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Pericarditis, cardiac tamponade and myocarditis

Pericarditis Essentials 1 Myocarditis is often associated with pericarditis. This has important clinical implications. 2 Pericarditis is diagnosed based on history and findings on both electrocardiography (ECG), and echocardiography. The diagnosis is based on two of the four criteria outlined in Table 5.6.1 . Table 5.6.1 European Society of Cardiology definition of and diagnostic criteria for pericarditis (2015) Pericarditis Definition and diagnostic criteria Acute Inflammatory pericardial…

Pulmonary embolism

Essentials 1 Venous thromboembolism (VTE) has protean clinical manifestations and is a continuum from deep venous thrombosis (DVT) to the main life-threatening complication of pulmonary embolism (PE). 2 Left untreated, patients with a diagnosis of PE have a significant recurrence rate and mortality; this can be considerably reduced with anticoagulation. 3 Diagnostic and treatment decisions rely on good risk stratification, preferably using validated scores such as…

Arrhythmias

Essentials 1 Cardiac arrhythmias require urgent attention, as some are life-threatening and can lead to sudden death. 2 The most important initial evaluation is for haemodynamic stability. Patients who are hemodynamically stable should have a 12-lead electrocardiogram (ECG), whereas unstable patients require immediate intervention. 3 Bradyarrhythmias should always be evaluated in the light of the patient’s presenting symptoms as well as the ECG abnormality. 4 Patients…

Assessment and management of acute pulmonary oedema

Essentials 1 Severe acute pulmonary oedema (APO) is associated with high morbidity and mortality. 2 APO is a pathophysiological state characterized by a maldistribution of fluid; most patients do not have fluid overload. 3 Diagnosis relies on a thorough history, focused physical exam and investigations including ECG, lung ultrasound and chest x-ray. 4 Therapy is aimed at maintaining oxygenation and cardiac output and reversing the underlying…

Acute coronary syndromes

Essentials 1 Every patient with possible acute coronary syndrome (ACS) must have a 12-lead ECG performed and interpreted as soon as possible, ideally within 10 minutes after arrival, to identify whether he or she may benefit from reperfusion therapy. 2 Every patient with suspected ACS should be given aspirin unless he or she has a strong contraindication. 3 The ECG cannot exclude ACS. 4 Patients presenting…

Chest pain

Essentials 1 The life-threatening differential diagnoses of acute coronary syndrome (ACS, [CR] ), pulmonary embolism (PE; Chapter 5.5 ) and thoracic aortic dissection ( Chapter 5.10 ) should be considered in all presentations of chest pain. 2 ACS is common, life threatening and treatable, so identifying and treating ACS is fundamental to the management of chest pain. 3 A normal ECG does not rule out ACS.…

Osteomyelitis

Essentials 1 Staphylococcus aureus is the most frequent pathogen in all age groups. 2 Surgery, trauma and diabetes predispose to chronic infection in adults. 3 Diagnosis may be difficult, relying on a combination of clinical features, imaging studies and microbiological cultures. Laboratory testing is often unhelpful. 4 Successful treatment requires appropriate parenteral antibiotics with surgical clearance of any necrotic bone. Introduction Osteomyelitis is an inflammatory process…

Foot injuries

Essentials 1 Most calcaneal fractures are intra-articular; they are associated with a Bohler angle of less than 20 degrees and are at risk of developing compartment syndrome. 2 Major talar fractures have a significant risk of subsequent avascular necrosis. 3 Fractures of the base of the second metatarsal are pathognomic of Lisfranc injury (Fleck sign). 4 Computed tomography (CT) imaging is indicated in Lisfranc injuries as…

Ankle joint injuries

Essentials 1 Ankle injuries are common and occur as isolated injuries or in relation to high-energy multitrauma. 2 Lateral malleolar fractures are the most common ankle fracture. 3 The Ottawa ankle rules (OAR) are used to determine the need for imaging of the ankle (or midfoot) in adults with an isolated acute ankle injury. 4 The Weber and Henderson (Potts) classifications are the most commonly used…

Tibial and fibular injuries

Essentials 1 Tibial shaft fractures are the commonest long bone fracture, with the subcutaneous nature of the tibia leaving it vulnerable to open injury. 2 Neurovascular injury and compartment syndrome are risks in tibial shaft fractures. 3 Proximal fibular fractures are associated with common peroneal (lateral popliteal) nerve injury. 4 Tibial tubercle injuries range from apophysitis to fracture. Anatomy The tibia is the weight-bearing strut of…

Knee injuries

Essentials 1 The knee is the most commonly injured joint in the body. 2 Knee injuries often occur in the young, usually associated with sport. 3 The mechanism of injury is an essential part of the history. 4 Immediate joint effusion indicates internal joint disruption necessitating orthopaedic follow-up and possibly also magnetic resonance imaging (MRI). 5 Initial physical examination is frequently limited by pain and swelling.…

Femoral injuries

Essentials 1 Early reduction of femoral fractures and immobilization in traction reduces mortality. 2 Haemorrhagic shock is a major complication; with a closed femoral fracture the average blood loss is 1200 mL. 3 Fractures of the femoral shaft are associated with other significant injuries including those to the pelvis, hip and/or knee as well as multitrauma. Femoral shaft fracture Mechanism Considerable force is required to break…

Hip injuries

Essentials 1 Fracture of the hip is a major cause of morbidity and mortality in the elderly, with a large impact on health care and resources. 2 Hip injuries are frequently a pathological disease of the elderly. However, hip fractures and dislocations also occur in young people who sustain high-energy trauma. 3 Extracapsular hip fractures are associated with significant haemorrhage. 4 Avascular necrosis (AVN) of the…

Pelvic injuries

Essentials 1 Pelvic fractures account for 3% of skeletal fractures. 2 Fractures are either stable or unstable. Unstable fractures result from considerable mechanical force; they are associated with concomitant injuries and with a significant overall mortality. 3 Understanding the mechanism of injury and recognizing the pelvic fracture pattern on x-ray provides insight into the potential for complications, such as associated haemorrhage or urogenital injuries. 4 Isolated…

Hand injuries

Essentials 1 Hand injuries are common, and most, if treated early and competently, carry a good prognosis. 2 A comprehensive knowledge of hand anatomy and function is essential for appropriate management of the injured hand. 3 Aftercare and rehabilitation, ideally with specialized hand therapists, are essential for return to normal function. Introduction Hand injuries are common causes of presentation to emergency departments (EDs). The most common…

Fractures of the forearm and carpal bones

Essentials 1 Forearm fractures are among the most common fractures seen in the emergency department (ED). 2 When the need for or potential success of reduction is being assessed, the external appearance of the limb is a key feature. 3 Median nerve function must be assessed before and after reduction of all distal radial fractures. 4 Splinting or functional bracing may be sufficient for stable fractures.…

Fractures of the humerus

Essentials 1 Fractures of the proximal humerus occur primarily in the elderly, whereas distal humeral fractures occur more often in children. 2 Falls producing fractures in elderly patients are often precipitated by an underlying medical problem that should be sought for and managed. 3 Most proximal humeral fractures do not require surgical intervention. 4 The aim of treatment is to minimize pain, maximize the return of…

Dislocations of the elbow

Essentials 1 Elbow dislocations are the third most common large joint dislocations. 2 Surgical intervention is rarely required for simple elbow dislocations. 3 Surgical intervention may be required when fractures of the radius, ulna and humerus are associated with elbow dislocation or when neurovascular injury occurs. 4 The commonest neurovascular complication involves the ulnar nerve. 5 After reducing elbow dislocations, it is important to reassess joint…

Injuries of the shoulder

Essentials 1 Most clavicular fractures heal despite displacement; therefore reduction is not necessary. 2 Injuries to the shoulder region may also involve injury to local neurovascular structures. 3 Acromioclavicular joint injuries and fractures of the scapula are usually treated conservatively. 4 Posterior sternoclavicular dislocations require reduction. 5 In dislocation of the shoulder, careful examination of the axillary (circumflex) nerve, brachial plexus and axillary artery is mandatory…

Massive transfusion

Essentials 1 Early prediction of massive transfusion and activation of massive transfusion guidelines can ease some of challenges of resuscitation. 2 Systems should be instituted for effective prenotification of patients at risk of massive transfusion and a team-based approach to resuscitation planned, with the emergency physician as the team leader. 3 Laboratory tests may require a considerable amount of time to provide results and are not…