Emergency Medicine

V

m

Emergency

Medicine

Sean O. Henderson

V

a

d

e

m

e

c

u

m

a

d

e

m

e

c

u

Table of contents

1. Emergency Resuscitation

2. Cardiovascular Disorders

3. Pulmonary Emergencies

4. Neurologic Emergencies

5. GI Emergencies

6. Genitourinary Emergencies

7. OB/GYN Emergencies

8. Orthopedic Emergencies

9. Endocrine and Electrolyte

Emergencies

10. Hematologic Emergencies

11. Infectious Disease Emergencies

The Vademecum series includes subjects generally not covered in other handbook

series, especially many technology-driven topics that reflect the increasing

influence of technology in clinical medicine.

The name chosen for this comprehensive medical handbook series is Vademecum,

a Latin word that roughly means “to carry along”. In the Middle Ages, traveling

clerics carried pocket-sized books, excerpts of the carefully transcribed canons,

known as Vademecum. In the 19th century a medical publisher in Germany, Samuel

Karger, called a series of portable medical books Vademecum.

The Landes Bioscience Vademecum books are intended to be used both in the

training of physicians and the care of patients, by medical students, medical house

staff and practicing physicians. We hope you will find them a valuable resource.

All titles available at

www.landesbioscience.com

LANDES

BIOSCIENCE

12. General Management

of the Poisoned Patient

13. Selected Environmental

Emergencies

14. ENT, Maxillofacial

and Dental Emergencies

15. Ophthalmologic Emergencies

16. Trauma

17. Psychiatric Emergencies

18. Special Imaging Studies

for the Emergency Department:

Angiography MRI V/Q

and Sestamibi

LANDES

BIOSCIENCE

Emergency Medicine Henderson a d eme c um V (excerpt)

ISBN 1-57059-668-9

9 781570 596681

V

m

Emergency

Medicine

Sean O. Henderson

V

a

d

e

m

e

c

u

m

a

d

e

m

e

c

u

Table of contents

1. Emergency Resuscitation

2. Cardiovascular Disorders

3. Pulmonary Emergencies

4. Neurologic Emergencies

5. GI Emergencies

6. Genitourinary Emergencies

7. OB/GYN Emergencies

8. Orthopedic Emergencies

9. Endocrine and Electrolyte

Emergencies

10. Hematologic Emergencies

11. Infectious Disease Emergencies

The Vademecum series includes subjects generally not covered in other handbook

series, especially many technology-driven topics that reflect the increasing

influence of technology in clinical medicine.

The name chosen for this comprehensive medical handbook series is Vademecum,

a Latin word that roughly means “to carry along”. In the Middle Ages, traveling

clerics carried pocket-sized books, excerpts of the carefully transcribed canons,

known as Vademecum. In the 19th century a medical publisher in Germany, Samuel

Karger, called a series of portable medical books Vademecum.

The Landes Bioscience Vademecum books are intended to be used both in the

training of physicians and the care of patients, by medical students, medical house

staff and practicing physicians. We hope you will find them a valuable resource.

All titles available at

www.landesbioscience.com

LANDES

BIOSCIENCE

12. General Management

of the Poisoned Patient

13. Selected Environmental

Emergencies

14. ENT, Maxillofacial

and Dental Emergencies

15. Ophthalmologic Emergencies

16. Trauma

17. Psychiatric Emergencies

18. Special Imaging Studies

for the Emergency Department:

Angiography MRI V/Q

and Sestamibi

LANDES

BIOSCIENCE

Emergency Medicine Henderson a d eme c um V (excerpt)

ISBN 1-57059-668-9

9 781570 596681

Sean O. Henderson, M.D.

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Emergency Medicine

GEORGETOWN, TEXAS

U.S.A.

vademecum

L A N D E S

B I O S C I E N C E

VADEMECUM

Emergency Medicine

LANDES BIOSCIENCE

Georgetown, Texas, U.S.A.

Copyright ©2006 Landes Bioscience

All rights reserved.

No part of this book may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopy, recording, or any

information storage and retrieval system, without permission in writing from the

publisher.

Printed in the U.S.A.

Please address all inquiries to the Publisher:

Landes Bioscience, 810 S. Church Street, Georgetown, Texas 78626, U.S.A.

Phone: 512/ 863 7762; Fax: 512/ 863 0081

ISBN: 1-57059-668-9

Cover artwork by Kristen Shumaker

Library of Congress Cataloging-in-Publication Data

Emergency medicine / [edited by] Sean O. Henderson.

p. ; cm. -- (Vademecum)

Includes bibliographical references and index.

ISBN 1-57059-668-9

1. Emergency medicine. I. Henderson, Sean O. II. Title. III. Series.

[DNLM: 1. Emergency Treatment--Handbooks. 2. Emergencies--Handbooks. WB 39

E5321 2006]

RC86.7.E5794 2006

616.02'5--dc22

2006005514

While the authors, editors, sponsor and publisher believe that drug selection and dosage and

the specifications and usage of equipment and devices, as set forth in this book, are in accord

with current recommendations and practice at the time of publication, they make no

warranty, expressed or implied, with respect to material described in this book. In view of the

ongoing research, equipment development, changes in governmental regulations and the

rapid accumulation of information relating to the biomedical sciences, the reader is urged to

carefully review and evaluate the information provided herein.

Dedication

Dedicated to the aspiring Emergency Physician.

Thanks to Drs. Greenspan, Calder, Swadron and Brown for their invalu￾able aid, and to all the authors, for their efforts on behalf of, and patience

with, this project.

Sean O. Henderson, M.D.

Contents

Preface............................................................................ xix

1.Emergency Resuscitation .................................................. 1

Stuart P. Swadron, Peter C. Benson and William K. Mallon

2.Cardiovascular Disorders ................................................ 16

Jason Greenspan, Shahram Tabib and Stuart P. Swadron

Part A: Hypertension and Hypertensive Emergencies ............................... 16

Part B: Acute Coronary Syndromes .......................................................... 23

Part C: Congestive Heart Failure............................................................... 34

Part D: Endocarditis.................................................................................. 39

Part E: Pericardial Diseases ....................................................................... 41

Part F: Structural Heart Disease ............................................................... 43

Part G: Aortic Emergencies ....................................................................... 49

3.Pulmonary Emergencies.................................................. 53

Deborah B. Diercks, Steven Offerman, Mark Thoma and Peter E. Sokolove

Part A: Acute Respiratory Failure (ARF) ................................................... 53

Part B: Asthma ......................................................................................... 56

Part C: Chronic Obstructive Pulmonary Disease ...................................... 61

Part D: Pneumonia ................................................................................... 63

Part E: Hemoptysis ................................................................................... 67

Part F: Pleural Effusions ........................................................................... 70

Part G: Pneumothorax .............................................................................. 72

Part H: Pulmonary Embolism ................................................................... 73

4.Neurologic Emergencies .................................................. 77

Jacquelyn Hasler Salas

Part A: Headache ...................................................................................... 77

Part B: Motor Deficits .............................................................................. 83

Part C: Altered Level of Consciousness ..................................................... 88

Part D: Infections of the Central Nervous System ..................................... 93

Part E: Cerebrovascular Emergencies ...................................................... 101

Part F: Dizziness and Vertigo .................................................................. 110

Part G: Seizures ....................................................................................... 115

5.GI Emergencies ............................................................. 121

Susan Stone and Andrew S. Kassinove

6.Genitourinary Emergencies........................................... 136

Chi Lee, Sean O. Henderson and Sabrina Grassl

7.OB/GYN Emergencies .................................................. 158

Stephen D. Docherty

Part A: Selected Obstetric Emergencies ................................................... 158

Part B: Selected Gynecologic Emergencies .............................................. 169

8.Orthopedic Emergencies ............................................... 175

Susan Zapalac and Mark G. Richmond

9.Endocrine and Electrolyte Emergencies ........................ 225

Jeffrey Denham and Wendy Denham

Part A: Endocrine Emergencies ............................................................... 225

Part B: Electrolyte Emergencies .............................................................. 243

10.Hematologic Emergencies ............................................. 251

Alicia Haglund

Part A: Transfusion in the Emergency Department ................................. 251

Part B: Thrombocytopenia ..................................................................... 255

Part C: Sickle Cell Anemia ...................................................................... 259

Part D: Oncologic Emergencies ............................................................... 264

Part E: Congenital Bleeding Disorders .................................................... 271

11.Infectious Disease Emergencies..................................... 278

Ellen M. Slaven, Fred A. Lopez and James Rhorer

12.General Management of the Poisoned Patient .............. 294

Kathryn Challoner

Part A: Initial Management .................................................................... 294

Part B: Individual Toxins ........................................................................ 297

13.Selected Environmental Emergencies ............................ 327

Paul Silka

14.ENT, Maxillofacial and Dental Emergencies ................. 357

Kirsten Calder and Jason Ruben

15.Ophthalmologic Emergencies ....................................... 388

Kirsten Calder and Jason Ruben

16.Trauma .......................................................................... 408

Stephen D. Docherty and Carla Valentine

17.Psychiatric Emergencies ................................................ 450

Carrie S. Korn, Adam J. Trenton and Glenn W. Currier

18.Special Imaging Studies for the Emergency

Department: Angiography MRI V/Q and Sestamibi ..... 471

Matt Hendrickson

19.Computed Tomography: Emergency Department

Applications .................................................................. 492

Sujal Mandavia and Diku Mandavia

20.Bedside Ultrasound in Emergency Medicine ................ 515

Diku Mandavia and Sujal Mandavia

21.Disaster Management ................................................... 533

Mark Hollinger

22.Special Pediatric Considerations ................................... 545

David Leader, Marilyn Hicks, Russell Karten, Lance Brown

and Olly Duckett

Part A: Pediatric Cardiopulmonary Arrest ............................................... 545

Part B: Cardiac Problems in Children ..................................................... 550

Part C: Genitourinary Problems in Children ........................................... 561

Part D: Orthopedic Problems in Children ............................................... 570

Part E: Infectious Disease Problems in Children ..................................... 577

Part F: ENT and Respiratory Problems in Children ............................... 586

Part G: Sickle Cell Disease in Children ................................................... 595

Part H: Neurologic Problems in Children ............................................... 599

Index ............................................................................. 615

Editor

Sean O. Henderson

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 6

Lance Brown

Division of Pediatric Emergency Medicine

Department of Emergency Medicine

Loma Linda University Medical Center and Children’s Hospital

Loma Linda, California, U.S.A.

Email: [email protected]

Chapter 22

Jason Greenspan

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 2

Stuart P. Swadron

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapters 1, 2

Assistant Editors

Kirsten Calder

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapters 14, 15

Associate Editor

Peter C. Benson

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 1

Kathryn Challoner

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 12

Glenn W. Currier

Department of Psychiatry

University of Rochester

Rochester, New York, U.S.A.

Email: [email protected]

Chapter 17

Jeffrey Denham

LAC+USC Medical Center

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 9

Wendy Denham

Huntington Memorial Hospital

Pasadena, California, U.S.A.

Email: [email protected]

Chapter 9

Deborah B. Diercks

Department of Emergency Medicine

University of California

Davis Medical Center

Sacramento, California, U.S.A.

Email: [email protected]

Chapter 3

Stephen D. Docherty

Department of Clinical

Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapters 7, 16

Olly Duckett

Department of Emergency Medicine

WakeMed

University of North Carolina - Chapel Hill

Raleigh, North Carolina, U.S.A.

Email: [email protected]

Chapter 22

Sabrina Grassl

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 6

Alicia Haglund

LAC+USC Medical Center

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 10

Matt Hendrickson

Cedars-Sinai Medical Center

and

Department of Emergency Medicine

Harbor-UCLA

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 18

Marilyn Hicks

Department of Emergency Medicine

WakeMed

University of North Carolina - Chapel Hill

Raleigh, North Carolina, U.S.A.

Email: [email protected]

Chapter 22

Mark Hollinger

Department of Emergency Medicine

LAC+USC Medical Center

Los Angeles County College of Nursing

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 21

Contributors

Russell Karten

Department of Emergency Medicine

Lankenau Hospital

Wynnewood, Pennsylvania, U.S.A.

Email: [email protected]

Chapter 22

Andrew S. Kassinove

Encino-Tarzana Medical Center

Tarzana, California, U.S.A.

Email: [email protected]

Chapter 5

Carrie S. Korn

Department of Emergency Medicine

Keck School of Medicine

and

LAC+USC Medical Center

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 17

David Leader

Department of Emergency Medicine

WakeMed

University of North Carolina - Chapel Hill

Raleigh, North Carolina, U.S.A.

Email: [email protected]

Chapter 22

Chi Lee

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 6

Fred A. Lopez

Department of Medicine

Louisiana State University

and

Medical Center of Louisiana

New Orleans, Louisiana, U.S.A.

Email: [email protected]

Chapter 11

William K. Mallon

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 1

Diku Mandavia

Department of Emergency Medicine

Cedars-Sinai Medical Center

and

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapters 19, 20

Sujal Mandavia

Department of Emergency Medicine

Cedars-Sinai Medical Center

and

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapters 19, 20

Steven Offerman

Department of Emergency Medicine

University of California

Davis Medical Center

Sacramento, California, U.S.A.

Chapter 3

James Rhorer

Our Lady of the Lake Hospital

Baton Rouge, Louisiana, U.S.A.

Chapter 11

Mark G. Richmond

Department of Emergency Medicine

Loma Linda University Medical Center

and

Children’s Hospital

Loma Linda, California, U.S.A.

Email: [email protected]

Chapter 8

Jason Ruben

LAC+USC Medical Center

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapters 14, 15

Jacquelyn Hasler Salas

Lompoc District Hospital

Lompoc, California, U.S.A.

Email: [email protected]

Chapter 4

Paul Silka

Department of Emergency Medicine

Cedars Sinai Medical Center

and

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 13

Ellen M. Slaven

Department of Emergency Medicine

Louisiana State University Health

Sciences Center

Charity Hospital

New Orleans, Louisiana, U.S.A.

Email: [email protected]

Chapter 11

Peter E. Sokolove

Department of Emergency Medicine

University of California

Davis Medical Center

Sacramento, California, U.S.A.

Email: [email protected]

Chapter 3

Susan Stone

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 5

Shahram Tabib

LAC+USC Medical Center

University of Southern California

Los Angeles, California, U.S.A.

Chapter 2

Mark Thoma

Department of Emergency Medicine

Davis Medical Center

University of California

Davis, California, U.S.A.

Email: [email protected]

Chapter 3

Adam J. Trenton

Department of Psychiatry

University of Rochester

Rochester, New York, U.S.A.

Chapter 17

Carla Valentine

Department of Emergency Medicine

Santa Barbara Cottage Hospital

Santa Barbara, California, U.S.A.

Email: [email protected]

Chapter 16

Susan Zapalac

Department of Emergency Medicine

Keck School of Medicine

University of Southern California

Los Angeles, California, U.S.A.

Email: [email protected]

Chapter 8

Preface

The idea when we started was to collect the core Emergency Medicine

information and present it in an abbreviated, succinct manner, useful to

housestaff and medical students. As we progressed it became obvious that

the very breadth of the specialty prevented any one person from accomplish￾ing this task. It also became obvious that our specialty had advanced past the

point where succinctness was possible. We peeled, boiled and pared, and

came up with this. We hope you find it useful.

Acknowledgments

To Carrie S. Korn, R.N., for her help in keeping track of all that paper.

CHAPTER 1

CHAPTER 1

Emergency Medicine, edited by Sean Henderson. ©2006 Landes Bioscience.

Emergency Resuscitation

Stuart P. Swadron, Peter C. Benson and William K. Mallon

What Is Resuscitation?

Resuscitation, a word derived from the Latin word meaning “to set in motion”, is

the term most commonly used to describe the emergent treatment of the most se￾verely ill and injured patients. To the emergency physician, the term encompasses

not only attempts to reanimate those patients in cardiopulmonary arrest, but the

treatment of virtually any diseases in the extremes of presentation. Resuscitation is

an active process that is intervention-oriented and often invasive. The emergency

physician (EP) confronted with a resuscitation must multitask and “set into mo￾tion” a team of health care workers which includes nurses, technologists and con￾sultants.

Resuscitation and the Downward Spiral of Disease

Most disease processes move through stages of severity, beginning with an asymp￾tomatic phase and progressing toward their end-stage. Generally speaking, distur￾bances in one physiologic function lead to disturbances in others and, through a

sort of pathologic “multiplier effect”, diseases gain momentum as they progress.

Diseases that have reached their end-stage often have such momentum that they

require intensive and rapid intervention if there is to be any hope of reversing the

underlying pathology. Although patients may present to the emergency department

at any stage in the continuum, it is those patients at the bottom of the spiral, those

with decompensated and end-stage disease, that will require resuscitation.

In general, attempts are made to tailor the treatment of a particular patient to the

tempo of their disease. The treatment of these processes should ideally occur at a

similar pace, because abrupt changes may cause additional risk to the patient. None￾theless, the momentum of end-stage disease will often force the emergency physician

to use drastic and potent therapy, and such therapy is usually not without adverse

consequences. The effect of the unwanted effects of therapy, together with the pow￾erful and synergistic downward forces of multiply deranged physiologic functions,

make resuscitation among the most challenging tasks of the emergency physician.

Shock: The Final Common Pathway

The final common pathway of most severe disease states is that of shock. Simply

defined, shock is the failure of the circulation to provide adequate tissue perfusion.

Although shock may not be present in all patients requiring emergent resuscitation,

if untreated or treated inadequately, most will eventually deteriorate into a shock

state. Once an illness progresses to a shock state, further deterioration involves a

complex interaction between the underlying disease, host factors and the patho￾physiology of the shock state itself.

Because of its central role in severe decompensated disease, a working knowledge

of the classification and approach to shock is essential. When the diagnosis is known,