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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.…

Otolaryngology

Key Concepts Otitis Media Otitis media is caused by eustachian tube inflammation and dysfunction leading to fluid accumulation in the middle ear and proliferation of nasopharyngeal bacteria, most commonly Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Diagnosis of acute otitis media (AOM) is made based on the presence of a middle ear effusion and signs of inflammation, including ear pain, tympanic membrane erythema and bulging, and…

Ophthalmology

Key Concepts Prophylactic topical antibiotics are not indicated for the treatment of corneal abrasions, and eye patches are not recommended because they can mask a worsening infection. Eyelid lacerations that may require referral to a plastic or ophthalmic surgeon include those with lid margin lacerations, a canalicular laceration, or levator or canthal tendon injuries. Alkaline burns to the cornea and conjunctiva need to be irrigated until…

Oral Medicine

Key Concepts Antibiotics do not have a role in the management of pulpitis, whether reversible or irreversible. Missing teeth must be accounted for. They may be hidden, left at the scene, aspirated, swallowed, or traumatically impacted. Avulsed permanent teeth should be stored in milk, saline, or a commercially available solution and reimplanted at the earliest possible opportunity. Primary teeth are not reimplanted. A localized periapical abscess…

Chemical Injuries

Key Concepts For chemical injury, the degree of skin destruction is determined mainly by the properties of the toxic agent, its concentration, and the duration of its contact. Chemical injuries are commonly encountered after exposures to acids and alkalis. Hazardous materials (HazMat) are substances that can cause physical injury and damage the environment if improperly handled. In dealing with HazMat incidents, two distinct goals need to…

Thermal Injuries

Key Concepts After removing the patient from the source of injury, burns should be cooled with room temperature water while avoiding hypothermia in patients with large burns. Clinical signs such as facial burns, hoarseness, drooling, carbonaceous sputum, and singed nasal hairs indicate inhalation injury; however, they are poor predictors of injury severity. Confirmation of inhalation injury is best accomplished by direct visualization of the glottic inlet…

Venomous Animal Injuries

Acknowledgments We acknowledge the efforts and expertise of the previous chapter author for editions (1–9), Dr. Edward Joseph “Mel” Otten. Key Concepts Snake venom causes neurotoxicity and hematotoxicity, but one usually predominates, depending on the species of snake. Pit vipers have triangular or arrow-shaped heads, elliptical pupils, and characteristic pits found bilaterally midway between the eye and the nostril. The amount of crotalid antivenom given depends…

Mammalian Bites

Key Concepts Mammalian bites require an evaluation for both trauma and their risk of infection. Cat and human bites are at higher risk for infection than dog bites. Most mammalian bite wound infections are polymicrobial. Pasteurella species are the most common pathogens in dog and cat bites. Preventing infection from mammalian bites relies more on vigilant cleaning, debridement, and irrigation than prophylactic antibiotics. Prophylactic antibiotics are…

Foreign Bodies

Key Concepts If the history and mechanism of injury are compatible with ocular penetration or if a small puncture wound of the globe is noted, anteroposterior and lateral radiographs of the orbit are an appropriate initial step when the foreign body is thought to be radiopaque. Computed tomography (CT) and ultrasound are complementary diagnostic studies. Although most otic and nasal foreign bodies are amenable to emergency…

Wound Management Principles

Key Concepts Risk factors for wound infection include crush mechanism; long (>5 cm) deep penetrating wounds; high-velocity missiles; diabetes; and contamination with saliva, feces, soil, or other foreign matter. Soaking wounds in povidone-iodine (Betadine) is toxic to healthy tissue. Prepare the skin with a chlorhexidine-alcohol solution. The most effective intervention to decrease wound bacterial counts and infection is thorough cleansing, with use of saline or tap…