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Social Determinants

Key Concepts Challenges with food, housing, transportation, and other social determinants of health account for approximately 50% of poor health outcomes in the United States. Emergency providers can connect patients to resources that can help address challenges with different social determinants of health. Legal services attorneys provide low-cost or free services that can assist with a number of health-harming legal needs. Health care providers and systems…

Sexual Minority Populations (LGBTQ)

Key Concepts Sexual orientation, gender identity, and gender expression occur along a continuum and may be completely separate and discordant from one another. Multiple health disparities exist in sexual minority populations, but many of the contributing factors are likely unknown due to lack of studies. ED provider education about sexual minorities is often inadequate, limited, or absent. Transgender individuals may utilize a variety of medical and…

Human Trafficking

Key Concepts Labor and sex trafficking involve the exploitation of a person for labor or commercial sex, respectively, affecting up to 25 million persons worldwide. Human smuggling, a crime in which a person contracts a smuggler to facilitate their illegal entry into a country, can evolve into trafficking during transit or at the destination and under such circumstances the person is considered a victim of human…

Multiculturalism, Diversity, and Care Delivery

Key Concepts Changing demography and an evolving culture in the United States are changing emergency medicine practice as disparities in health and health care delivery continue, despite efforts to improve care. Emergency department interventions should focus on social determinants of health, health literacy, and empowerment of patients to participate in their care. Treatment plans created with patients and based on what matters to them have the…

The Combative and Difficult Patient

Key Concepts The emergency department (ED) should develop a written plan of action to deal with violence that integrates the roles and activities of ED staff, hospital administration, security, and local authorities. ED staff should be trained to recognize potentially violent individuals and to intervene with verbal de-escalation techniques prior to the use of physical or chemical restraint when possible. The emergency clinician should be familiar…

The Morbidly Obese Patient

Key Concepts Obesity has reached epidemic proportions in the United States (US), as well as much of the world, with nearly 40% of American adults classified as obese. Obesity results in several physiologic changes including aberrations to lung physiology and predisposes patients to obstructive sleep apnea and obesity hypoventilation syndrome. Drug dosages can be challenging in obese patients because some medications are lipophilic and will need…

The Solid Organ Transplant Patient

Key Concepts The solid organ transplant recipient’s altered anatomy, denervated allograft, and immunosuppression frequently result in atypical disease presentations both related and unrelated to the transplanted organ. An understanding of the solid organ transplant recipient’s altered anatomy, including vascular and nonvascular anastomoses, is critical to evaluating early post-transplantation complications. Rejection can manifest at any point post-transplantation with constitutional symptoms and signs of allograft insufficiency, requiring prompt…

The Immunocompromised Patient

Key Concepts Immunocompromised patients who present with acute infections, especially those that are neutropenic, may appear deceptively benign initially. Their symptoms and signs often mimic noninfectious complications. Broad-spectrum antibiotics are indicated after obtaining appropriate cultures of all potential sites of infection, especially if the patient is neutropenic. Immunocompromised patients can have serious local or systemic infections without fever. Symptoms, signs, and findings of infection may include…

Geriatric Abuse and Neglect

Key Concepts Elder mistreatment, which includes physical abuse, sexual abuse, neglect, emotional/psychological abuse, abandonment, financial/material exploitation, and self-neglect, is common and may have serious medical and social consequences. Elder mistreatment is under-recognized by emergency clinicians and under-reported to the authorities. Signs suggestive of potential elder abuse and neglect that should be recognized by emergency clinicians may exist in the medical history, physical examination, and medical/laboratory markers.…

Geriatric Drug Therapy

Key Concepts Those with a chronologic age of 65 years or older are commonly referred to as older adults (or the elderly), but physiologic age is more indicative of a drug’s therapeutic or toxicologic effect. Besides age, overall patient assessment should include organ function, comorbidity, and functional status to guide drug dosing. Pharmacokinetic and pharmacodynamic changes that occur with age need to be considered to optimize…

Geriatric Trauma

Key Concepts Do not let a low-impact mechanism, patient cognitive impairment, or vital signs within the range of normal reduce your pretest probability of significant injury in an older patient. Age-specific trauma alert criteria improve the care of injured older adults. Vital signs, including tachycardia and hypotension, are unreliable to detect hemodynamic instability in older adults. Ultrasound is a helpful tool to assess volume status in…

Care of the Geriatric Patient

Key Concepts The population is aging, with 10,000 Americans turning 65 every day, resulting in an increasing proportion of ED patients that are elderly. Older ED patients have the greatest resource use, longest lengths of stay, and highest admission rates of any age group. Delirium, especially hypoactive delirium, is underrecognized by emergency clinicians; the diagnosis of delirium should prompt investigation for life-threatening emergencies, including infection, metabolic…

Trauma in Pregnancy

Key Concepts Female trauma patients of reproductive potential should be screened for pregnancy and assumed to be pregnant until proven otherwise. Management of life- and limb-threatening injury in the mother comes first. Saving the mother provides the best chance of saving the baby. Even in the stable pregnant trauma patient, the fetus is at increased risk of morbidity and mortality; therefore, the fetus should be monitored…

Labor and Delivery

Key Concept Most ED deliveries require only basic equipment to cut and clamp the umbilical cord and dry and suction the infant. However, the ED should have additional equipment and trained staff should be available to care for a newborn requiring further resuscitation. Women in labor who present to the ED are generally best cared for in the obstetric suite. Women with the urge to push…

Drug Therapy in Pregnancy

Key Concepts Chemically induced birth defects are responsible for approximately 1% to 3% of anomalous births. Gestational age is crucial in determination of the impact of any given exposure, especially during organogenesis (days 21–56 of fetal life), when major body organs are formed. Human data on teratogenicity and fetal toxicity of medications are often limited, and causal associations are difficult to determine, especially with newer medications.…

Medical Emergencies During Pregnancy

Key Concepts Asthma The treatment goal for a pregnant woman with an acute asthma exacerbation is to prevent fetal hypoxia by keeping maternal oxygen saturation above 95%. Inhaled beta-agonists and corticosteroids are first-line emergency department treatment and are considered safe for use in pregnancy. Cardiac Disease Hypertensive emergency in pregnancy is defined as acute-onset persistent hypertension with systolic blood pressure greater than 160 mm Hg or…

Complications of Pregnancy

Acknowledgment We thank Dr. Sidhant Nagrani and Dr. Bisan Salhi for their contributions to previous editions of this chapter. Key Concepts Miscarriage is defined as the spontaneous termination of pregnancy before 20 weeks of gestational age. Approximately 25% of women experience some bleeding during pregnancy. Most miscarriages are due to uterine malformations or chromosomal abnormalities. Beta hCG discriminatory levels for detecting intrauterine pregnancy are usually considered…

Child Abuse

Physical Abuse Key Concepts The ultimate determination of whether abuse has occurred can take days or weeks. Emergency clinicians should focus on recognizing possible abuse, treating medical injuries, and establishing a safe disposition for the child. Completely undress infants and preverbal children for the physical examination; pay particular attention to the skin, ears, mouth and oral cavity, scalp, fontanel, and genitalia. Consider abuse routinely for sentinel…

Pediatric Drug Therapy

Key Concepts Awareness of differences in pediatric pharmacokinetics and specific drug toxicities is of critical significance for the safe and effective use of medications in children. Avoid prescription and over-the-counter (OTC) cough and cold medications in children because these agents have limited efficacy data and may cause harm. Counsel parents about the management of fever and appropriate indications and proper use of antipyretics. Perform a risk…

Pediatric Musculoskeletal Disorders

Key Concepts The pediatric physis is the weakest part of the bone and more likely to separate before adjacent tendon or ligament tears, occurring more frequently during periods of rapid growth. Displaced supracondylar fractures are at greater risk for neurovascular injury and compartment syndrome. A lateral elbow radiograph with an elevated fat pad is suspicious for occult fracture. Transient synovitis has a peak presentation between 3…