An Introduction to Clinical Emergency Medicine Swaminatha V. Mahadevan, MD, FACEP, FAAEM Associate Chief, Division of Emergency Medicine Assistant Professor of Surgery (Emergency Medicine) Stanford University School of Medicine Emergency Department Medical Director Medical Student Clerkship Director Stanford University Medical Center, Stanford, CA Gus M. Garmel, MD, FACEP, FAAEM Co-Program Director, Stanford/Kaiser Emergency Medicine Residency Clinical Associate Professor of Surgery (Emergency Medicine) Stanford University School of Medicine Senior Staff Emergency Physician, The Permanente Medical Group Clerkship Director for Medical Students and Rotating Interns Kaiser Permanente Medical Center, Santa Clara, CA    Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge  , UK First published in print format - ---- - ---- © Cambridge University Press 2005 Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. 2005 Information on this title: www.cambridg e.org /9780521542593 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. - --- - --- Cambridge University Press has no responsibility for the persistence or accuracy of s for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Published in the United States of America by Cambridge University Press, New York www.cambridge.org paperback eBook (NetLibrary) eBook (NetLibrary) paperback Contents v Contents Contents List of contributors xi Foreword xv Acknowledgments xvii Dedication xix Gus M. Garmel S.V. Mahadevan and Shannon Sovndal Robert R. Leschke S.V. Gurudevan Robert J. Sigillito and Peter M.C. DeBlieux David E. Manthey Paul D. Biddinger and Stephen H. Thomas Eustacia (Jo) Su S.V. Mahadevan 9 Abdominal pain 145 Section 2 Primary Complaints 8 Pain management 131 7 Prehospital care and emergency medical services 117 6 Traumatic injuries 93 5 Shock 85 4 Cardiac dysrhythmias 63 3 Cardiopulmonary and cerebral resuscitation 47 2 Airway management 19 1 Approach to the emergency patient 3 Section 1 Principles of Emergency Medicine Tim Meyers and Gus M. Garmel Steven Go Barry Simon and Flavia Nobay Jeffrey A. Tabas and Susan B. Promes Victoria Brazil Lee W. Shockley Christopher R.H. Newton Rawle A. Seupaul Andrew K. Chang Ear pain 253 Gregory H. Gilbert and S.V. Mahadevan Nosebleed 265 Gregory H. Gilbert Throat pain 273 Michelle Huston Dan Garza and Gregory W. Hendey 20 Extremity trauma 287 19 Ear pain, nosebleed and throat pain (ENT) 253 18 Dizziness and vertigo 241 17 Diarrhea 233 16 Diabetes-related emergencies 225 15 Crying and irritability 217 14 Constipation 211 13 Chest pain 193 12 Altered mental status 179 11 Allergic reactions and anaphylactic syndromes 171 10 Abnormal behavior 161 Contents vi Contents Janet G. Alteveer Tamas R. Peredy and Gus M. Garmel Lynne McCullough and Eric Savitsky J. Scott Taylor Gino A. Farina and Kumar Alagappan Loretta Jackson-Williams and Robert Galli Douglas W. Lowery and Melissa J. Lamberson Mel Herbert and Mary Lanctot-Herbert Peter G. Kumasaka Jamie Collings and Brigham Temple Jonathan E. Davis Stephen R. Hayden Sharon E. Mace 33 Shortness of breath in adults 485 32 Seizures 473 31 Scrotal pain 461 30 Rash 443 29 Pelvic pain 427 28 Low back pain 413 27 Joint pain 401 26 Hypertensive urgencies and emergencies 393 25 Headache 375 24 Gastrointestinal bleeding 365 23 Fever in children 353 22 Fever in adults 333 21 Eye pain, redness and visual loss 313 Contents vii Contents Lance Brown and Steven M. Green Amal Mattu Steven A. McLaughlin Fred A. Severyn Pamela L. Dyne and Rita Oregon Jennifer A. Oman R. Jason Thurman and Kristy Self Reynolds Carolyn J. Sachs Heat illness 619 Ken Zafren Hypothermia 626 Ken Zafren Lightning injuries 633 Ken Zafren Near-drowning 639 Ken Zafren Terrestrial venomous bites and stings 644 Robert L. Norris 42 Environmental emergencies 619 41 Child abuse, elder abuse, intimate partner violence 607 Section 3 Unique Issues in Emergency Medicine 40 Weakness 581 39 Vomiting 569 38 Vaginal bleeding 555 37 Urinary-related complaints 543 36 Toxicologic emergencies 531 35 Syncope 517 34 Shortness of breath in children 503 Contents viii Contents Michael A. Gisondi Gregory Guldner and Amy Leinen Stephen J. Playe and Cemil M. Erdem George Sternbach Peripheral venous cannulation 681 Central venous cannulation 683 Intraosseous infusion 687 Arterial puncture 688 Nasogastric intubation 689 Bladder catheterization 691 Lumbar puncture 693 Slit lamp examination 695 Reduction of dislocations 696 Tube thoracostomy 700 Cervical spine clearance 703 Abscess incision and drainage 704 Michelle Lin F.C. von Trampe and Wendy C. Coates Eustacia (Jo) Su and Robert L. Cloutier Rita A. Sweeney and Diku Mandavia Appendix E Focused assessment with sonography in trauma 733 Appendix D Procedural sedation and analgesia 725 Appendix C Laceration repair 713 Appendix B Wound preparation 707 Appendix A Common emergency procedures 681 Section 4 Appendices 45 Occupational exposures in the emergency department 669 44 Legal aspects of emergency care 661 43 Ethics and end-of-life issues 653 Contents ix Contents Contents x Contents J. Michael Ballester Complete blood count with differential 739 Serum chemistries 740 Other chemistries 742 Liver function tests 743 Amylase 744 Lipase 744 Cardiac markers 744 B-type natriuretic peptide 745 PT, PTT, INR 746 D-dimer (ELISA) 746 Arterial blood gas 747 Alveolar–arterial oxygen gradient 747 Urinalysis 748 Pregnancy tests 749 Rh factor 750 Type and screen 750 Type and crossmatch 750 Erythrocyte sedimentation rate 750 Toxicology screen 751 References 751 Index 753 Appendix F Interpretation of emergency laboratories 739 Kumar Alagappan, MD, FACEP, FAAEM Associate Chairman, Emergency Medicine Long Island Jewish Medical Center New Hyde Park, NY Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine Janet G. Alteveer, MD Associate Prof. Emergency Medicine, Assistant Director Emergency Department, Cooper Hospital, Robert Wood Johnson Medical School of UMDNJ, Camden, NJ J. Michael Ballester, MD Assistant Professor of Emergency Medicine University of Cincinnati Department of Emergency Medicine, Cincinnati, OH Paul D. Biddinger, MD Director of Prehospital Care and Disaster Medicine, Massachusetts General Hospital Department of Emergency Medicine Instructor in Surgery, Harvard Medical School Boston, MA Victoria Brazil, MBBS, FACEM Staff Specialist and Director of Emergency Medicine Training, Royal Brisbane Hospital Australia Lance Brown, MD, MPH, FACEP Chief, Division of Pediatric Emergency Medicine Associate Professor of Emergency Medicine and Pediatrics, Loma Linda University Medical Center and Children’s Hospital, Loma Linda California Andrew K. Chang, MD Assistant Professor, Dept of Emergency Medicine, Albert Einstein College of Medicine Montefiore Medical Center, Bronx, NY Robert L. Cloutier, MD, FAAEM, FAAP Assistant Professor of Emergency Medicine Adjunct Assistant Professor of Pediatrics Oregon Health and Science University Doernbecher Children’s Hospital, Portland Oregon Wendy C. Coates, MD Associate Professor of Medicine and Chair Acute Care College, UCLA School of Medicine Director, Medical Education, Harbor-UCLA DEM, Torrance, CA Jamie Collings, MD Program Director, Department of Emergency Medicine, Northwestern University Hospital Assistant Professor of Emergency Medicine Northwestern University Feinberg School of Medicine, Chicago, IL Jonathan E. Davis, MD Associate Residency Program Director Assistant Professor, Georgetown University Hospital/Washington Hospital Center Washington, D.C. Peter M.C. DeBlieux, MD LSUHSC Professor of Clinical Medicine LSUHSC Charity Hospital, New Orleans Louisiana Pamela L. Dyne, MD Associate Professor of Clinical Medicine/ Emergency Medicine, Olive View-UCLA Department of Emergency Medicine, Sylmar, CA Cemil M. Erdem, MD Attending Physician, Holyoke Medical Center Holyoke, Massachusetts Gino A. Farina, MD, FACEP Assistant Professor of Emergency Medicine Albert Einstein College of Medicine-Long Island Jewish Medical Center, New Hyde Park, NY Robert Galli, MD, FACEP Professor and Chair, University of Mississippi Medical Center, Jackson, MS Gus M. Garmel, MD, FACEP, FAAEM Co-Program Director, Stanford/Kaiser Emergency Medicine Residency Clinical Associate Professor of Surgery (Emergency Medicine), Stanford University School of Medicine Senior Staff Emergency Physician, The Permanente Medical Group Clerkship Director for Medical Students and Rotating Interns, Kaiser Permanente Medical Center, Santa Clara, CA Dan Garza, MD Sports Medicine Fellow, Department of Orthopedic Surgery Clinical Instructor, Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA List of contributors xi List of contributors List of contributors Gregory H. Gilbert, MD Clinical Instructor, Division of Emergency Medicine Associate Medical Student Clerkship Director Stanford University School of Medicine Stanford, CA Michael A. Gisondi, MD Assistant Professor of Emergency Medicine Associate Residency Director Department of Emergency Medicine Northwestern University, Chicago, IL Steven Go, MD Assistant Dean for Medical Education University of Missouri-Kansas City School of Medicine, Kansas City, Missouri Steven M. Green, MD, FACEP Professor of Emergency Medicine & Pediatrics Loma Linda University, Loma Linda California Gregory Guldner, MD, MS, FACEP Program Director, Emergency Medicine Residency, Loma Linda University Medical Center & Children’s Hospital, Loma Linda, CA Swaminatha V. Gurudevan, MD Assistant Professor of Clinical Medicine University of California, Irvine School of Medicine Associate Director, Noninvasive Cardiac Laboratories, UCI Medical Center Glenn C. Hamilton, MD, MS Professor and Chair Department of Emergency Medicine Wright State University School of Medicine Dayton, Ohio Stephen R. Hayden, MD, FACEP, FAAEM Associate Professor of Clinical Medicine Program Director Emergency Medicine Residency, University of California San Diego Medical Center, San Diego, CA Gregory W. Hendey, MD, FACEP Associate Clinical Professor of Medicine UCSF Fresno Medical Education Program Mel Herbert, MD, FACEP, FAAEM Associate Professor of Clinical Emergency Medicine, Keck USC School of Medicine Michelle Huston, MD Staff Emergency Physician, Franklin Square Hospital Center Baltimore, MD Loretta Jackson-Williams, MD, PHD Assistant Professor Emergency Medicine Clinical Course Director for Students and Residents Director Basic Science Research University of Mississippi Medical Center Peter G. Kumasaka, MD Assistant Professor of Clinical Medicine University of Minnesota Department of Emergency Medicine Regions Hospital, St. Paul, MN Melissa J. Lamberson, MD, FACEP Assistant Professor, Dept of Emergency Medicine Emory University School of Medicine Atlanta, GA Mary Lanctot-Herbert, RN, MSN, FNP Assistant Clinical Professor of Nursing, Acute Care Division, UCLA School of Nursing Amy Leinen, ESQ Senior Attorney, Snell & Wilmer, LLP, Irvine, CA Robert R. Leschke, MD Assistant Professor, Associate Residency Program Director, Director of Undergraduate Medical Education, Medical College of Wisconsin, Milwaukee, WI Michelle Lin, MD Assistant Clinical Professor of Medicine UC San Francisco, San Francisco General Hospital Emergency Services, San Francisco, CA Douglas W. Lowery, MD Associate Professor of Emergency Medicine Emory University, Atlanta, Georgia Sharon E. Mace, MD, FACEP, FAAP Associate Professor, Department of Emergency Medicine Ohio State University School of Medicine Director Pediatric Education/ Quality Improvement, Observation Unit, Cleveland Clinic Foundation, Cleveland, Ohio Swaminatha V. Mahadevan, MD, FACEP, FAAEM Associate Chief, Division of Emergency Medicine Assistant Professor of Surgery (Emergency Medicine), Stanford University School of Medicine Emergency Department Medical Director Medical Student Clerkship Director Stanford University Medical Center Stanford CA List of contributors xii List of contributors