental state, cardiovascular complications, such as tachyarrhythmias and cardiac failure, and…

Diabetic ketoacidosis and hyperosmolar, hyperglycaemic state

Essentials 1 Diabetic ketoacidosis (DKA) consists of the triad of ketonaemia, hyperglycaemia and acidaemia—a high anion-gap metabolic acidosis. 2 DKA is caused by insulin omission or error, intercurrent illness (including infection) or is a presenting feature of new diabetes. 3 Key management components of DKA include: fluids (0.9% normal saline) to replace deficits of sodium of 7 to 10 mmol/kg and water 100 mL/kg soluble insulin…

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…