Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Headache

Key Concepts Patients with a known headache disorder who present with a change in the character of the headache should be evaluated for potential serious causes. The physical examination in the headache patient focuses primarily on mental status, funduscopic exam, meningeal signs, and neurologic examination, particularly cranial nerves (CNVs) II, III, IV, and VI, as well as specific cerebral territories. Mild to moderate primary and nonspecific…

Dizziness and Vertigo

Key Concepts Neurologic complaints, such as imbalance, dysarthria, or numbness in patients with dizziness/vertigo raise the likelihood of transient ischemic attack (TIA) or stroke as the cause. Benign paroxysmal positional vertigo (BPPV) requires head movement to elicit symptoms. Consequently, the Hallpike test should not be performed if the patient is actively symptomatic during history taking (and the patient’s head has not been recently moved) because such…

Seizures

Key Concepts Lifetime seizure incidence reaches up to 10% in the US population and depends upon multiple factors including age, history of epilepsy, structural brain or neurodegenerative disease, genetic predisposition, acuity and severity of metabolic derangements. Seizures are the result of an imbalance in the excitation and inhibitory neuronal synapses in the cerebral cortex or limbic system. Epilepsy is a condition associated with a lower seizure…

Confusion

Key Concepts Confusion and delirium are symptoms, not a diagnosis. Focal cortical dysfunction, such as from tumor or stroke, typically does not cause confusion. Any underlying clinical process that disrupts optimal central nervous system (CNS) functioning can result in confusion. Emergent causes of confusion that need immediate detection and treatment include hypoglycemia, hypoxemia, hypotension, sepsis, and toxic ingestions. Assessment of attention is fundamental for the assessment…

Depressed Consciousness and Coma

Key Concepts Coma is a state of depressed consciousness in which a patient is not aware, is not awake, and does not respond to vigorous stimulation. Consciousness consists of arousal (subcortical) and awareness (cortical). Damage to the dorsal brainstem, thalamus, axonal projections to the cortex, or extensive injury to bilateral cortices may result in depressed consciousness or coma. Toxicologic, metabolic, infectious, and other disorders causing diffuse…

Syncope

Foundations Epidemiology Syncope is a common clinical entity with a lifetime prevalence between 20% and 40%, and is slightly more common in women than in men. Key Concepts Syncope is defined as a sudden, spontaneous loss of consciousness and postural tone with rapid, complete, and spontaneous recovery. This loss of consciousness typically lasts seconds to minutes and is not followed by a persistent alteration in mental…

Cyanosis

Key Concepts Cyanosis occurs due to an absolute amount of desaturated hemoglobin (∼5 g/dL) rather than a percentage; anemic patients exhibit cyanosis at a lower Pa o 2 than those with normal hemoglobin levels. Cyanosis is an insensitive indicator of tissue oxygenation; its presence suggests hypoxemia, but its absence does not exclude it. Central cyanosis is most commonly due to global arterial hypoxemia or abnormal hemoglobin…

Weakness

Key Concepts Weakness is a common complaint among emergency department (ED) patients, with a preponderance in elders and those with chronic disease, and therefore may require a broad approach to investigating underlying causes. Patients may use the term weakness to reflect a variety of vague symptoms including decreased motor strength, fatigue, poor energy, dyspnea, or even depression. Global weakness is typically caused by a systemic condition…

Fever in the Adult Patient

Key Concepts Younger adults with fever usually have benign self-limited disease with low mortality. The challenge in this group is to identify rare causes of fever such as meningitis or septic condition when confronted with a predominance of self-limited viral and focal bacterial illness. For older patients (greater than 65 years), immune-compromised patients, or those with chronic disease, fever indicates a high risk for serious disease.…

Procedural Sedation and Analgesia

Key Concepts Safe, effective procedural sedation and analgesia requires high-level experience and sound protocols for patient selection and patient monitoring. After procedural sedation, patients should be discharged with and remain in the company of a responsible adult for 4 to 8 h after recovery. Propofol is the agent of choice for deep sedation in the emergency department but requires supplementation with an opioid analgesic when a…

Pain Management

Key Concepts Acute pain is an urgent condition for the patient. Pain should be rapidly assessed, treated, and frequently reassessed in tandem with diagnostic evaluations. Therapy for acute pain is different than for chronic pain. Chronic pain treatment should be undertaken in consultation with the clinician(s) responsible for the patient’s long-term management. In general, opioid analgesic agents should not be administered in the ED or prescribed…

Adult Resuscitation

Key Concepts Cardiopulmonary resuscitation (CPR) quality is critical to successful resuscitation from cardiac arrest. Important benchmarks of quality CPR include compression rate 100–120 compressions/min, compression depth 5–6 cm, compression fraction at least 80%, full chest recoil between compressions, and a ventilation rate of 10 breaths Restoration of adequate cardiac function is the defining factor of return of spontaneous circulation (ROSC). Restoration of good neurologic function is…

Brain Resuscitation

Key Concepts Neuronal injury is a dynamic process that continues for hours or days after an ischemic insult to the brain. Avoid hypotension and hypoperfusion by maintaining a mean arterial pressure greater than 65 mm Hg and a cerebral perfusion pressure of 60 mm Hg. Maintain normal oxygen levels or mild hyperoxemia, with a PaO2 of 80 to 120 mm Hg and oxyhemoglobin saturations in the…

Shock

Key Concepts Shock can occur with normal arterial blood pressure and not all patients with arterial hypotension have shock. A base deficit more negative than −4 mEq/L or a serum lactate level greater than 4.0 mmol/L warrants a presumptive diagnosis of shock. Urine output is a reliable index of vital organ perfusion in patients with suspected shock. Normal urine output is 1.0 mL Output less than…

Mechanical Ventilation and Noninvasive Ventilatory Support

Key Concepts Noninvasive positive-pressure ventilation (NPPV) is often adequate for reversal of impending respiratory failure due to a rapidly reversible cause, and should be considered as the first-line therapy for patients with exacerbations of chronic obstructive pulmonary disease (COPD) and acute cardiogenic pulmonary edema (ACPE) in whom immediate intubation is not required. NPPV should generally be avoided for definitive management of patients with pneumonia or acute…

Airway

Key Concepts Anticipating the clinical course of the patient’s condition and assessing the likelihood of deterioration are crucial to the decision to intubate, especially if the patient is to leave the emergency department (ED) for a period of time (e.g., interfacility transfer, diagnostic testing). Although videolaryngoscopy (VL) has reduced the chance of a failed intubation attempt caused by difficult anatomic features that often thwart direct laryngoscopy…

Commonly Used Formulas and Calculations

Introduction This appendix presents a list of calculations commonly used by emergency physicians. It is not all-inclusive and purposely does not include decision tools or scales that do not require algebraic calculations. Many of these equations can be found in online calculators on websites such as or . English-to-Metric Conversions Patients frequently express common figures such as weight, temperature, and volume in standard measurements.…

Procedures in the Setting of Anticoagulation

Introduction Performing an invasive procedure on an anticoagulated emergency department (ED) patient can be challenging for the emergency provider (EP). Regardless of the procedure, some anticoagulated patients are at potential significant risk of hemorrhage from the procedure. However, emergency reversal of anticoagulation in order to perform the procedure may also place the patient at risk for serious thrombotic complications. When deciding to perform a procedure on…

Radiation in Pregnancy and Clinical Issues of Radiocontrast Agents

The annual, population-wide exposure to ionizing radiation from medical sources increased a staggering 750% from 1980 to 2009, and medical imaging now comprises nearly one-half of Americans' radiation exposure. The World Health Organization classifies x-rays officially as carcinogens, and indeed a report by the National Academy of Science indicates that a 100 mGy dose is associated with a lifetime attributable risk for development of a solid cancer…

Noncardiac Implantable Devices

In addition to cardiac pacemakers and defibrillators, a number of noncardiac devices have been developed for electronic neuromodulation and drug delivery. Although these devices are placed by a variety of subspecialists for the treatment of chronic illnesses, if the devices malfunction, patients may arrive at the emergency department in an acute state, thereby necessitating intervention by the emergency provider. Insulin Infusion Devices Background External insulin infusion…