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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…

Physical and Chemical Restraint

Emergency clinicians often face the challenge of caring for agitated, uncooperative, combative, and violent patients who are unable to participate in their care, make rational health care decisions, and/or are a danger to themselves and others. Psychiatric illness, acute chemical intoxication or withdrawal, delirium, medical illness, uncontrolled rage, hypoxia, and rarely, central nervous system infection are causes of agitated or violent behavior in the emergency department…

Standard Precautions and Infectious Exposure Management

Contamination of health care workers (HCWs) with body fluids is a frequent occurrence in the emergency department (ED). A survey of ED and trauma staff found that almost half reported a needlestick injury within the preceding year. Body fluids often contain various transmissible infectious diseases, and the prevalence of human immunodeficiency virus (HIV) infection, hepatitis, and other communicable diseases has been shown to be high in…

Bedside Laboratory and Microbiologic Procedures

Assessment of Urine Obtaining a Urine Specimen Several methods are available for obtaining a urine specimen. They can be found in Table 67.1 and are listed in order of increasingly precise collection techniques. They come at the cost of increasing difficulty, patient discomfort, or both. TABLE 67.1 Urine Collection Methods Listed in Order of Increasing Precision METHOD DESCRIPTION AND COMMENTS Random voided Any specimen provided by…

Ultrasound

Bedside ultrasound has become an indispensable tool in the emergency department (ED). It has enabled physicians to make a rapid diagnosis at the bedside and formulate a plan of care. Perhaps most importantly, ultrasound has revolutionized procedures performed in the ED. Use of ultrasound gives the physician the advantage of viewing the anatomy and directly imaging the procedure while it is being performed. Procedures that had…

Procedures Pertaining to Hypothermia and Hyperthermia

Procedures Pertaining to Hypothermia With an increase in outdoor activities, changing weather patterns, and the growing epidemic of homelessness in our country, issues pertaining to hypothermia remain in the forefront. Hypothermia is not only a common diagnosis in rural areas but has also become more commonplace in urban centers across the nation secondary to inadequate housing or lack of preparation for cold weather changes. It is…

Emergency Dental Procedures

Complaints pertaining to the teeth and supporting maxillofacial structures are common, and patients frequently go to the emergency department (ED) for evaluation. Complaints may range in scope from a simple chipped tooth to an odontogenic deep space infection or a maxillofacial injury. Treating these patients can be challenging and frustrating for busy emergency clinicians. Many emergency clinicians and other acute care providers do not receive specific…

Otolaryngologic Procedures

The procedures presented in this chapter are most effectively performed with special equipment and techniques ( Videos 63.1 – 63.10 ). Some are within the realm of general emergency medicine clinical expertise; others are not. They are reviewed from the perspective of the emergency clinician who must decide whether the patient needs treatment acutely in the emergency department (ED), can be managed with timely referral, or…