Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

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…

Thyroid and Adrenal Disorders

Key Concepts Hyperthyroidism Hyperthyroidism induces a hypermetabolic state and increases β-adrenergic activity. The resulting clinical manifestations range from vague constitutional symptoms to more organ-specific symptoms (see Box 117.1 ). BOX 117.1 Symptoms of Thyrotoxicosis Constitutional: Weight loss despite hyperphagia, fatigue, generalized weakness Hypermetabolic: Heat intolerance, cold preference, excessive perspiration Cardiorespiratory: Palpitations, dyspnea, dyspnea on exertion, chest pains, poor exercise tolerance Gastrointestinal: Nausea, vomiting, diarrhea, dysphagia Neuropsychiatric:…

Rhabdomyolysis

Key ConceptS Rhabdomyolysis is a process wherein striated muscle cells break down, resulting in the release of creatine kinase, potassium, calcium, phosphate, and uric acid. Rhabdomyolysis is associated with a variety of causes including overexertion, extreme body temperature changes, ischemia, infection, immobility, drugs, toxins, endocrine disease, autoimmune reactions, trauma, and genetic conditions. The classic presentation of rhabdomyolysis is myalgia, weakness, and dark-colored urine. However, the absence…

Diabetes Mellitus and Disorders of Glucose Homeostasis

Key Concepts The diagnosis of diabetes can be determined by one or more of four methods—random plasma glucose level above 200 mg/dL, fasting plasma glucose concentration above 126 mg/dL, 2-hour, 75-g post-load oral glucose tolerance test (OGTT) > 200 mg/dL, or HbA 1c value above 6.5%. Diabetic ketoacidosis (DKA) is diagnosed by the presence of hyperglycemia, anion gap metabolic acidosis, and elevated ketoacid levels. The essential…

Electrolyte Disorders

Key Concepts Electrolyte abnormalities are common in emergency medicine and can vary greatly in importance, severity, and symptoms. Asymptomatic electrolyte abnormalities can be gradually corrected, whereas those causing alterations in consciousness or life-threatening dysrhythmias require immediate therapy to avoid permanent sequelae or death. In some cases, therapy for life-threatening electrolyte disorders may precede laboratory confirmation. Asymptomatic electrolyte abnormalities can usually be corrected slowly, but those that…

Acid-Base Disorders

Key Concepts Metabolic acidoses are classified into wide anion gap and normal anion gap acidoses, based on basic metabolic panel (BMP) values. A wide anion gap metabolic acidosis is present when the gap exceeds 15 mmol Common causes of a wide anion gap metabolic acidosis are summarized with the mnemonic MUDPILES (Methanol, Uremia, DKA, Paraldehyde, Polyethylene glycol, or Paracetamol (Acetaminophen), Iron, Lactate, Ethylene Glycol, Salicylates). When…

Oncologic Emergencies

Foundations As improved therapies prolong the lives of cancer patients, the prevalence of oncologic emergencies continues to increase. However, nonspecific clinical features misattributed to the underlying cancer complicate their diagnosis. In this chapter, we review febrile neutropenia, metastatic spinal cord compression (MSCC), malignant pericardial disease, hypercalcemia of malignancy, tumor lysis syndrome (TLS), leukostasis, superior vena cava (SVC) syndrome, and complications of cancer immunotherapies including monoclonal antibodies,…

Disorders of Hemostasis

Key Concepts Although hemostatic disorders are confirmed through laboratory testing, a careful history and thorough physical examination may provide clues to the diagnosis. The use of antithrombotic agents remains widespread, whereas diseases such as hemophilia or disseminated intravascular coagulation (DIC) are encountered infrequently in the emergency department (ED) setting. Critical thrombocytopenia increases the risk of bleeding, particularly with trauma or invasive procedures. Platelet dysfunction may occur…

White Blood Cell Disorders

Key Concepts Chronic lymphocytic leukemia (CLL) is the most common leukemia in the elderly, and acute lymphocytic leukemia (ALL) is the most common leukemia in children. Splenomegaly is a common finding in leukemias. Leukostasis is usually not accompanied by clinical sequelae until the white blood cell (WBC) count is more than 500,000. Neutropenia plus a fever should be treated as a potentially life-threatening infection until proven…