CLINICAL PEARLS FOR EMERGENCY DEPT DOCTORS

 CLINICAL PEARLS FOR EMERGENCY DEPT DOCTORS

 

Nephrolithiasis

The acute presentation of nephrolithiasis resembles other pathologies; the correct studies and appropriate interpretation of laboratory data will help to establish the diagnosis. Any patient with severe nausea, vomiting, fever, or signs of infection should be hospitalized. Adequate pain control for patients with suspected nephrolithiasis is a priority even before all test results return. All urine should be strained to confirm the diagnosis and for the stone composition to be discerned. The absence of pain does not mean follow-up is unnecessary. Identifying the etiology of stone formation is important to prevent a recurrence.

Streptococcal Pharyngitis (“Strep Throat”)

  The most common cause of pharyngitis is viral. The Centor criteria suggestive of GABS pharyngitis include tonsillar exudate, tender anterior cervical adenopathy, history of fever, and absence of cough. GABS pharyngitis is more common in patients younger than 15 years of age, and less common in those older than 45 years of age. Overtreatment of pharyngitis with antibiotics is common and is a major source of antibiotic overuse. Glomerulonephritis is a rare complication of GABS pharyngitis (but not GABS infections of other tissues) that is not clearly prevented by antibiotic therapy. Rheumatic fever is an exceedingly rare complication of GABS pharyngitis that can be prevented by antibiotic therapy. Complicated upper airway conditions should be considered when a patient presents with “sore throat.” In general, cricothyroidotomy is the safest method of surgically securing an airway in the ED.

ACS

CLINICAL PEARLS MONA greets chest pain at the door (morphine, oxygen, nitroglycerin, and, most importantly, aspirin). An ECG should be performed immediately in all patients with chest pain concerning for ACS. The ECG will dictate the next step in management: new ST elevation generally requires immediate reperfusion therapy. “Time is myocardium.”

Atrial Fibrillation

  Treatment of atrial fibrillation (AF) begins with searching for any underlying reversible causes of the arrhythmia. In an acute setting, the most important goal of therapy is ventricular rate control, typically through the use of AV nodal blocking drugs. Unstable patients with AF or Wolff-Parkinson-White tachyarrhythmia with AF should undergo immediate electrical cardioversion. Stable patients with AF for less than 48 hours can be cardioverted in the ED provided they have no prior history of thromboembolism, mitral valve disease, or LV dysfunction. Stable patients with AF of greater than 48 hours or unknown duration can be cardioverted in two ways: (1) anticoagulation for 3-4 weeks prior to, and following cardioversion, or (2) imaging by TEE and, if no intracardiac thrombus is seen, acute anticoagulation with heparin/LMWH, followed by cardioversion, and anticoagulation for 3-4 weeks. 70% of new-onset AF will spontaneously convert to sinus rhythm. Patients with AF have a two to three times higher risk of stroke than the general population. The choice of antithrombotic therapy for long-term AF depends on an individual’s CHADS2 score and risk of bleeding. Anticoagulation with either warfarin (INR goal 2-3) or dabigatran reduces the risk of thromboembolism.

 supraventricular tachycardia 

Regular rate tachycardias include several types of supraventricular tachycardia and ventricular tachycardia. As a general rule, narrow-QRS complex tachycardias arise from above the ventricles while wide-QRS complex ones may be supraventricular or ventricular in origin. If the patient is unstable (as evidenced by hypotension, pulmonary edema, altered mental status, or ischemic chest pain), synchronized cardioversion should be performed immediately. In stable patients, a 12-lead ECG should be obtained, and medical therapy can be initiated. If the provider cannot distinguish between VT and SVT with aberrancy with certainty, the patient should be treated as if VT is present. Always order an ECG in a patient with suspected tachyarrhythmia.

 DKA

Hyperglycemia, ketosis, and acidosis confirm the diagnosis of DKA and are enough to start fluids and insulin. Patients in DKA are almost always dehydrated and have significant sodium and potassium deficits, regardless of their specific laboratory values. Abdominal pain is a common feature in DKA and is usually idiopathic, especially in younger patients. Most morbidity in DKA is iatrogenic.

  severe sepsis

The most common causes of severe sepsis are urosepsis and pneumonia. Older, younger, or immunocompromised individuals may present with subtle signs such as lethargy, decreased appetite, or hypothermia. Early goal-directed therapy for sepsis includes careful monitoring of multiple markers of organ perfusion, with aggressive measures to restore any imbalance between oxygen supply and demand. Initially, large volumes of fluid administered in multiple boluses may be necessary (and in some cases sufficient) to maintain perfusion. An early and thorough search for a source must be undertaken, with immediate measures taken to control it. Whether or not an operable source is found, broad-spectrum antibiotics should be started immediately. If an operable source is found, it should be surgically treated as soon as the patient can tolerate it. A vasopressor agent such as norepinephrine or dopamine is the next step in treating hypotension that persists despite intravenous fluids.

  trauma patient

Evaluation of a trauma patient begins with assessment and stabilization of the ABCs. Hypotension in a trauma patient is hemorrhage until proven otherwise. A trauma patient should be assessed systematically for the source of hemorrhage. Laboratory evaluation is not as sensitive as the combination of history, clinical examination, physical examination findings, and vital sign abnormalities for the diagnosis of hemorrhagic shock. Therapy must be initiated promptly with fluid and/or blood product administration. Definitive therapy for control of hemorrhage should be arranged as soon as possible.

 The systematic approach to the trauma patient is ABCDE (airway, breathing, circulation, disability, exposure). A wound that does not penetrate the abdominal fascia may be irrigated and closed without further diagnostic studies. Penetrating trauma to the chest below the nipple line may cause thoracic, intra-abdominal, and occult diaphragmatic injuries. The FAST (focused abdominal sonogram for trauma) is fairly accurate in assessing intraperitoneal free fluid. Approximately 85% of penetrating cardiac stab wounds originate from a puncture to the “cardiac box.” patient is ABCDE (airway, breathing, circulation, disability, exposure). A wound that does not penetrate the abdominal fascia may be irrigated and closed without further diagnostic studies. Penetrating trauma to the chest below the nipple line may cause thoracic, intra-abdominal, and occult diaphragmatic injuries. The FAST (focused abdominal sonogram for trauma) is fairly accurate in assessing intraperitoneal free fluid. Approximately 85% of penetrating cardiac stab wounds originate from a puncture to the “cardiac box.”

The Canadian C-spine rule is an effective evaluation system to clinically clear C-spines in asymptomatic patients. Cervical spine injuries occur in 1% to 3% of all victims following blunt trauma. Distal radius fractures have a bimodal pattern with peaks in late childhood and after the sixth decade of life. 

anaphylaxis

 The airway should be secured early and often. It is much easier to extubate a patient without severe laryngeal edema than to intubate a patient with an occluded posterior oropharynx. Epinephrine should be given at the first sign of cardiovascular compromise. Look for causes of anaphylaxis after you have started your initial resuscitation. Steroids, antihistamines, and beta-agonists are all helpful pharmacologic adjuvants for managing the many symptoms of anaphylaxis.

 asthma

Initiate therapy with albuterol while obtaining history and performing a physical examination for patients with significant asthma. Glucocorticosteroids should be administered early for asthmatic exacerbations and continued for at least 1 week. Measure peak flow to help assess asthma severity and monitor progression during treatment. Use lower than traditional ventilator settings to prevent barotrauma in the intubated asthmatic. Most asthmatics should be discharged from the ED with inhaled corticosteroids for ongoing preventative therapy. The individual who presents with an initial episode of “wheezing” may have etiologies other than asthma, for example, foreign body, pneumonia, or congestive heart failure. Absence of wheezing can sometimes be misleading in the individual in extremis because of very little air movement.

 facial lacerations

The vermillion border must be precisely approximated because of its important cosmetic characteristics. Even a small discrepancy in lining up of the tissue is noticeable. The facial nerve courses from the mastoid region across the cheek area and is prone to injury in facial lacerations. Care must be taken to identify an injury to the nerve to prevent permanent deformity. Complex lacerations of the face, eye, ear, nose, and mouth, including lacerations associated with focal neurologic deficits (eg, facial droop or ptosis) should be cared for with expert consultation such as an ENT surgeon or ophthalmologist. Meticulous hemostasis is important in repairing ear lacerations to avoid “cauliflower ear.” Tetanus is an acute disease of wound contamination, which is largely preventable with immunization. All patients at risk for tetanus and not up- to-date on their tetanus vaccination should receive tetanus immunoglobulin or tetanus toxoid.

 In the United States, rabies transmission by dogs is nearly zero whereas transmission by bats is more often seen. Worldwide, dog transmission is still common. Rabies prophylaxis is indicated for uncaught wild animals and animals that start behaving abnormally. Bites that are more than 6 hours old are, in general, left open, because of the risk of infection. Snakebites should be treated like other bites with special attention paid to species identification and rapid administration of antivenin if required.

 Strokes may present in a variety of ways, and the differential diagnosis of stroke is broad. Clinicians must take a careful history, including the time of onset of symptoms. The NIHSS measures the impairment due to stroke. A bedside glucose measurement and a CT scan of the head are the most urgent diagnostic studies in suspected stroke. Treatment is aimed at stabilizing the ABCs, evaluating for possible thrombolytic administration, and addressing comorbid conditions such as hypertension.

 The primary goal of the EP in the evaluation of patients with syncope is to be able to identify those who are at high risk for morbidity and mortality. The causes of syncope are varied, and a successful diagnosis hinges on diligent history collection and appropriate use of diagnostic tools. Even the most experienced clinician will be unable to determine the cause of syncope in up to 50% of patients. Reassuring clinical signs in syncope are youth, a normal ECG, absence of comorbidities, and reassuring historical features. Unstable patients should be treated emergently and stabilized, first addressing the ABCs.

 High clinical suspicion is the most important factor in determining the workup of PE, as its presentation is often elusive. High-sensitive D-dimer study is useful for its negative predictive value in excluding DVT and PE. V/Q scan is useful in risk-stratifying renal failure and possibly the pregnant patient with suspected PE. MDCTA has become the initial test of choice for patients with a high pre-test probability for PE and no contraindications. Eighty percent of PEs develop from DVTs involving the iliac, femoral, or popliteal veins.

 Hypertensive emergency is defined as markedly elevated blood pressure in the presence of end-organ damage, whereas hypertensive urgency is markedly elevated blood pressure without end-organ effects. One of the most common reasons for hypertensive emergency is patient noncompliance with antihypertensive medication. It is critical to cautiously lower blood pressure to avoid inducing a hypoperfusion state that leads to cerebral ischemia. Patients with hypertensive emergency should be admitted to a monitored setting, preferably an intensive care unit.

 Most patients with the diagnosis of “undifferentiated abdominal pain” determined after thorough ED evaluation will have spontaneous resolution of pain. Narcotic medications will affect the characteristics and intensity of all abdominal pain, regardless of etiology. Up to one-third of elderly patients with abdominal pain evaluated in the ED have conditions that may require surgical intervention.

 Children account for the vast majority of cases of swallowed foreign bodies. In the pediatric patient, objects most commonly lodge in the proximal esophagus, whereas most adult patients have distal esophageal obstructions. Findings such as fever, subcutaneous air, or peritoneal signs suggest perforation and necessitate an emergent surgical consult. Button batteries in the esophagus as well as sharp, pointed objects in the stomach must be removed as soon as possible. In general, the preferred method of swallowed foreign body removal is endoscopy (except in body packers because of the risk of packet rupture).

  Persistent pain in a patient with small-bowel obstruction is usually suggestive of bowel ischemia or impending bowel necrosis. Localized tenderness in a patient with small-bowel obstruction may indicate an isolated segment of closed-loop obstruction, localized ischemic injury, or localized perforation. Because the symptoms and physical findings associated with large-bowel obstruction are nonspecific, they can be easily overlooked by both the patient and the physician. Adhesions represent the most common cause of small-bowel obstruction, whereas colorectal carcinoma is the most common cause of large-bowel obstruction.

 The vast majority of acute diarrhea is caused by an infectious etiology. Most acute diarrheas are self-limited. One should be cautious when assessing acute diarrhea in immunosuppressed patients, very young, or elderly patients. Significant dehydration, grossly bloody diarrhea, high fever, and nonresponse after 48 hours are warning signs of possible complicated diarrhea. In general, acute uncomplicated diarrhea can be treated with oral electrolyte-fluid solution with or without empiric ciprofloxacin.

 The acute presentation of nephrolithiasis resembles other pathologies; the correct studies and appropriate interpretation of laboratory data will help to establish the diagnosis. Any patient with severe nausea, vomiting, fever, or signs of infection should be hospitalized. Adequate pain control for patients with suspected nephrolithiasis is a priority even before all test results return. All urine should be strained to confirm the diagnosis and for the stone composition to be discerned. The absence of pain does not mean follow-up is unnecessary. Identifying the etiology of stone formation is important to prevent recurrence.

 A thorough history and physical examination will often help to identify the cause of acute urinary retention. Bladder decompression should be performed as quickly as possible to prevent further damage to the urinary system. Consultation with a urologist may be necessary if urethral catheterization cannot be accomplished with a Foley or coudé catheter. Admission should be considered for patients with renal dysfunction, a serious infection, or volume overload and for those who are unable to care for themselves.

  The classic triad of symptoms for diagnosing PID include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness. Laparoscopy remains the gold standard for diagnosing PID. TOAs often present in a subtle or indolent fashion and require imaging for diagnois. TOAs require hospital antibiotic therapy and the majority can be treated medically. Patients with a ruptured TOA present in shock. This is a surgical emergency. Long-term sequelae of PID include infertility, pelvic adhesions, chronic pelvic pain, risk of ectopic pregnancy, and Fitz-Hugh-Curtis syndrome. Disseminated gonococcal infection, although uncommon, is a serious complication of untreated gonorrhea, which is a very common infection. Persons found to have a positive gonorrhea culture should also be treated for Chlamydia because concomitant infection is found in as many as 40% of patients. In any person presenting with asymmetric polyarthritis, tenosynovitis, and pustular skin lesions, disseminated gonococcal infection should be considered in the differential diagnosis.

 Bell palsy is an idiopathic seventh cranial nerve peripheral neuropathy, leading to both upper and lower facial weakness. The diagnosis of Bell palsy is one of exclusion. The most important assessment in a patient who presents with possible Bell palsy is to rule out serious disorders such as intracranial tumors and strokes. Protection of the eye to prevent corneal drying and abrasions is accomplished with an eye patch during sleep and lubricants to the affected eye. The prognosis of Bell palsy is usually favorable, but persistent weakness, the appearance of other neurologic deficits, or blisters that appear on the ear are indications for referral.

 In any woman of childbearing age, consider pregnancy. If the pregnancy test is positive, consider an ectopic pregnancy. Consider pregnancy even when a woman has had a tubal ligation or is using contraception. When the serum quantitative hCG level is above 1500 to 2000 mIU/mL and transvaginal ultrasound does not reveal an intrauterine pregnancy, the risk of ectopic pregnancy is high. Surgery, not methotrexate, is the best treatment for the patient who is hemodynamically unstable or with significant abdominal pain. Laparoscopy remains the gold standard for ectopic pregnancy.

 Nausea and vomiting in pregnancy is common, so that significant volume or metabolic derangements in these patients can be minimized. Hyperemesis is a diagnosis of exclusion. The physiologic changes of pregnancy should be considered when interpreting ABGs. For instance when the PCO2 exceeds 40 mm Hg in a pregnant asthmatic, severe hypercarbia is present and intubation should be considered. Dyspnea and hypoxemia after treatment for pyelonephritis is usually caused by endotoxin-related pulmonary injury, ARDS. Hyperthyroidism is typically treated with methimazole or PTU, and a β-blocker. When the hCG level exceeds the threshold of 1200 to 1500 mIU/mL and no gestational sac is seen in the uterus on transvaginal ultrasound, then an ectopic pregnancy is highly likely. The history for a gush of fluid followed by constant leakage is 90% accurate for rupture of membranes. In there is strong clinical suspicion, and the speculum examination is negative for ROM, an ultrasound assessment for amniotic fluid volume is helpful.

 A useful working differential diagnosis for vision-threatening causes of red eye includes acute angle-closure glaucoma, anterior uveitis, endophthalmitis, corneal ulcer, corneal infection, chlamydial/gonococcal conjunctivitis, orbital cellulitis, hyphema, retrobulbar hemorrhage, and scleritis. Subconjunctival hemorrhages should be painless and does not affect vision. In the setting of blunt trauma, continue evaluating for hyphema, hypopyon, globe rupture, endophthalmitis, or retrobulbar hemorrhage if the patient complains of pain or vision changes and emergently consult an ophthalmologist. Slit-lamp examination, fluorescein staining, and measurement of intraocular pressure are essential elements of a thorough evaluation of the red eye. Beware of systemic complications from topical ophthalmologic medications. Allergic reactions and complications such as bronchospasm from topical β-blockers are common.

  The classic triad of fever, neck stiffness, and a change in mental status is present in less than 50% of patients with bacterial meningitis. Younger patients that are otherwise healthy do not require neuroimaging prior to LP if they have a normal neurologic examination including mental status. Initial antimicrobial therapy in adults should include a third-generation cephalosporin and vancomycin to cover drug-resistant S pneumoniae. Patients older than 50 years, alcoholics, and immunocompromised patients should have ampicillin added to the empiric antimicrobial therapy to cover L monocytogenes. Dexamethasone prior to or with the first dose of antibiotics has been shown to decrease neurologic sequelae as well as mortality among adults with bacterial meningitis.

 Identifying the patient within one of the following subgroups facilitates the evaluation and management of the seizure patient in the emergency department: (a) new-onset (first-time) seizure, (b) recurrent seizures in patients with epilepsy, (c) febrile seizures, (d) post-traumatic seizures, and (e) alcohol- and drug-related seizures. The possibility of reactive seizures should be considered in all seizure patients who present to the ED, including patients with a history of epilepsy. Failure to treat the underlying cause of reactive seizure is a major pitfall. Seizures may be confused with other nonictal states such as syncope, hyperventilation, and breath-holding spells in children, migraines, transient global amnesia, cerebral vascular disease, narcolepsy, and psychogenic seizures. Prolonged altered mental status following a seizure should not be attributed to an uncomplicated postictal state.

Be sure to talk with family, EMS, nursing home care providers and review medical records for important pieces of historical information, new medications, and baseline behavior and functional status. Check vitals signs frequently, making sure to get accurate readings on pulse oximetry, temperature, and blood pressure. A glucose level should be checked immediately in all patients with altered mental status. Be careful not to classify a confused elderly patient as demented without first ruling out organic causes of their confusion. 

Always order an ultrasound and perform arthrocentesis in a child with fever who refuses to move a joint. Transient synovitis should be a diagnosis of exclusion. Consider Legg-Calve-Perthes disease in boys aged 4 to 8 who present with a limp as it requires a high index of suspicion. SCFE treatment is operative and 30% to 60% will eventually have bilateral disease. To prevent delay in diagnosis of the second slip, all patients should be followed closely by an orthopedist until the child has finished growing. Perform a thorough history (with and without the parent) and physical on children who present with fractures to evaluate for possible child abuse. 

  Most patients with acute low back pain have a resolution of symptoms within 4 to 6 weeks. Pain that interferes with sleep, significant unintentional weight loss, or fever suggests an infectious or neoplastic cause of back pain. Low back pain with associated bowel and bladder dysfunction is suspicious for cauda equina syndrome. Most patients do not require diagnostic tests or imaging studies. However, further testing may be advisable if there is a concern for rheumatologic, infectious, neoplastic processes; fracture; or cauda equina syndrome. Pain control is important in the management of patients with low back pain. Acetaminophen, NSAIDs, and narcotics are all viable options.

 Historical information may help narrow the list of likely pathogens based on clinical symptomatology and risk factors for specific infections. Patients at the extremes of age and those immunocompromised may present atypically (clinically as well as radiographically). The chest x-ray is usually the most important diagnostic study in patients with suspected pneumonia. Empiric antibiotics are chosen based on the most likely pathogens (as determined by assessment of risk factors, clinical presentation, and radiographic findings). Factors to be considered when determining need for admission include the patient’s age and comorbidities, physical examination and diagnostic findings, ability to tolerate oral medications, social situation, and ability to obtain close follow-up.

 Although most GI bleeds resolve spontaneously, each case is potentially life threatening. The main priorities are to determine whether there has been significant blood loss and to maintain hemodynamic stability. In upper GI bleeds, endoscopy is the study of choice because it can also be used to treat. Anoscopy, sigmoidoscopy, or colonoscopy are preferred in lower GI bleeds. In general, all patients with GI bleeding are admitted. If hemodynamically unstable or actively bleeding, they should be admitted to an ICU setting.

 The most common causes of CHF include coronary artery disease and hypertension while the most common causes of an acute exacerbation are myocardial ischemia or infarct and noncompliance. BNP is a hormone released by the ventricles in response to stretch. It can be useful as a marker for heart failure. Treatment of CHF includes oxygenation, correction of the underlying cause, and relief of symptoms by vasodilation, diuresis, and possibly inotropic support.

 The clinical manifestations of cocaine intoxication result from sympathetic overstimulation and vasoconstriction. Cocaine intoxication can cause life-threatening complications, such as dysrhythmias, hyperthermia, and hypertensive emergencies. Cocaine can cause a quinidine-like effect, prolonging the QT interval and leading to wide-complex dysrhythmias, bradycardia, and hypotension. β-Blockers are avoided in patients with cocaine intoxication because of the risk of unopposed α-adrenergic stimulation. Benzodiazepines are a mainstay of treatment for cocaine toxicity and many of its complications.

Because the devastating effects of APAP toxicity may be delayed for 24 to 72 hours and antidotal therapy is most effective if started within 8 hours of ingestion, the clinician must have a high level of suspicion of APAP toxicity in any poisoned patient. APAP toxicity is caused by the formation of a toxic metabolite, N-acetylp-benzoquinoneimine (NAPQI). N-acetylcysteine (NAC) is the antidote for APAP toxicity and should be given if a toxic ingestion is suspected (based on ingested dose or APAP level and Rumack-Matthew nomogram). The priorities when dealing with a patient with an APAP overdose are to perform a rapid assessment, stabilize the ABCs, decontaminate, minimize absorption, and administer NAC if appropriate. In general, an APAP level should be drawn on any patient with an overdose history even when APAP ingestion is denied.

  Sickle cell disease can manifest in any organ system and has a variety of clinical presentations ranging from mild to life-threatening. Because patients with sickle cell disease are functionally asplenic after early childhood, they are at risk for infection by encapsulated organisms (eg, Haemophilus influenzae, Streptococcus pneumoniae), and therefore must be immunized with the appropriate vaccines. Acute chest syndrome is the leading cause of premature death in patients with sickle cell disease. Having a low threshold of suspicion in patients presenting with respiratory complaints, abnormal oxygen saturation, or findings on lung examination, is critical. Treatment of acute chest syndrome involves supplemental oxygen, hydration, analgesia, empiric antibiotics, and possibly exchange transfusion. Splenic sequestration has a very high mortality. Patients present with an abrupt drop in hemoglobin and the potential for shock, requiring emergent transfusion and spleenectomy. Aplastic crisis occurs from a transient suppression of erythropoiesis. It is characterized by significant anemia accompanied by a low reticulocyte count. It is most commonly caused by parvovirus B19. Patients in pain crises require prompt attention and treatment of their pain. Intravenous opiates, such as morphine or hydromorphone, are the mainstay of pain management in the ED.

 Because hypothermia and frostbite often occur simultaneously, prevention of further systemic heat loss is the highest priority. Field rewarming is rarely warranted because of the potential for incomplete or interrupted rewarming. Injured parts should be protected, core temperature stabilized and patient transferred to the ED for rapid rewarming. A rewarming bath should be maintained at a temperature of 37°C to 41°C (98.6°F-105.8°F). Standard hospital thermometers only read as low as 34°C (93°F), so a specialized low-temperature thermometer is required to obtain an accurate core body temperature. A severely hypothermic patient can present with rigidity, asystolic, and with fixed pupils; however, he or she should not be pronounced deceased until the core body temperature has been warmed to at least 35°C (95°F). Hypoglycemia, sepsis, and hypothyroidism are conditions that may mimic or coexist with hypothermia. Ethanol abusers and the elderly are at high risk for cold-exposure injuries.

 Precipitants (such as alcohol use, seizures, and hypoglycemia) and associated cervical spine and head injuries must be considered in any submersion victim. The most common complications involve pulmonary or central nervous system dysfunction or dysrhythmias. The most important treatment to optimize outcome is rapid initiation of resuscitation in the prehospital arena . Victims of submersion injury often require aggressive respiratory support.

  Potentially ominous historical findings include sudden onset, “the worst headache of life,” headaches dramatically different from past episodes, immunocompromised, new onset after age 50 years, and onset with exertion. Diagnostic testing must be based on clinical suspicion. For example, if there is a concern for a subarachnoid hemorrhage, a CT scan of the head and lumbar puncture (if CT is negative) are warranted. In general, management includes stabilizing any life-threatening conditions, controlling pain, and addressing any underlying disease or specific etiologies.

 Heat stroke is distinguished from other heat illnesses by a loss of thermoregulation, tissue damage, and multiorgan failure. Classically, these patients present with hyperpyrexia and CNS dysfunction. Because heat stroke has a mortality of 10% to 20% even with treatment, it is essential to diagnose and begin therapy immediately. The treatment of heat stroke consists of stabilizing the ABCs, rapid cooling, replacing fluid and electrolyte losses, and treating any complications (eg, shivering, seizures, rhabdomyolysis).

 Victims of lightning strike should be treated with aggressive ventilatory and circulatory support until cerebral function can be assessed, because many patients will recover function with time. Typical signs of brain death, fixed/dilated pupils and apnea, do not necessarily indicate brain death in electrical victims. Moreover, typical triage criteria for mass casualty situations do not apply to electrical injury. Even with small outward sign of injury, major internal damage is common. Children may have excessive bleeding from chewing on electrical cords.

 TRALI, thought to be mediated by antileukocyte antibodies, presents with fever, tachycardia, and dyspnea as the most common presenting symptoms. The hallmark of TRALI is respiratory distress with the presence of diffuse, bilateral alveolar and interstitial infiltrates on radiographic imaging.

 Testicular torsion should always be considered in the differential diagnoses of acute scrotal or abdominal pain. No single historical or examination finding can definitively distinguish testicular torsion from other processes. Time is testicle. If testicular torsion is suspected, prompt urological consultation is mandatory. Definitive treatment of testicular torsion is surgery. Manual detorsion may be attempted as a temporizing measure.

 The first priority in evaluating a pediatric or geriatric trauma patient is the ABCs. The most life-threatening injury in intentional child injury is head injury. Soft-tissue and skin injuries are the most common child injury. Myocardial infarction is the leading cause of death among 80-year-old patients in the postinjury setting. Early management of geriatric trauma patient should be directed toward early monitoring of patients to avoid hypovolemia, inadequate treatment of pain, and hypothermia.

 Dysfunctional uterine bleeding (DUB) is a diagnosis of exclusion and indicates excessive or prolonged bleeding without structural pathology of the genital tract. The most common reason for DUB is anovulation, the bleeding pattern is heavy and unpredictable. Therapeutic options of acute and active significant vaginal hemorrhage due to DUB include IV estrogen therapy and uterine D and C. A clinical effect from the estrogen can be seen within 4 hours. Pregnancy must be ruled out in any woman presenting with DUB. Endometrial sampling should be considered in any woman over the age of 35 with DUB and in individuals at risk for endometrial hyperplasia/cancer. Oral contraceptive agents are a reasonable option for the treatment of patients with DUB who are hemodynamically stable once pregnancy, coagulopathy, and structural lesions of the uterus are excluded. A teenager who presents with DUB may have a bleeding diathesis such as von Willebrand.

 Boerhaave syndrome shoul d always be considere d in th e differential diagnosis of acute CP and especially if the patient has been vomiting or performing any activity where barotrauma may have been sustained due to valsalva maneuver. Gas trografin should be used instead of barium to avoi d severe mediastinal and intra-pleural inflammatory reactions when doing contrast studies to locate the site of esophageal perforation. GI Cocktail can not be used to reliably rule out a cardiac etiology for an episode of CP. Response to a trial of sublingual nitroglycerin does no t distinguish between coronary artery disease and GERD induced esophageal spasm. A single normal ECG can not be used to make the diagnosi s of NCCP. A significant percentage of patients (2%-3%) labeled with a diagnosis of NCCP will have an adverse cardiac event within 30 days

 In a patient with known or suspected renal failure, ECG changes consistent with hyperkalemia should be treated immediately as a life-threatening emergency. Do not await laboratory confirmation. The ECG findings of hyperkalemia can progress very rapidly, and do not reliably pass through all the stages of the “typical” textbook presentation. Intravenous calcium is the antidote of choice for life-threatening arrhythmias related to hyperkalemia, but its effect is brief and additional agents must be used. Symptoms of renal failure and hyperkalemia are usually nonspecific, so risk factors must be used to suspect the diagnosis.

  All urinary tract infections in men are considered complicated. The definitive diagnosis of a UTI is made on urine culture from a noncontaminated urine sample. Care should be taken to exclude other etiologies, such as cervicitis, vulvovaginitis, and pelvic inflammatory disease, in female patients who present with urinary complaints. All pregnant patients with bacteriuria require antibiotic treatment to prevent complications. Patients with a UTI and an obstructed kidney stone are at high risk for morbidity and require urgent urologic consultation. Antibiotic therapy should be tailored to the type of UTI, the community resistance rates, and the patient ability to tolerate the medications.

 Remember the noninvasive maneuvers and interventions that may eliminate the need for intubation: nasopharyngeal airways, chin lift, suction, BiPAP. Always have suction available. Bag-valve-mask ventilation is a lifesaving intervention for almost all patients with respiratory failure—know how to do it! Use an oral airway when bagging a patient. Head position is key for both basic and advanced airway management. Take time to thoroughly prepare for RSI. Poor preparation should never be the reason for a failed airway. Call anesthesia and/or surgery early if a difficult airway is anticipated. Always anticipate the difficult airway and have back-up airway devices immediately available.

 Alcohol is a CNS depressant. Withdrawal leads to CNS stimulation and autonomic hyperactivity. The differential diagnosis of alcohol withdrawal includes infections, other seizure disorders, endocrine disorders, trauma, metabolic abnormalities, psychiatric disorders, drug intoxications, and other types of withdrawal syndromes. The mainstay of treatment for alcohol withdrawal is benzodiazepines.

 Patients who are hypoxic from an overdose typically will require a definitive airway such as endotracheal or nasotracheal intubation. Fever from an overdose is a poor prognostic indicator and should usually be addressed with large doses of benzodiazepines and intravenous fluids. Symptomatic patients require observation or admission until they are asymptomatic. In the undifferentiated altered mental status patient, blood sugar level should immediately be checked. The nearest poison control center should be contacted (1-800-222-1222) for overdoses, accidental ingestions, and adverse drug effects.

  A careful history and physical examination are useful in narrowing the differential diagnosis in patients with skin rashes. Patients with rashes should be examined from head to toe, including mucous membranes. “Red flags” for potentially serious or life-threatening causes of rash include history of immunocompromised, fever, toxic appearance, hypotension, petechiae or purpura, diffuse erythema, severe or localized pain, and mucosal lesions.

SOURCE-Case Files Emergency Medicine