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Alcohol-Related Disease

As eloquently stated by Paracelsus in the 16th century, “all substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a remedy.” Key Concepts Moderate alcohol consumption is defined as one or two drinks/day for men and one drink/day for women. DSM–5 integrates alcohol abuse and alcohol dependence into a single disorder called alcohol use disorder (AUD), with…

Toxic Alcohols

Key Concepts The classic finding of an elevated osmolar and anion gap should raise suspicion of methanol or ethylene glycol toxicity but may not be present depending on the timing of ingestion. Early ingestion has a high osmolar gap without acidosis, and late ingestion has acidosis without an osmolar gap. Serum osmolarity is calculated by the following equation: Calculatedosmolarity(mOsm/kg)=2Na++(BUN)+(glucose/18)+(ethanol) Calculated osmolarity ( mOsm / kg )…

Care of the Poisoned Patient

Key Concepts Toxidromes are constellations of signs and symptoms based primarily on vital signs and neuropsychiatric functions that are characteristic manifestations of certain toxic exposures. Recognition of the presence of a toxidrome can suggest a potential intoxicant and guide early interventions and management strategies. Examples of toxidromes include sympathomimetic, antimuscarinic, cholinergic, sedative-hypnotic, and opioid categories. Qualitative urine drug assays have limited roles in the clinical setting…

Radiation Injuries

Key Concepts Patients contaminated with radiation pose minimal risk to health care providers when appropriate precautions and decontamination procedures are employed. Decontamination should not delay or impede emergency stabilization of patients with radiation exposure. Tissues with greater rates of cellular division, particularly the hematopoietic and gastrointestinal systems, are most radiosensitive. Children are more radiosensitive than adults. Vomiting, diarrhea, and skin burns occurring shortly following radiation exposure…

Drowning

Key Concepts Drowning is a leading cause of death and loss of years of life with over 90% of cases occurring in lower- and middle-income countries. Cost-effective prevention strategies have been developed for settings where resources limit treatment for drowning victims. Significant drowning injuries induce pulmonary injury and hypoxia in proportion to the amount of water aspirated and the duration of submersion. Pulmonary and neurologic support…

High-Altitude Medicine

Acknowledgment The author would like to acknowledge Drs. Benjamin Honigman, Michael Yaron, Ryan D. Paterson, and Christopher B. Davis for their contributions to previous editions of this chapter. Key Concepts All forms of altitude illness can be treated with oxygen and rapid descent. The diagnosis of acute mountain sickness requires the presence of headache in the setting of a recent elevation change to greater than 8,000…

Scuba Diving and Dysbarism

Key Concepts The majority of dive injuries are diagnosed on the basis of the focused dive history and physical examination and are best differentiated into disorders of descent, disorders of depth, and disorders of ascent. The U.S. Navy Diving Manual and the Divers Alert Network (DAN) are valuable resources for the clinician presented with a diving emergency. DAN provides a 24-hour medical emergency hotline at 1-919-684-9111…

Electrical and Lightning Injuries

Acknowlegments The authors wish to acknowledge and thank Kelly P. O’Keefe and Rachel Semmons for their valuable contributions, expertise, and authorship of this chapter in previous editions. Key Concepts Electrical current follows the path of least resistance, which is often along neurovascular bundles. Deep tissue injuries and organ damage are often more extensive than indicated by examination of the overlying skin. Testing is not indicated for…

Heat Illness

Key Concepts Classic heatstroke is generally diagnosed in older patients with comorbidities during heat waves, whereas exertional heatstroke is more common in young athletic patients or military personnel. Heat exhaustion and heatstroke are a continuum of the same pathophysiologic process. Neurologic dysfunction is a hallmark of heatstroke, and cerebral edema is common. In heat stroke, morbidity and mortality are directly related to the duration of core…

Hypothermia, Frostbite, and Nonfreezing Cold Injuries

Accidental Hypothermia Key Concepts Patients with hypothermia should be actively rewarmed whenever possible. Specific indications for active rather than passive rewarming include trauma, cardiovascular instability, temperature below 32°C (89.6°F), poor rate of passive rewarming, and endocrine insufficiency. Rewarming methods should be chosen to minimize core temperature afterdrop. If tachycardia is out of proportion to core temperature then hypoglycemia, hypovolemia, or an overdose should be considered. The…

Sepsis Syndrome

Key Concepts Sepsis is a progressive disease due to a dysregulated inflammatory cascade, leading to organ dysfunction and circulatory compromise in severe cases. Older adults, immunocompromised and neutropenic patients, and patients with multiple comorbidities are at increased risk for the development of sepsis syndromes. A thorough history, physical examination, and laboratory testing should guide the diagnostic evaluation. Early treatment should focus on appropriate identification, improvement of…

Skin and Soft Tissue Infections

Key Concepts Bacterial skin infections such as cellulitis and abscess are common and are rarely life-threatening. Necrotizing infection is suggested by pain out of proportion to physical findings, crepitance, gas seen on imaging studies, or clinical instability. Suspected necrotizing infection should be managed with prompt broad-spectrum antibiotics and surgical consultation. Emergency clinicians should be familiar with toxic shock syndrome and Rocky Mountain spotted fever, which are…

Bone and Joint Infections

Key Concepts Skeletal infection should be considered in the differential diagnosis of all patients who present with bone or joint pain. Laboratory evaluation is of little value in the diagnosis of bone and joint infections, with the exception of the ESR and CRP level, which are elevated in approximately 90% of cases of bone and joint infections. Joint aspiration is the definitive diagnostic procedure, and intraoperative…

Tuberculosis

Key Concepts Early recognition of patients with risk for TB should begin at ED triage. Patients with possible active pulmonary TB should be placed in respiratory isolation promptly. TB should be considered in the differential diagnosis of patients who present with fever, cough, and weight loss. Risk factors for TB include HIV infection, immunosuppression, age older than 60 years, being from an endemic country, being undomiciled,…

Tickborne Illnesses

Key Concepts Tickborne illnesses frequently are misdiagnosed as common viral or bacterial infections. Diagnosis can be facilitated by considering tickborne illnesses in patients who recently have been in endemic areas and routinely asking for a history of recent tick or insect bites in patients with febrile illnesses. Lyme disease should be suspected in patients who present with signs of a viral illness, monarticular arthritis, meningitis, multiple…

Parasites

Key Concepts Parasitic diseases may manifest with almost any constellation of signs and symptoms. The combination of presenting signs and symptoms and a history of recent travel to specific geographic regions can lead to early diagnosis and the initiation of pharmacotherapy, decreasing morbidity and mortality and increasing the probability of eradication of the infection. Parasitic coinfections are particularly common in patients with HIV infection and AIDS.…

HIV

Key Concepts HIV/AIDS can affect any organ system, and the nonspecific complaints seen with viral illness are common. Consider acute HIV infection in the evaluation of patients with mononucleosis-like syndromes in the presence of risk factors. The presenting illness may originate from acute HIV infection, opportunistic infections, medication side effects, inflammation, and immune reconstitution inflammatory syndrome (IRIS). Patients with CD4 + count above 500 cells/μL tend…

Coronaviruses

Key Concepts Coronaviruses infect humans and animals and have the ability for recombination, generating novel viruses. Most human coronaviruses cause mild disease. Three coronaviruses, severe acute respiratory syndrome (SARS) associated virus, Middle East respiratory syndrome (MERS), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have caused severe disease in humans. The hallmark presentation of severe disease in coronavirus patients is respiratory failure, usually manifesting as acute…

Viruses

Key Concepts Recent outbreaks of vaccine-preventable childhood infections have occurred secondary to unvaccinated individuals and travel to areas where disease is still endemic. Emergency clinicians should recognize the possibility of these once rare diseases. Herpes simplex encephalitis is fatal if untreated. Clinicians should suspect this diagnosis when evaluating severely ill patients for suspected meningitis or encephalitis and promptly institute empirical therapy with IV acyclovir while awaiting…

Bacteria

Key Concepts All septic patients should be treated with antibiotics as soon as possible, even before a definitive diagnosis is made. Patients with pneumococcemia, meningococcemia, and aggressive soft tissue infections can decompensate rapidly. The source of sepsis should be identified as soon as possible, and surgical causes should be addressed. A surgeon should be consulted as soon as possible for patients with sepsis and a débridable…