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Decontamination of the Poisoned Patient

Introduction In 2014, the National Poison Data System of the American Association of Poison Control Centers reported 2,165,142 human toxic exposures and 1408 resultant fatalities. Of these total exposures, 28.3% were managed in a health care facility. Massive exposure to some toxic agents (e.g., calcium channel blockers, tricyclic and other antidepressants, antipsychotics, β-blockers, colchicine, chloroquine, cyanide, Amanita phalloides mushrooms, and paraquat) will probably result in severe…

Balloon Tamponade of Gastroesophageal Varices

Introduction Managing patients with acute gastrointestinal bleeding from gastroesophageal varices can be one of the most challenging scenarios in emergency medicine. These patients often have advanced liver disease and can arrive at the emergency department (ED) with massive hematemesis, airway compromise, hemodynamic instability, critical anemia, thrombocytopenia, and coagulopathy. Gastroesophageal varices are the fourth most common cause of upper gastrointestinal bleeding (UGIB) and account for almost 12%…

Nasogastric and Feeding Tube Placement

Nasogastric (NG) intubation ( Videos 40.1 – 40.5 ) is commonly used to evaluate or treat bowel obstruction, ileus, or gastric hemorrhage, preoperatively or postoperatively, or to administer food or medication into the gastrointestinal (GI) tract. Patients with long-term feeding tube complications and those requiring replacement or other manipulation of tubes are frequently seen and treated in the emergency department (ED). Properties of NG and Feeding…

Esophageal Foreign Bodies

Patients with foreign bodies (FBs) lodged in the esophagus commonly present to the emergency department (ED) for evaluation and treatment. Though most commonly accidental, FBs may sometimes be swallowed purposefully. Patients may have a sensation of a recently passed FB, minor irritation, life-threatening airway obstruction, or other significant complications. Because of the anatomic and physiologic features of the esophagus, FBs in this area of the gastrointestinal…

Burn Care Procedures

Two million people suffer a burn-related injury every year in the United States. The American Burn Association (ABA) estimates that almost 500,000 of these patients received medical evaluation and treatment in 2014 and approximately 40,000 required hospitalization. According to the 2014 National Burn Repository, patients who suffer burn injuries are predominately male (69%), and their mean age is 32 years old. Children younger than 5 years…

Incision and Drainage

Incision and drainage (I&D) procedures ( Videos 37.1 – 37.5 ) in the emergency department (ED) are most commonly performed for soft tissue abscesses ( Fig. 37.1 ). The total number of ED visits increased from 90 million to 115 million over a 10-year period, with visits for abscess-related complaints increasing faster than overall ED visits. Of an estimated 34.8 million ambulatory visits for skin and…

Foreign Body Removal

Evaluation and Diagnosis A foreign body (FB) is any substance that is not naturally part of the body. These cases are common in the clinical setting. An FB should be suspected whenever the skin is broken. A thorough history and physical examination are essential to assess the risk for an FB. During assessment, FBs may not be obvious especially when the wound may appear closed, but…

Methods of Wound Closure

Wound Tape Surgical tape strips are now routinely used to close simple wounds. Tape strips can be applied by health care personnel in many settings, including emergency departments (EDs), operating rooms, clinics, and first aid stations. Advantages include ease of application, reduced need for local anesthesia, evenly distributed wound tension, no need for suture removal, no residual suture marks, minimal skin reaction, superiority for some grafts…

Principles of Wound Management

Management of acute traumatic wounds is one of the most common procedures in emergency medicine. Although many aspects of traumatic wound management remain controversial, the clinician can follow some basic principles to maximize the chance for successful healing. The purpose of this chapter is to give the clinician a general approach to wound care and to describe appropriate indications and techniques for wound management. Wound care…

Systemic Analgesia and Sedation for Procedures

Procedural sedation and analgesia (PSA) refers to the use of analgesic, dissociative, and sedative agents to relieve the pain and anxiety associated with diagnostic and therapeutic procedures. PSA is an integral element of emergency medicine residency and pediatric emergency medicine fellowship training and curricula, and graduates of these programs are skilled in the practice of PSA. Moreover, by virtue of their training, emergency clinicians are proficient…

Intravenous Regional Anesthesia

Clinical use of intravenous regional anesthesia (IVRA) has been well established as a safe, quick, and effective alternative to general anesthesia in selected cases requiring surgical manipulation of the upper and lower extremities. Though historically relegated to the operating room, the procedure is also readily applicable to outpatient use. Because of its reliability, safety, and ease of use, it is now commonly used in the emergency…

Regional Anesthesia of the Thorax and Extremities

Virtually every peripheral nerve can be blocked at some point along its course from the spine to the periphery ( Videos 31.1 to 31.14 ), but digital nerve blocks (e.g., fingers and toes) are more commonly used than proximal blocks. Other common applications include femoral blocks for fractures of the femur, ankle blocks for foot injuries and infections, intercostal blocks for rib fractures, and wrist blocks…

Regional Anesthesia of the Head and Neck

Emergency physicians encounter patients with dental pain, facial lacerations, and other injuries of the head on a regular basis. The assessment of these injuries can be both time consuming and painful. Thankfully, regional anesthesia for these conditions is easy to instill, reliable, and safe. Techniques such as nerve blocks can be used for patient comfort during repair of lacerations of the face, ear, forehead, and, particularly,…

Local and Topical Anesthesia

Local anesthetic agents are important tools used in the everyday practice of emergency medicine. This chapter describes the mechanism of action, the nuances of clinical use, and the adverse reactions to anesthetics that are commonly used in the emergency department (ED). Detailed technical guidance for the performance of topical and infiltrative local anesthesia is provided. Background The first local anesthetic was cocaine, an alkaloid in the…

Transfusion Therapy : Blood and Blood Products

Transfusion of blood components (red cells, white cells, platelets, whole plasma, or plasma fractions) is commonplace in the emergency department (ED). Annually in the United States, 15 million blood donations take place and 14 million units of red blood cells (RBCs) are transfused. Although acute hemorrhage is the most common emergency indication for blood transfusion, more nonemergency transfusions and blood component therapy now occur in the…

Autotransfusion

Introduction Autologous blood transfusion, or autotransfusion, is the collection and reinfusion of a patient's own blood for volume replacement. Preoperative blood banking and intraoperative cell salvage techniques have increased in a multitude of surgical specialties. Autotransfusion in the emergency department (ED) is usually limited to patients with severe, traumatic hemothorax and clinically significant blood loss. Autotransfusion is usually performed in trauma centers or in EDs with…

Alternative Methods of Drug Administration

The rapid administration of lifesaving, pain-relieving, and sedative medications lies at the core of the practice of emergency medicine. The intravenous (IV) route is usually the delivery method of choice. However, there are circumstances in which vascular access is either not available or contraindicated. Thus, emergency providers need to have a working knowledge of alternative routes of drug administration. This chapter describes the endotracheal (ET), intranasal…

Intraosseous Infusion

Establishing vascular access in critically ill and injured patients is central to the practice of emergency medicine. Moreover, placing an intravenous (IV) catheter in an acutely ill child can be one of the most challenging and frustrating procedures that a clinician can be called on to perform. Children have small peripheral vessels that collapse during shock, and their higher proportion of body fat makes visualization and…

Indwelling Vascular Access Devices: Emergency Access and Management

Indwelling vascular access devices (IVADs) provide routes for short- and long-term infusion of antibiotics, antifungal agents, hyperalimentation fluids, chemotherapeutic agents, blood products, analgesics, and anesthetic agents. In addition, they provide access for lifesaving procedures such as hemodialysis (HD) and plasmapheresis. As of 2013, nearly 422,000 patients were receiving HD therapy, with 3 to 5 million central venous catheters being placed yearly in patients in the United…

Venous Cutdown

Management of critically ill or injured patients requires immediate and adequate vascular access, especially during trauma resuscitation, when rapid infusion of crystalloid or blood products may be necessary. Venous cutdown, a time-honored surgical technique, has largely been replaced by alternative methods of obtaining venous access, including intraosseous lines, the Seldinger technique, and ultrasound-guided central and peripheral venous cannulation. Nonetheless, venous cutdown still has a role as…