Approach to Common ED Presentations Flashcards
Patients that often present atypically
very young, elderly, alcoholics, immunosuppressed patients often present atypically
Patients that can have blunt peritoneal findings
Old age, pregnancy (T3), and chronic corticosteroid use can blunt peritoneal findings, so have an increased level of suspicion for an intra-abdominal process in these individuals
Differential elevate AST ALT
Think hepatocellular injury
AST > ALT: alcohol-related
ALT > AST: viral, drug, toxin
Differential elevated ALP GGT
Think biliary tree obstruction
effect of opioids on abdo exam
growing evidence that small amounts of opioid analgesics improve diagnostic accuracy of physical exam of surgical abdomen
abdominal pain differential diagnosis emergent and usually less emergent
GI
Perforated viscus, bowel obstruction, ischemic bowel, appendicitis, strangulated hernia, IBD flare, esophageal rupture, peptic ulcer disease
Diverticulitis, gastroenteritis, GERD, esophagitis, gastritis, IBS
HPB
Hepatic/splenic injury, pancreatitis, cholangitis spontaneous bacterial peritonitis
Biliary colic, cholecystitis, hepatitis
Genital
Female: Ovarian torsion, PID, ectopic pregnancy Male: Testicular torsion
Female: tubo-ovarian abscess, ovarian cyst, salpingitis, endometriosis Male: epididymitis, prostatitis
Urinary
Pyelonephritis
Renal colic
Cystitis
CVS
MI, Aortic dissection, AAA
Pericarditis
Respirology
PE, Empyema
Pneumonia
Metabolic
DKA, sickle cell crisis, toxin, Addisonian crisis
Lead poisoning, porphyria
Other
Significant trauma, acute angle closure glaucoma
Abdominal wall injury, herpes zoster, psychiatric, abscess, hernia, mesenteric adenitis
Acute pelvic pain differential diagnosis
gynecological
■ ovaries: ruptured ovarian cysts (most common cause of pelvic pain), ovarian abscess, ovarian torsion (rare, 50% will have ovarian mass)
■ fallopian tubes: salpingitis, tubal abscess, hydrosalpinx, adnexal neoplasm
■ uterus: leiomyomas (uterine fibroids) – especially with torsion of a pedunculated fibroid or in a pregnant patient (degeneration), PID, endometriosis, neoplasm
■ other: ectopic pregnancy (ruptured/expanding/leaking), spontaneous abortion (threatened or incomplete), endometriosis and dysmenorrhea, sexual or physical abuse , Mittelschmerz, PID + cervicitis
non-gynecological (see causes of lower abdominal pain above)
Chandelier sign diagnosis
suggests PID
ovarian cyst management
◆ unruptured or ruptured, and hemodynamically stable: analgesia and follow-up
◆ ruptured with significant hemoperitoneum: may require surgery
Ovarian torsion management
surgical detorsion or removal of ovary
PID management
broad spectrum abx
uncomplicated leiomyomas, endometriosis, and secondary dysmenorrhea management
usually outpatient and d/c with gynecology f/u
Altered level of consciousness includes what types of diagnoses/etiologies
■ delirium
■ dementia
■ lethargy: state of decreased awareness and alertness (patient may appear wakeful)
■ stupor: unresponsiveness but rousable
■ coma: a sleep-like state, not rousable to consciousness
Possible causes of coma (GCS 3-8)
AEIOU TIPS Acidosis/Alcohol Epilepsy Infection Oxygen (hypoxia)/Opiates Uremia
Temperature/Trauma (especially head)
Insulin (too little or too much)
Psychogenic/Poisoning
Stroke
Majority - toxic/metabolic M – Major organ failure E – Electrolyte/Endocrine T – Toxins/Temperature A – Acid disorders B – Base disorders O – decreased Oxygen level L – Lactate I – Insulin/Infection (sepsis) C – Cardiac/hyperCalcemia
Minority - Primary CNS disease/trauma
either
Bilateral cerebral hemispheres (affecting cognition) secondary to diffuse trauma/ischemia or diffuse lesion
or brainstem (affecting reticular activitating system) secondary to compression (supra/infratentorial tumour or sub/epidural hematoma) or direct (brainstem infarct or hemorrhage)
Abrupt onset of altered loc suggests what etiology
CNS hemorrhage/ischemia or cardiac cause
onset of altered loc over hours to days suggests what etiology
suggests progressive CNS lesion or toxic/metabolic cause
When to intubate with altered LOC
In general, intubate if GCS <8; but ability to protect airway is primary consideration
Altered LOC diagnosis
• administer appropriate universal antidotes
■ thiamine 100 mg IV if history of EtOH or patient looks malnourished
■ one ampule D50W IV if hypoglycemic on finger-prick
■ naloxone 0.4-2 mg IV or IM if opiate overdose suspected
• distinguish between structural and toxic-metabolic coma
■ structural coma
◆ pupils, extraocular movements, and motor findings, if present, are usually asymmetric
◆ look for focal or lateralizing abnormalities
■ toxic-metabolic coma
◆ dysfunction at lower levels of the brainstem (e.g. caloric unresponsiveness)
◆ respiratory depression in association with an intact upper brainstem (e.g. equal and reactive pupils; see exceptions in Table 13)
◆ extraocular movements and motor findings are symmetric or absent
• essential to re-examine frequently because status can change rapidly
• diagnosis may become apparent only with the passage of time
■ delayed deficit after head trauma suggestive of epidural hematoma (characteristic “lucid interval”)
Toxic-metabolic causes of dilated fixed pupils
Anoxia Anticholinergic agents (e.g. atropine, TCAs) Methanol (rare) Cocaine Opioid withdrawal Amphetamines Hallucinogen
Toxic-metabolic causes of dilated to normal fixed pupils
Hypothermia
Barbiturates
Antipsychotics
Toxic-metabolic causes of constricted fixed pupils
Cholinergic agents (ex. organophosphates)
Opiates (ex. heroin), except meperidine
Chest pain differential diagnosis emergent and usually less emergent
CVS
MI, unstable angina, aortic dissection, cardiac tamponade, arrhythmia
Stable angina, pericarditis, myocarditis
Resp
PE, pneumothorax
Pneumonia, pleural effusion, malignancy
GI
Esophageal rupture, pneumomediastinum
Peptic ulcer disease, esophagitis, GERD, esophageal spasm, pancreatitis, cholecystitis
MSK
Rib fracture
Costochondritis
Other
Herpes zoster, pshychiatric/panic attack
Life threatening causes of chest pain
PET MAP PE Esophageal rupture Tamponade MI/angina Aortic dissection Pneumothorax
What is necessary for all suspected aortic dissections
Imaging is necessary for all suspected aortic dissections, regardless of BP
Angina characteristics and risk for CAD
Angina Characteristics
- Retrosternal location
- Provoked by exertion
- Relieved by rest or nitroglycerin
Risk for CAD 3/3 = “typical angina” - high risk
2/3 = intermediate risk for women >50 yr, all men
1/3 = Intermediate risk in men >40 yr, women >60 yr
ACS history
New or worsening pattern of retrosternal squeezing/ pressure pain, radiation to arm/neck, dyspnea, worsened by exercise, relieved by rest N/V; syncope
ACS physical exam
New or worsened murmur, hypotension, diaphoresis pulmonary edema
ACS diagnostic investigations
ECG: ischemia (15-lead if hypotensive, AV node involvement or inferior MI), serial troponin I (sensitive 6-8 h after onset), CK-MB, CXR
ACS management and disposition
ABCs, aspirin, anticoagulation and emergent cardiology consult to consider percutaneous intervention or thrombolytic
when is ACS more likely to be atypical
ACS more likely to be atypical in females, diabetics, and >80 yr. Anginal equivalents include dyspnea, diaphoresis, fatigue, nonretrosternal pain
PE history
Pleuritic chest pain (75%), dyspnea; risk factors for venous thromboembolism
PE physical exam
Tachycardia, hypoxemia; evidence of DVT
PE diagnostic investigations
Wells’ criteria: D-dimer, CT pulmonary angiogram*, V/Q scan; leg Doppler, CXR
PE management and disposition
ABCs, anticoagulation; consider airway management and thrombolysis if respiratory failure
Signs of PE on CXR
Westermark’s sign: abrupt tapering of a vessel on chest film
Hampton’s hump: a wedge-shaped infiltrate that abuts the pl ura Effusion, atelectasis, or infiltrates 50% normal
Acute pericarditis classic history
Vira prodrome, anterior precordial pain, pleuritic, relieved by sitting up and leaning forward
Acute pericarditis physical exam
Triphasic friction rub
Acute pericarditis diagnostic investigations
ECG: sinus tachycardia, diffuse ST elevation, PR depression in II, III, avF and V4-6; reciprocal PR elevation and ST depression in aVR ±V1; echocardiography
Acute pericarditis management and dispo
ABCs, rule out MI, high dose NSAIDs ± colchicine; consult if chronic/recurrent or non-viral cause (e.g. SLE, renal failure, requires surgery)
Pneumothorax history
Trauma or spontaneous pleuritic chest pain often in tall, thin, young male athlete
Pneumothorax physical exam
Hemithorax with decreased/absent breath sounds, hyper-resonance; deviated trachea and hemodynamic compromise
Pneumothorax diagnostic investigations
Clinical diagnosis CXR: PA, lateral, expiratory views – lung edge, loss of lung markings, tracheal shift; deep sulcus sign on supine view
Pneumothorax management and dispo
ABCs, if unstable, needle to 2nd ICS at MCL; urgent surgical consult / thoracostomy 4th ICS and chest tube
Aortic dissection history
Sudden severe tearing retrosternal or midscapular pain ± focal pain/neurologic loss in extremities in context of HTN
Aortic dissection physical exam
HTN; systolic BP difference >20 mmHg or pulse deficit between arms; aortic regurgitant murmur
Aortic dissection diagnostic investigations
CT angio; CXR - wide mediastinum left pleural effusion, indistinct aortic knob, >4 mm separation of intimal calcification from aortic shadow, 20% normal
Aortic dissection management and dispo
ABCs, reduce BP and HR; classify type A (ascending aorta, urgent surgery) vs. B (not ascending aorta, medical) on CT angio and urgent consult
Cardiac tamponade history
Dyspnea, cold extremities, ±chest pain; often a recent cardiac intervention or symptoms of malignancy, connective tissue disease
Cardiac tamponade physical exam
Beck’s triad - hypotension, elevated JVP, muffled heart sounds; tachycardia, pulsus paradoxus >10 mmHg
Cardiac tamponade diagnostic investgiations
Clinical diagnosis CXR: may show cardiomegaly, evidence of trauma
Cardiac tamponade management and dispo
ABCs, cardiac surgery or cardiology consult, pericardiocentesis if unstable, treat underlying cause
Esophageal rupture history
Sudden onset severe pain after endoscopy, forceful vomiting, labour, or convulsion, or in context of corrosive injury or cancer
Esophageal rupture physical exam
Subcutaneous emphysema, findings consistent with sepsis
Esophageal rupture diagnostic investigations
CXR: pleural effusion (75%), pneumomediastinum; CT or water soluble contrast esophagogram
Esophageal rupture management and dispo
ABCs, early antibiotics resuscitation, thoracics consult, NPO, consider chest tube
Esophagitis or GERD clinical history
Frequent heartburn, acid reflux, dysphagia, relief with antacids
Esophagitis or GERD physical exam
Oral thrush or ulcers (rare)
Esophagitis or GERD diagnostic investigations
None acutely
Esophagitis or GERD management and dispo
ABCs, PPI, avoid EtOH, tobacco, trigger foods
Herpes zoster history
Abnormal skin sensation – itching/tingling/pain – preceding rash by 1-5 d
Herpes zoster physical exam
None if early; maculopapular rash developing into vesicles and pustules that crust
Herpes zoster diagnostic investigations
Clinical diagnosis; direct immunofluorescence assay
Herpes zoster management and dispo
ABCs, anti-virals, analgesia ±steroids, dressing; r/o ocular involvement/refer if necessary
MSK chest pain history
history of injury
MSK chest pain physical exam
Reproduction of symptoms with movement or palpation (not specific – present in 25% of MI)
MSK chest pain diagnotic investigations
MSK injury or fracture on X-rays
MSK chest pain management and dispo
ABCs, NSAIDs, rest, orthopedics consultation for fractures
Anxiety chest pain history
Symptoms of anxiety, depression, history of psychiatric disorder; may coexist with physical disease
Anxiety chest pain physical exam
Tachycardia, diaphoresis, tremor
Anxiety chest pain diagnostic investigations ;
Diagnosis of exclusion
Anxiety chest pain management and dispo
ABCs, arrange social supports, rule out suicidality and consider psychiatry consult
How to differentiate STEMI from pericarditis on ECG
STEMI - reciprocal changes
Pericarditis - diffuse elevations
Effect of addition of Clopidogrel to Aspirin and Fibrinolytic Therapy for Myocardial Infarction with ST Segment elevation
Addition of clopidogrel improves the patency rate of infarct-related arteries and reduces ischemic complications, both of which are associated with improved long-term survival after MI. The trial was not powered to detect a survival benefit, and none was seen
Common life threatning dysrhythmias and ECG findings
Torsades de pointes - Ventricular complexes in upward-pointing and downward-pointing continuum (250-350 bpm)
Ventricular tachycardia - 6 or more consecutive premature ventricular beats (150-250 bpm)
Ventricular flutter - Smooth sine wave pattern of similar amplitude (250-350 bpm)
Ventricular fibrillation - Erratic ECG tracing, no identifiable waves
Immediate treatment of acute MI
BEMOAN
β-blocker Enoxaparin Morphine Oxygen ASA Nitrogycerin
Common life threatening conduction pathologies and ECG findings
2nd degree heart block (Mobitz type II) - PR interval stable, some QRSs dropped Total AV dissociation, but stable P-P and R-R intervals
3rd degree heart block - Prolonged QRS complex (>0.12 s) RSR’ in V5 or V6
Left bundle branch block - Monophasic I and V6 May see ST elevation Difficult to interpret, new LBBB is considered STEMI equivalent
Common life threatening ischemia pathology and ECG changes
STEMI - ST elevation in leads associated with injured area of heart and reciprocal lead changes (depression)
Common life threatening metabolic pathology and ECG changes
Hyperkalemia - Tall T waves
Hypokalemia - P wave flattening QRS complex widening and flattening U waves appear Flattened T waves
Digitalis Toxicity - Gradual downward curve of ST At risk for AV blocks and ventricular irritability
Common life threatening syndromes pathology and ECG changes
Brugada - RBBB with ST elevation in V1, V2, and V3 Susceptible to deadly dysrhythmias, including VFib
Wellens - Marked T wave inversion in V2 and V3 Left anterior descending coronary stenosis
Long QT syndrome - QT interval longer than ½ of cardac cycle Predisposed to ventricular dysrhythmias
Common therapteutic approach to severe migraine
- 1 L bolus of NS
- prochlorperazine 10 mg IV
- diphenhydramine 25 mg IV
- ketorolac 30 mg IV
- dexamethasone 10 mg IV
- Other options include haloperidol, metoclopramide, ergotamine, sumatriptan, analgesics
Headache differential
• common and less serious
■ common migrane (without aura)/classic migraine (with aura)
◆ common: unilateral, throbbing, aggravated by activity, moderate/severe, N/V, photo-/ phonophobia
◆ classic: varied aura symptoms, e.g. flashing lights, pins and needles (paresthesia), loss of vision, dysarthria abortive treatment: fluids, NSAIDs, antiemetics, antiepileptic drugs, vasoactive medications
◆ family doctor to consider prophylactic treatment
■ tension/muscular headache
◆ mild-moderate headache with gradual onset lasting minutes to days
◆ bilateral-frontal or nuchal-occipital
◆ increased with stress, sleep deprivation
◆ treatment: modify stressor(s), local measures, NSAIDs, tricyclic antidepressants
• less common but potentially fatal
■ subarachnoid hemorrhage (SAH) (see Neurosurgery, NS18)
◆ sudden onset, “worst headache of life,” maximum intensity within minutes
◆ increased pain with exertion, N/V, meningeal signs
◆ diagnosis – new generation CT 100% sensitive within 6 h of onset (hyperattentuating signal around Circle of Willis) – LP if suspected SAH and normal CT after 6 h
◆ management: urgent neurosurgery consult
■ increased ICP
◆ worse in morning, when supine or bending down, with cough or valsalva
◆ physical exam: neurological deficits, cranial nerve palsies, papilledema
◆ diagnosis: CT head
◆ management: consult neurosurgery
■ meningitis
◆ flu-like symptoms (fever, N/V, malaise), meningeal signs, petechial rash
◆ altered LOC and confusion
◆ rule out increased ICP; if CT head or normal mental status, no neurological signs and no papilledema, then do LP for diagnosis
◆ treatment: early empiric antibiotics ± acyclovir, steroid therapy
Do not delay IV antibiotics for LP • Deliver first dose of dexamethasone with or before first dose of antibiotic therapy
■ temporal arteritis (causes significant morbidity, blindness) (see Ophthalmology, OP35)
◆ vasculitis of large and mid-sized arteries, gender 3:1 F:M, most commonly age >70 yr
◆ headache, scalp tenderness, jaw claudication, arthralgia, myalgia, fever, malaise or weight loss
◆ temporal artery tender on palpation, relative afferent pupillary defect (RAPD), optic disc edema on fundoscopy
◆ labs: elevated ESR, CRP
◆ temporal artery biopsy is gold standard for diagnosis
◆ associated with polymyalgia rheumatica
◆ treatment: high-dose steroids immediately if suspected, no need to hold treatment until pathology results
Ottawa SAH Rule
- Use for alert patients older than 15 yr with new severe non-traumatic headache reaching maximum intensity within 1 h
- Not for patients with new neurologic deficits, previous aneurysms, SAH, brain tumours, or history of recurrent headaches (≥3 episodes over the course of ≥6 mo)
- Investigate if ≥1 high-risk variables present:
- Age ≥40 yr
- Neck pain or stiffness
- Witnessed loss of consciousness
- Onset during exertion
- Thunderclap headache (instantly peaking pain)
- Limited neck flexion on examination
Subarachnoid hemorrhage can be predicted with 100% sensitivity using this rule.
Parenteral dexamethasone for preventing recurrence of acute severe migraine headache
Single dose parenteral dexamethasone wth standard abortive therapy is associated with a 26% relative reduction in headache recurrence within 72 h.
Headaches requiring admission or those that can be discharged
- admission: if underlying diagnosis is critical or emergent, if there are abnormal neurological findings, if patient is elderly or immunocompromised (atypical presentation), or if pain is refractory to oral medications
- discharge: assess for risk of narcotic misuse; most patients can be discharged with appropriate analgesia and follow-up with their family physician; instruct patients to return for fever, vomiting, neurologic changes, or increasing pain
Joint aspirate investigations
WBC, protein, glucose, Gram stain, crystals
Septic joint management
IV antibiotics ± joint decompression and drainage
■ antibiotics can be started empirically if septic arthritis cannot be ruled out
Crystalline synovitis management
NSAIDs at high dose, colchicine within first 24 h, corticosteroids
■ do not use allopurinol, as it may worsen acute attack
Acute polyarthritis management
NSAIDs, analgesics (acetaminophen ± opioids), local or systemic corticosteroids
OA management
NSAIDs, acetaminophen
Soft tissue pain management
allow healing with enforced rest ± immobilization
■ non-pharmacologic treatment: local heat or cold, electrical stimulation, massage
■ pharmacologic: oral analgesics, NSAIDs, muscle relaxants, corticosteroid injections, topical agents
Back pain approach
- rule out vascular emergencies: aortic dissection, AAA, PE, MI, retroperitoneal bleed
- rule out spinal emergencies using red flags: osteomyelitis, cauda equina, epidural abscess or hematoma
- evaluate risk for fracture (osteoporosis, age), infection (IV drug user recent spinal intervention, immunosuppression), cancer, vascular causes (cardiac risk factors)
- typical benign back pain is moderate, dull, aching, worse with movement or cough
- palpate spine for bony tenderness, precordial, respiratory, abdominal and neurological exams guided by history
- reserve imaging for suspicion of emergencies, metastases, and patients at high risk of fracture, infection, cancer, or vascular causes
Back pain management
- treat underlying cause
- lumbosacral s rain and disc herniation: analgesia and continue daily activities as much as tolerated; discuss red flags and organize follow-up
- spinal infection: early IV antibiotics and ID consultation
- cauda equina: dexamethasone, early neurosurgical consultation
Red flags for back pain
Bowel or bladder dysfunction
Anesthesia (saddle)
Constitutional symptoms
K - Chronic disease, Constant pain
Paresthesia
Age >50 and mild trauma
IV drug use/infection
Neuromotor deficits
Seizures and status epilepticus definition
- paroxysmal alteration of behaviour and/or EEG changes resulting from abnormal, excessive activity of neurons
- status epilepticus: continuous or intermittent seizure activity for greater than 5 min without regaining consciousness (life threatening)
Seizures categories and etiologies
- generalized seizure (consciousness always lost): tonic/clonic, absence, myoclonic, atonic
- partial seizure (focal): simple partial, complex partial
- causes: primary seizure disorder, structural (trauma, intracranial hemorrhage, infection, increased ICP) metabolic disturbance (hypo-/hyperglycemia, hypo-/hypernatremia, hypocalcemia, hypomagnesemia, toxins/drugs) differential diagnosis: syncope, pseudoseizures, migraines, movement disorders, narcolepsy/cataplexy, myoclonus
Seizure physical exam
injuries to head and spine and bony prominences (e.g. elbows), tongue laceration, aspiration, urinary incontinence
Seizure history
- from patient and bystander: flaccid and unconscious, often with deep rapid breathing
- preceding aura, rapid onset, loss of bladder/bowel control, tongue-biting (sides of the tongue)
- length of seizure and post-ictal symptoms (e.g. cognitive impairments, migraine, focal symptoms: aphasia, hemiparesis)
Concurrent investigation and management of status epilepticus timing
Immediate:
Protect airway with positioning; intubate if airway compromised or elevated ICP
Monitor: vital signs, ECG, oximetry; bedside blood glucose
Establish IV access
Benzodiazepine - IV lorazepam 0.1 mg/kg up to 4 mg/dose at 2 mg/min preferred over IV diazepam 0.15 mg/kg up to 10 mg/dose at 5 mg/min; repeat at 5 min if ineffective
Fluid resuscitation Give 50 mL 50% glucose (preceded by thiamine 100 mg IM in adults)
Obtain blood samples for glucose, CBC, electrolytes, Ca2+, Mg2+, toxins, and antiepileptic drug levels; consider prolactin, β-hCG
Vasopressor support if sBP <90 or MAP <70 mmHg
Urgent:
Establish second IV line, urinary catheter
If status persists, phenytoin 20 mg/kg IV at 25-50 mg/min in adults; may give additional 10 mg/kg IV 10 min after loading infusion
If seizure resolves, antiepileptic drug still required to prevent recurrence
EEG monitoring to evaluate for non-convulsive status epilepicus
Refractory:
If status persists after maximum doses above, consult ICU and start one or more of:
Phenobarbital 20 mg/kg IV at 50 mg/min
Midazolam 0.2 mg/kg IV loading dose and 0.05-0.5 mg/kg/h
Propofol 2-5 mg/kg IV loading dose then 210 mg/kg/h
Post-seizure
Investigate underlying cause: consider CT, LP, MRI, intracranial pressure monitoring
Minimum workup in an adult with 1st time seizure
CBC and diff
Extended lytes
Head CT
What is required with phenytoin admin
If administering phenytoin, patient must be on a cardiac monitor as dysrhythmias and/or hypotension may occur
Initial control of seizures without IV access
If IV access is not feasible, midazolam 0.2 mg/kg IM up to 10 mg can be used for initial control of seizure in adults
Seizure disposition
• decision to admit or discharge should be based on the underlying disease process identified
■ if a patient has returned to baseline function and is neurologically intact, then consider discharge with outpatient follow-up
- first-time seizure patients being discharged should be referred to a neurologist for follow-up
- admitted patients should generally have a neurology consult
• patient should not drive until medically cleared (local regulations vary)
■ complete notification form to appropriate authority regarding ability to drive
• warn regarding other safety concerns (e.g. no swimming, bathing children alone, etc.)
Shortness of breath differential diagnosis high motality/morbidity and usually less emergent
Resp - Airway obstruction (foreign body epiglottitis, abscess, anaphylaxis) Pneumo/hemothorax Gas exchange –Pulmonary edema, PE, pneumonia, Acute exacerbations of COPD Chronic obstructive, interstitial or restrictive lung disease Pleural effusion
Cardiac -
CHF, MI, valvular disease, tamponade, arrhythmia
Chronic CHF, angina
Metabolic -
Metabolic acidosis NYD, carbon monoxide inhalation
Anemia, Hemoglobinopathy
Neuromuscular
Myasthenia gravis, diaphragmatic paralysis
CNS lesion, primary muscle weakness
Other - Anxiety, deconditioning
Management of dyspnea in CO2 retainers
consider intubation in CO2 retainers (e.g. COPD)
Syncope definition
sudden, transient loss of consciousness and postural tone with spontaneous recovery
• usually caused by generalized cerebral or reticular activating system hypoperfusion
types of syncope
5 Types of Syncope • Vasomotor • Cardiac • CNS • Metabolic • Psychogenic
Syncope history
• gather details from witnesses, and clarify patient’s experience (e.g. dizziness, ataxia, or true syncope)
■ two key historical features: prodrome and situation
• distinguish between syncope and seizure (see Neurology, N19)
■ some patients may have myoclonic jerks with syncope – NOT a seizure
◆ signs and symptoms during presyncope, syncope, and postsyncope
◆ past medical history, drugs
◆ think anatomically in differential; pump (heart), blood, vessels, brain
• syncope is cardiogenic until proven otherwise if
■ there is sudden loss of consciousness with no warning or prodrome
■ syncope is accompanied by chest pain
Causes of syncope by system
HEAD, HEART, VeSSELS Hypoxia/Hypoglycemia Epilepsy Anxiety Dysfunctional brainstem Heart attack Embolism (PE) Aortic obstruction Rhythm disturbance Tachycardia Vasovagal Situational Subclavian steal ENT (glossopharyngeal neuralgia) Low systemic vascular resistance Sensitive carotid sinus
San Francisoco Syncope Rule
High risk of adverse outcomes in syncope patients if:
CHESS
CHF: Hx of CHF Hct: Low ECG: Abnormal SOB: Hx of dyspnea SBP: sBP <90 at triage
Sexual assault epidemiology
• 1 in 4 women and 1 in 10 men will be sexually assaulted in their lifetime; only 7% are repo ted
Sexual assault general approach
- ABCs, treat acute, serious injuries; physician priority is to treat medical issues and provide clearance
- ensure patient is not left alone and provide ongoing emotional support
- obtain consent for medical exam and treatment, collection of evidence, disclosure to police (notify police as soon as consent obtained)
- Sexual Assault Kit (document injuries, collect evidence) if <72 h since assault
- label samples immediately and pass directly to police
- offer community crisis resources (e.g. shelter, hotline)
- do not report unless victim requests or if <16 yr old (legally required)
Sexual assault history
• ensure privacy for the patient – others should be asked to leave
• questions to ask: who, when, where did penetration occur, what happened, any weapons, or physical assault?
• post-assault activities (urination, defecation, change of clothes, shower, douche, etc.)
• gynecologic history
■ gravidity, parity, last menstrual period
■ contraception use
■ last voluntary intercourse (sperm motile 6-12 h in vagina, 5 d in cervix)
• medical history: acute injury/illness, chronic diseases, psychiatric history, medications, allergies, etc.
Sexual assault physical exam
• never re-traumatize a patient with the examination
• general examination
■ mental status
■ sexual maturity
■ patient should remove clothes and place in paper bag
■ document abrasions, bruises, lacerations, torn frenulum/broken teeth (indicates oral penetration)
• pelvic exam and specimen collection
■ ideally before urination or defecation
■ examine for seminal stains, hymen, signs of trauma
■ collect moistened swabs of dried seminal stains
■ pubic hair combings and cuttings
■ speculum exam
◆ lubricate with water only
◆ vaginal lacerations, foreign bodies
◆ Pap smear, oral/cervical/rectal culture for gonorrhea and chlamydia
◆ posterior fornix secretions if present or aspiration of saline irrigation
◆ immediate wet smear for motile sperm
◆ air-dried slides for immotile sperm, acid phosphatase, ABO group
• fingernail scrapings and saliva sample from victim
Sexual assault investigations
- Venereal Disease Research Lab (VDRL): repeat in 3 mo if negative
- serum β-hCG
- blood for ABO group, Rh type, baseline serology (e.g. hepatitis, HIV)
Risk of sexually transmitted disease after sexual assault
- Gonorrhea: 6-18%
- Chlamydia: 4-17%
- Syphilis: 0.5-3%
- HIV: <1%
Sexual assault management
• involve local/regional sexual assault team
• medical
■ suture lacerations, tetanus prophylaxis
■ gynecology consult for foreign body, complex lacerations
■ assume positive for gonorrhea and chlamydia
◆ management: azithromycin 1 g PO x 1 dose (alt: doxycycline 100 mg PO bid x 7 d) and cefixime 800 mg PO x 1 dose (alt: ceftriaxone 250 mg IM x 1 dose)
■ may start prophylaxis for hepatitis B and HIV
■ pre and post counselling for HIV testing
■ pregnancy prophylaxis offered
◆ levonorgestrel 075 mg PO STAT, repeat within 12 h (Plan B®)
• psychological
■ high incidence of psychological sequelae
■ have victim change and shower after exam completed
Sexual assault disposition
- discharge if injuries/social situation permit
- follow up with physician in rape crisis centre within 24 h
- best if patient does not leave ED alone
Domestic violence consent
patient must consent to follow-up investigation/reporting (unless for children)
Things that increase suspicion of domestic violence
■ suggestive injuries (bruises, sprains, abrasions, occasionally fractures, burns, or other injuries; often inconsistent with history provided)
■ somatic symptoms (chronic and vague complaints)
■ psychosocial symptoms
■ clinician impression (your ‘gut feeling’, e.g. overbearing partner that won’t leave patient’s side)
Domestic violence management
- treat injuries and document findings
- ask about sexual assault and children at home (encourage notification of police)
- safety plan with good follow-up with family physician/social worker
