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Small Intestine

Small Bowel Obstruction Key Concepts Small bowel obstruction (SBO) is a common clinical condition accounting for 2% of patients presenting to the emergency department with abdominal pain, leading to an estimated 300,000 hospitalizations annually in the United States. The most common cause of SBO is adhesions from prior abdominal surgery, which are found in approximately 60% of cases. Tumors and abdominal hernias account for another 20%…

Pancreas

Key Concepts Acute pancreatitis represents a wide spectrum of disease, ranging from mild to severe life-threatening disease with a mortality rate as high as 30%. The most common causes of acute pancreatitis are gallstones and chronic alcohol consumption. Acute pancreatitis is diagnosed by the presence two of three criteria—characteristic abdominal pain, serum lipase or amylase levels greater than three times the upper limit of normal, and…

Liver and Biliary Tract Disorders

Key Concepts Viral Hepatitis The clinical presentation of viral hepatitis is highly variable, and many cases may be asymptomatic, particularly in children. Hepatitis A is transmitted through oral fecal spread, whereas hepatitis B and C are spread through parenteral or intimate contact. Highly effective immunizations exist against hepatitis A and B viruses. Postexposure, passive immunization exists for hepatitis A and B viruses, though its use is…

Esophagus, Stomach, and Duodenum

Key Concepts Dysphagia Dysphagia can be caused by obstructive lesions (e.g., esophageal neoplasm), motility disorders (e.g., achalasia), or neuromuscular disorders that can be vascular (e.g., cerebral vascular accident), immunologic (e.g., myasthenia gravis, multiple sclerosis [MS]), infectious (e.g., botulism), or metabolic in nature. The incidence of achalasia increases with age, presenting insidiously with equal frequency for solids or liquids. Dysphasia can be the initial presentation of myasthenia…

Pulmonary Embolism and Deep Vein Thrombosis

Key Concepts Hallmarks of deep venous thrombosis (DVT) include unilateral limb pain and swelling, though these findings can be subtle and nonspecific. Patients with low pretest probability (PTP) can have DVT ruled out in the ED with a negative D-dimer or venous ultrasound (US), patients with high PTP can have DVT ruled out in the ED with a negative D-dimer and venous US. Three-point US evaluates…

Peripheral Arteriovascular Disease

Key Concepts Acute arterial occlusion is a limb-threatening emergency requiring early anticoagulation and Fogarty catheter embolectomy. The clinical diagnosis is based on some variant of the five Ps: pain, pallor, pulselessness, paresthesias, and paralysis. Confirmatory tests are unnecessary and increase the limb’s ischemic time. Atheroembolism (blue toe syndrome) is associated with cool, painful cyanotic toes in the presence of palpable distal pulses. A proximal source should…

Abdominal Aortic Aneurysm

Key Concepts A ruptured abdominal aortic aneurysm (AAA) should be considered in any patient with otherwise unexplained abdominal or back pain. The complete triad of pain, hypotension, and a pulsatile mass may not be present. In a patient with an AAA and acute symptoms such as severe abdominal or back pain or hypotension, rupture is imminent or has already occurred. A patient with a ruptured AAA…

Aortic Dissection

Key Concepts Aortic dissection most commonly presents as abrupt, sharp, severe pain maximally intense at onset in the chest or back. There may be various seemingly unconnected associated symptoms due to altered blood pressure or insufficiency of disparate vascular beds. Definitive diagnosis is most commonly made with an imaging study such as computed tomography of the aorta with intravenous contrast. A combination of standardized clinical assessment,…

Hypertension

Key Concepts Elevated blood pressure with or without associated symptoms is exceedingly common in the emergency department (ED). A true hypertensive emergency is defined by the presence of acute target organ damage (TOD) and is distinct from other clinical presentations. Commonly encountered hypertensive emergencies include ischemic and hemorrhagic stroke, myocardial infarction, acute heart failure, aortic dissection, and pre-eclampsia. Management strategies regarding target blood pressure reduction, rate…

Infective Endocarditis and Valvular Heart Disease

Key Concepts Infectious endocarditis (IE) is more often caused by Staphylococcus species than Streptococcus, and increasingly occurs in elderly, recently hospitalized patients, those with prosthetic valves and intra-cardiac devices, and in patients who inject opioids. IE should be considered in any patient with a predisposing condition plus fever; IE frequently presents with a complication, including heart failure, embolic stroke, or osteomyelitis. At least two sets of…

Pericardial and Myocardial Disease

Key Concepts Pericarditis and myocarditis have chest pain, laboratory results, and ECG findings that can mimic acute myocardial infarction (AMI). When the diagnosis is not clear, early coronary angiography definitively identifies or excludes AMI. Acute pericarditis is treated with aspirin or nonsteroidal antiinflammatory drugs. Adding colchicine decreases the rate of recurrence. Cardiac tamponade presents many ways. Patients with dyspnea, distended neck veins, hypotension, and muffled heart…

Heart Failure

KEY CONCEPTS Heart failure (HF) is the clinical syndrome defined by signs and symptoms of elevated intracardiac pressures or depressed cardiac output, which in turn are due to either functional or structural cardiovascular (CV) abnormalities. By definition, HF presentations managed in the emergency department (ED) are acute heart failure (AHF) (ie, HF in which the signs and symptoms require unscheduled care). AHF is a multiorgan, multifactorial,…

Implantable Cardiac Devices

Key Concepts Pacemaker malfunction soon after implantation (within 6 to 8 weeks) is usually a result of a lead problem, such as a lead displacement, or a pacemaker programming issue, such as a pacing rate too slow for the patient’s needs. Pacemaker malfunction is categorized as failure to pace, oversensing, undersensing, or pacing at an inappropriate rate (too fast or too slow). Pacemaker or implantable cardioverter-defibrillator…

Dysrhythmias

Key Concepts Electrical therapy is appropriate for unstable patients in whom a dysrhythmia is the cause of symptoms—pacing if the heart rate is slow, countershock with sedation if fast. Any regular new-onset, symptomatic, wide-complex tachycardia should be assumed to be ventricular tachycardia until proven otherwise. Type II second-degree AV block is never a normal variant and implies a conduction block below the AV node. When the…

Acute Coronary Syndromes

Key Concepts Symptoms of acute coronary syndrome (ACS) are variable. Clinicians must consider ACS in a broad range of presentations, especially in patients prone to subtle or non-chest pain presentations (for example, women, older patients, or those with comorbidities such as diabetes). The ECG is crucial in the initial evaluation of ACS. Limitations of the 12-lead ECG in suspected ACS include initial nondiagnostic findings, evolving fluctuations…

Pleural Disease

Key Concepts Point of care thoracic ultrasound can be used to rule out pneumothorax with high sensitivity. For healthy young patients with a small primary spontaneous pneumothorax, observation with supplemental oxygen is an appropriate treatment option. For larger symptomatic primary spontaneous pneumothorax, simple aspiration with a catheter is often successful. In most cases of secondary pneumothorax, tube thoracostomy should be considered because less invasive approaches are…

Pneumonia

Key Concepts Empirical antimicrobial therapy should be started in the emergency department (ED) for patients admitted with pneumonia. Streptococcus pneumoniae is the most commonly encountered pathogen in hospitalized patients, especially those requiring the intensive care unit. No characteristic radiographic pattern is pathognomonic for a specific pneumonia pathogen. Legionella should be suspected in patients with gastrointestinal or neurologic symptoms presenting with pneumonia. As part of the evaluation…

Upper Respiratory Tract Infections

Key Concepts Viral infections cause most cases of pharyngitis. Patients should not be treated with antibiotics based on symptoms and exam alone. Patients with a Centor criteria score of 0 or 1 do not require further testing or treatment. Those with a score of 2 or greater should undergo rapid antigen testing with treatment decisions based on results. Throat cultures are recommended in children but are…

Chronic Obstructive Pulmonary Disease

Key Concepts Chronic obstructive pulmonary disease (COPD) is “a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.” COPD exacerbation is a worsening of symptoms from baseline beyond day-to-day variation and requiring additional treatment. It is most commonly caused by viral infections,…

Asthma

Key Concepts Inhaled and systemic steroid medications are effective in controlling airway inflammation and have important roles in the management of asthma exacerbations. Inhaled bronchodilators and systemic corticosteroids remain the mainstays of management for most acute asthma exacerbations. Acute severe asthma requires rapid identification. Treatment may use strategies not used in mild-to-moderate exacerbations, such as infusion of magnesium sulfate, use of non-invasive ventilation, and endotracheal intubation.…