Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Ophthalmologic Procedures

The following discussion focuses on procedures performed by emergency clinicians during the evaluation and treatment of injuries and diseases of the eye. Emphasis is placed on practical application of the techniques; cautions to be heeded by the emergency clinician are included. Not all procedures are mandated to be performed by the emergency clinician, and if beyond the expertise available in the ED, they may be referred…

Special Neurologic Tests and Procedures

Evaluation of the Comatose Patient Coma is defined as a state of deeply reduced consciousness from which a patient cannot be aroused by verbal, tactile, or noxious external stimuli. This subsection will review procedures that have important diagnostic and prognostic significance in the comatose patient: caloric testing and the evaluation of brain death. Caloric Testing Background In a comatose individual with normal brain stem and cranial…

Spinal Puncture and Cerebrospinal Fluid Examination

Cerebrospinal fluid (CSF) examination is performed in the emergency department (ED) to obtain information relevant to the diagnosis and treatment of specific disease entities. Many urgent and life-threatening conditions require immediate and accurate knowledge of the nature of the CSF. However, on rare occasions, certain harmful consequences may result from a spinal puncture. Perform a careful neurologic examination before the procedure, and give special thought to…

Management of Increased Intracranial Pressure and Intracranial Shunts

Headache and head injury are encountered commonly in the emergency department (ED). If either is accompanied by vomiting, decreased level of consciousness, or abnormal vital signs, the possibility of increased intracranial pressure (ICP) should be considered. Acutely increased ICP is a neurologic emergency that must be managed rapidly to prevent further brain damage and death. In some cases the accompanying clinical symptoms may be vague or…

Examination of the Sexual Assault Victim

The majority of sexually assaulted individuals do not share the experience with anyone, suffering in silence. An estimated one-third of all sexual assaults are reported to law enforcement. In many cases, after contact with law enforcement, patients are taken to the emergency department (ED) for evaluation, examination, and treatment. Sexual assault patients may also present to the ED de novo, without prior law enforcement contact. In…

Gynecologic Procedures

Pelvic Examination In an emergency department (ED) there are several reasons to perform a pelvic examination: lower abdominal pain, vaginal discharge, vaginal bleeding, suspected sexually transmitted disease (STD), retained foreign body, and possible Bartholin abscess (BA) of the vulva. Emergency physicians do not routinely screen for cervical cancer. The evaluation of sexual assault victims is discussed in Chapter 58 . Before performing a pelvic examination, the…

Emergency Childbirth

Background Of the more than 3.9 million births in the United States in 2013, 98.6% were delivered in a hospital setting. Although a physician was present for 91.7% of these births, the percentage of these births that occur in the emergency department (ED) setting is unknown. Childbirth is a relatively rare occurrence in the ED but ‘complications of pregnancy, childbirth, and puerperium’ is one of the…

Urologic Procedures

Introduction This chapter addresses urologic conditions that are either initially or eventually associated with an emergency procedure or may need to be performed in the absence of a urologic surgeon. Testicular torsion is a scrotal emergency that can be challenging to diagnose under the best clinical circumstances. Although surgical exploration is the only definitive diagnostic and therapeutic procedure, many urologists prefer an initial diagnostic imaging study…

Compartment Syndrome Evaluation

Open fractures, dislocations, and exposed joints are true orthopedic emergencies that must be managed aggressively to prevent morbidity and mortality. Even when managed appropriately, these injuries may be further complicated by a compartment syndrome, a condition of increased pressure within a limited space that results in compromised tissue perfusion leading to tissue ischemia, and ultimately dysfunction of the neural and muscular structures contained within that space.…

Arthrocentesis

Background Arthrocentesis, the puncture and aspiration of a joint, is an acknowledged, useful procedure that is easily performed in the emergency department (ED). It has been established as both a diagnostic and therapeutic tool for various clinical situations. When performed properly, the procedure offers a wealth of clinical information and is associated with few complications. In the ED it is difficult to make an accurate assessment…

Treatment of Bursitis, Tendinitis, and Trigger Points

Bursitis and tendinitis are terms frequently used to describe a variety of common and often ill-defined regional musculoskeletal conditions characterized chiefly by pain and disability at the involved site. They are either periarticular or contained within specific soft tissue structures. Myofascial pain syndromes are characterized by sensory, motor, and autonomic symptoms that are associated with a trigger point, a hyperirritable point in skeletal muscle that reproduces…

Podiatric Procedures

Normal daily activities cannot easily be accomplished without walking, so patients with painful or infectious conditions of the feet often seek medical attention. This chapter focuses on procedures performed for common maladies of the foot. Other procedures on the foot are described elsewhere in this text, including anesthesia of the foot and ankle (see Chapters 29 and 31 ), management of nail bed injuries (see Chapters…

Splinting Techniques

Splints are used frequently in the emergency department (ED) for temporary immobilization of fractures and dislocations and for definitive treatment of soft tissue injuries. Patients with a variety of nontraumatic musculoskeletal disorders (e.g., gout, inflammatory joint diseases, infections, burns) also benefit from short-term immobilization. Immobilization is the mainstay of fracture therapy, but though intuitively beneficial, it is difficult to find firm scientific data that support the…

Management of Common Dislocations

Joint dislocations are frequently encountered in patients seen in the emergency department (ED). They can range from a simple finger joint dislocation to limb- or life-threatening consequences of high-energy trauma. Keys to clinical assessment and radiographic evaluation of these injuries are discussed along with methods of reduction. The emphasis of the chapter is on simple dislocations that should be diagnosed and initially managed in the ED…

Extensor and Flexor Tendon Injuries in the Hand, Wrist, and Foot

Extensor Tendons Extensor tendons are quite superficial, covered only by skin and a thin layer of fascia, and are thus highly susceptible to injury by commonly experienced trauma. Such injuries may result from lacerations, bites, or burns, but they may also be caused by closed injury or with even seemingly superficial lacerations. Whereas some extensor tendon injuries must be managed by a hand surgeon, others may…

Management of Amputations

Rapid and appropriate emergency care of a patient with an amputated body part is crucial to the salvage and preservation of function. This chapter discusses the emergency management priorities of patients with amputation injuries, the acute care of amputated parts before they are replanted, and the management of distal digit amputations and dermal “slice” wounds. Amputation may be partial or complete. Injuries with any interconnecting tissue…

Prehospital Immobilization

Modern emergency medical service (EMS) was created in 1966 as a result of the National Highway Safety Act. Since then, provision of medical care in the prehospital setting has undergone considerable change. Today's EMS providers perform many advanced lifesaving procedures. Nonetheless, the task of immobilizing potential injuries to the spine, pelvis, and extremities has remained a primary EMS function. This chapter reviews basic prehospital immobilization techniques…

Anorectal Procedures

Patients with anorectal disorders frequently seek care in the emergency department (ED). The condition may be isolated or the anorectal complaint may be an outward manifestation of a serious underlying illness. A thorough history and physical examination must precede any procedure. Because of the nature of these conditions, extreme sensitivity and professionalism must be applied. Patients may be anxious about anorectal examination or associated procedures, including…

Abdominal Hernia Reduction

When a patient is seen in the emergency department (ED) with a suspected abdominal hernia, the emergency clinician should consider three issues: (1) Is a palpable mass truly a hernia? (2) Is the hernia easily reducible or incarcerated? (3) Is the vascular supply to the bowel strangulated? A patient with an easily reducible hernia can be discharged safely for outpatient follow-up and elective repair, whereas an…

Peritoneal Procedures

Paracentesis and diagnostic peritoneal lavage (DPL) constitute the two primary intraperitoneal procedures. They are fundamentally similar in purpose and design; however, the former is generally reserved for medical concerns and the latter for evaluation of traumatic pathology. DPL Root and colleagues introduced DPL in 1964. It has withstood the passage of several decades and remains a useful diagnostic adjunct for the management of penetrating torso trauma.…