(2-Volume Set) Rosen's Emergency Medicine - Concepts and Clinical Practice : Expert Consult Premium Edition - Enhanced Online Features and Print, 8e

Rosen's Emergency Medicine, Eighth Edition (2014) 1618pp. 978-1-4557-4987-4 e9781455749874v1 1 Front cover 1 Endsheet_Front_for_Vol1 2 Half title page 5 Rosen's Emergency Medicine 7 Copyright page 8 Dedication 9 Acknowledgments 11 Emeritus Editors 13 Preface to the Eighth Edition 15 How This Medical Textbook Should Be Viewed by the Practicing Clinician and the Judicial System 16 Contributors 17 Table of Contents 35 I Fundamental Clinical Concepts 43 One Critical Management Principles 45 1 Airway 45 Perspective 45 Pathophysiology 45 Decision to Intubate 45 Failure to Maintain or Protect the Airway 45 Failure of Ventilation or Oxygenation 45 Anticipated Clinical Course 45 Clinical Features 46 Identification of the Difficult Airway 46 Difficult Direct Laryngoscopy: LEMON 46 Difficult Bag-mask Ventilation: MOANS 47 Difficult Extraglottic Device Placement: RODS 48 Difficult Cricothyrotomy: SMART 48 Measurement and Incidence of Intubation Difficulty 48 Confirmation of Endotracheal Tube Placement 49 Management 50 Approach to Intubation 50 Difficult Airway 50 Failed Airway 52 Therapeutic Modalities 52 Methods of Intubation 52 Rapid Sequence Intubation 52 Preparation. 53 Preoxygenation. 53 Pretreatment. 53 Paralysis with Induction. 54 Positioning. 54 Placement of Tube. 54 Postintubation Management. 54 Blind Nasotracheal Intubation 54 Awake Oral Intubation 54 Oral Intubation without Pharmacologic Agents 55 Pharmacologic Agents 55 Neuromuscular Blocking Agents 55 Succinylcholine. 55 Uses and Dosing. 55 Cardiovascular Effects. 55 Fasciculations. 55 Hyperkalemia. 55 Increased Intraocular Pressure. 56 Masseter Spasm. 56 Malignant Hyperthermia. 56 Refrigeration. 56 Competitive Agents. 56 Rocuronium. 56 Vecuronium. 56 Paralysis after Intubation. 56 Induction Agents 57 Etomidate. 57 Ketamine. 57 Propofol. 57 Other Induction Agents. 57 Special Clinical Circumstances 58 Status Asthmaticus 58 Hemodynamic Consequences of Intubation 58 Elevated Intracranial Pressure 58 Potential Cervical Spine Injury 59 Pediatric Intubation 59 Evolution of Airway Devices 60 Direct Laryngoscopy 60 Videolaryngoscopes 60 Fiberoptic and Video Intubating Stylets 61 Flexible Intubating Scopes 61 Extraglottic Devices 61 Laryngeal Mask Airways. 61 Other Extraglottic Devices. 63 Surgical Airway Management 63 Needle Cricothyrotomy with Transtracheal Jet Ventilation 63 Cricothyrotomy 64 Outcomes 64 References 65 2 Mechanical Ventilation and Noninvasive Ventilatory Support 69 Perspective 69 Principles of Mechanical Ventilation 69 Physiology of Positive Pressure Breathing 69 Invasive Mechanical Ventilation 69 Positive End-Expiratory Pressure 71 Noninvasive Techniques 71 Management 71 General Approach: Noninvasive versus Invasive Ventilation 71 Approach to Initial Ventilator Settings 72 Ongoing Management 72 Other Management Considerations 73 Complications of Positive-Pressure Ventilation 74 Troubleshooting the Ventilator 74 Special Clinical Circumstances 75 Acute Exacerbation of Chronic Obstructive Pulmonary Disease 75 Status Asthmaticus 75 Acute Lung Injury and Acute Respiratory Distress Syndrome 75 Outcomes 76 References 77 3 Pain Management 79 Perspective 79 Pathophysiology 79 Pain Conduction Pathways 79 Pain Detection 79 Information Transmission 80 Peripheral Nerve Fibers 80 Pain Transmission 80 Dorsal Horn 80 Visceral Pain 82 Ascending Tracts Associated with Pain 82 Pain Modulation 82 Central Sensitization 82 Pain Expression 82 Reflex Responses to Pain 82 Endorphin System 83 Acute versus Chronic Pain 83 Management Principles 84 Pain Assessment 84 Oligoanalgesia 84 Pain Measurement 84 Treatment 85 Chronic Pain 85 Recurrent Pain 86 Chronic Pain of Malignancy 86 Neuropathic Pain 86 Acute Pain 86 Analgesic Agents 86 Opioid Analgesic Agents 86 Mechanism of Action and Toxic Effects. 86 Suggestion of Drug-Seeking Behavior. 88 Administration. 88 Specific Agents 88 Morphine. 88 Meperidine. 89 Hydromorphone. 89 Fentanyl. 89 Oxycodone. 89 Hydrocodone. 89 Codeine. 90 Propoxyphene. 90 Methadone. 90 Naloxone. 90 Tramadol. 90 Tapentadol. 90 Opioid Agonist-Antagonist Analgesic Agents. 90 Opioid Use in Acute Abdominal Pain. 90 Nonopioid Analgesic Agents 90 Acetaminophen. 90 Nonsteroidal Anti-inflammatory Agents 91 Drug Interactions 91 Aspirin. 91 Oral Anticoagulants. 91 Angiotensin-Converting Enzyme Inhibitors. 92 Diuretics. 92 Glucocorticoids. 92 Lithium. 92 Methotrexate. 92 Nonselective Cyclooxygenase Inhibitors. 92 Ketorolac Tromethamine. 92 Ibuprofen. 92 Cyclooxygenase-2–Specific Inhibitors. 92 Skeletal Muscle Relaxants. 92 Nitrous Oxide and Oxygen Mixtures. 93 Local Anesthesia 93 Mechanism of Action 93 Classes of Local Anesthetic Agents 93 Specific Agents 93 Potency. 93 Duration of Anesthesia. 94 Onset of Action. 94 Allergy. 94 Local and Systemic Toxicity 94 Local Toxicity. 94 Systemic Toxicity. 94 Reducing the Pain of Local Anesthetic Injection 95 Topical Anesthesia 95 Topical Anesthetics Applied to Intact Skin 95 Eutectic Mixture of Local Anesthetics. 95 Ethyl Chloride and Fluori-Methane sprays. 95 Agents Applied to Mucosal Surfaces 95 Cocaine. 95 Lidocaine. 95 Tetracaine. 95 Benzocaine. 96 Agents Applied to Open Skin 96 Tetracaine, Adrenaline, and Cocaine. 96 Lidocaine, Epinephrine, and Tetracaine. 96 Intravenous Regional Anesthesia (Bier Block) 96 Nonpharmacologic Interventions 96 Transcutaneous Electrical Nerve Stimulation 96 Hypnosis 96 Pain Management in Children 96 Pain Management in Elder Patients 96 Out-of-Hospital Analgesia 96 Treatment Endpoints 97 References 98 4 Procedural Sedation and Analgesia 102 Perspective 102 Terminology 102 Approach to Procedural Sedation and Analgesia for Procedures 103 Patient Assessment 103 Preprocedural Fasting 104 Personnel 104 Supplies and Equipment 104 Monitoring 105 Recovery 105 Discharge Criteria and Instructions 105 Pharmacology 106 Route of Administration 106 Opioids 106 Fentanyl 106 Morphine 108 Benzodiazepines 108 Midazolam 108 Barbiturates 109 Methohexital 109 Pentobarbital 109 Ketamine 109 Etomidate 110 Propofol 110 Ketamine Plus Propofol (“Ketofol”) 110 Nitrous Oxide 110 Reversal and Rescue Agents 111 Naloxone 111 Flumazenil 111 Drug Selection and Administration 111 Special Considerations for Pediatric Populations 112 References 113 5 Monitoring the Emergency Patient 118 Perspective 118 Noninvasive Blood Pressure Measurement 118 Pulse Oximetry 118 End-Tidal Carbon Dioxide Monitoring 119 Cerebral Function Monitoring 122 Fetal Monitoring 122 Monitor Alarms and Limits 123 References 124 6 Shock 126 Perspective 126 Classification 126 Epidemiology 126 Specific Causes 126 Hemorrhagic Shock 126 Septic Shock 127 Cardiogenic Shock 128 Clinical Features 128 Management 130 Monitoring Perfusion Status 130 Quantitative Resuscitation 130 Ventilation 130 Volume Replacement 130 Treating Specific Causes 131 Hemorrhagic Shock 131 Septic Shock 132 Cardiogenic Shock 133 References 134 7 Blood and Blood Components 135 Perspective 135 Pathophysiologic Principles 135 Blood Banking 135 Blood Typing 135 Special Clinical Circumstances 136 Administering Blood before Completion of Compatibility Testing 136 Massive Transfusion 136 Administration 136 Legal Aspects 136 Infusion Adjuncts 137 Management 137 Decision-Making 137 Whole Blood 137 Packed Red Blood Cells 137 Artificial Oxygen Carriers 137 Fresh Frozen Plasma 137 Platelets 138 Autotransfusion 138 Therapeutic Modalities 138 Packed Red Blood Cells 138 Fresh Frozen Plasma 138 Platelets 138 Outcomes 138 Immune-Mediated Adverse Effects 138 Acute 138 Intravascular Hemolytic Transfusion Reaction. 138 Febrile Transfusion Reaction. 139 Allergic Reactions (Urticaria to Anaphylaxis). 139 Transfusion-Related Acute Lung Injury. 139 Delayed 139 Extravascular Hemolytic Transfusion Reaction. 139 Transfusion-Associated Graft-versus-Host Disease. 139 Non–Immune-Mediated Adverse Effects 139 Acute 139 Circulatory Overload. 139 Bacterial Contamination. 139 Chronic 140 Risk of Transfusion-Transmitted Viruses. 140 References 141 8 Brain Resuscitation 143 Perspective 143 Pathophysiology 143 Management 143 Standard Strategies 143 Return of Spontaneous Circulation 143 Treatment of Hypotension, Hypoperfusion, and Hypoxia 144 Maintenance of Body Temperature 146 Resuscitative Mild Hypothermia 146 Treatment of Hyperglycemia 147 Seizure Management 148 Immobilization, Sedation, and Head Position 148 Clinical Outcomes 148 Summary 148 References 150 9 Adult Resuscitation 151 Perspective 151 Epidemiology 151 Principles of Disease 151 Etiology 151 Clinical Features and Management 151 History and Physical Examination 152 Monitoring 152 Arterial Blood Pressure and Coronary Perfusion Pressure 153 End-tidal Carbon Dioxide 153 Central Venous Oxygen Saturation 154 Echocardiography 155 Laboratory Testing 155 Resuscitation 155 Ventricular Fibrillation and Pulseless Ventricular Tachycardia 155 Pulseless Electrical Activity 157 Asystole 157 Post–Cardiac Arrest 158 References 161 10 Pediatric Resuscitation 163 Cardiac Arrest and Cardiopulmonary Resuscitation 163 Perspective 163 Epidemiology 163 Pathophysiologic Principles 163 Physiology of Cardiac Arrest 163 Pediatric Anatomy Relevant to Cardiopulmonary Resuscitation 163 Clinical Features 164 Four Phases of Cardiac Arrest 164 Prearrest Phase. 164 No-Flow Phase (Untreated Cardiac Arrest). 164 Low-Flow Phase (Resuscitation). 165 Postresuscitation Phase. 165 Management 165 Chest Compressions 165 Circumferential versus Focal Sternal Compressions 165 Chest Compression Rate 165 Chest Compression–Ventilation Ratios (Table 10-2) 166 Leaning 167 Real-Time Cardiopulmonary Resuscitation Feedback 167 Compression-Ventilation (Standard) versus Compression-Only (“Hands-Only”) Cardiopulmonary Resuscitation 167 Advanced Life Support Medications during the Low-Flow Phase of Cardiopulmonary Resuscitation 167 Pediatric Ventricular Fibrillation and Ventricular Tachycardia 167 Defibrillation 169 Cardiopulmonary Resuscitation in Pediatric Bradycardia 170 Extracorporeal Circulatory Support during Cardiac Arrest 170 Septic Shock in the Pediatric Patient 170 Perspective 170 Pathophysiologic Principles 170 Clinical Features 171 Management 171 Substrate Correction: Hypoglycemia and Hypocalcemia 171 Fluid Resuscitation 171 Vasoactive Medications 172 Corticosteroids 173 Respiratory Failure 173 Perspective and Epidemiology 173 Pathophysiologic Principles 173 Anatomic Features Pertinent to Laryngoscopy and Intubation in Children 173 Clinical Features 173 Pediatric Respiratory Physiology 173 Lung. 173 Respiratory Mechanics. 173 Airway. 173 Cellular Oxygenation. 173 Management Considerations Specific to Pediatrics 174 Effectiveness of Tracheal Intubation versus Bag-Valve Mask Ventilation in Prehospital Care 174 Equipment Considerations for Pediatric Intubation 174 Endotracheal Tubes. 174 Medications 174 Atropine. 174 Succinylcholine. 174 Rescue Devices 174 Acute Life-Threatening Events 174 Sudden Infant Death Syndrome 175 Psychosocial Considerations for Sudden Infant Death Syndrome 175 References 177 11 Neonatal Resuscitation 181 Perspective 181 Pathophysiology 181 Transition from Fetal to Extrauterine Life 181 Neonatal Responses 181 Hypoxia 181 Hypothermia 181 Hypoglycemia 182 Indications for Resuscitation 182 Specific Disorders 182 Meconium Aspiration 182 Anatomic Anomalies 183 Diaphragmatic Hernia 183 Meningomyelocele and Omphalocele 184 Choanal Atresia 184 Pierre Robin Sequence 184 Preparation 184 Management 184 Dry, Warm, Position, Suction, Stimulate, Assess Need for Further Intervention 184 Ventilation, Oxygen, Intubation 185 Chest Compressions 185 Medications 186 Oxygen 186 Epinephrine 186 Naloxone 186 Glucose 187 Volume Expanders 187 Dopamine 187 Therapeutic Hypothermia 187 Disposition 187 References 188 Two Cardinal Presentations 189 12 Fever in the Adult Patient 189 Perspective 189 Epidemiology 189 Pathophysiology 189 Diagnostic Approach 190 Differential Considerations 190 Pivotal Findings 191 Symptoms 192 Signs 192 Ancillary Testing 192 Differential Diagnosis 193 Empirical Management 193 Disposition 193 References 194 13 Weakness 195 Perspective 195 Epidemiology 195 Pathophysiology 195 Differential Considerations 195 Diagnostic Algorithm 195 Unilateral Weakness with a Combination of Arm, Hand, or Leg with Ipsilateral Facial Involvement 196 Unilateral Weakness: A Combination of Arm, Hand, or Leg but with Contralateral Facial Involvement 196 Unilateral Weakness: A Combination of Arm, Hand, or Leg without Facial Involvement 196 Unilateral Weakness: One Limb Only (Monomelic Weakness, Monoparesis, or Monoplegia) 196 Bilateral Weakness: Lower Extremities Only (Paraparesis or Paraplegia) 197 Bilateral Weakness: Upper Extremities Only 198 Bilateral Weakness: All Four Extremities without Facial Involvement (Quadriparesis or Quadriplegia) 198 Bilateral Weakness: Proximal Portions of Extremities Only 198 Bilateral Weakness: Distal Portions of Extremities Only 198 Facial Weakness without Extremity Involvement 198 Pivotal Findings 199 Empirical Management 199 Disposition 199 References 200 14 Cyanosis 201 Perspective 201 Epidemiology 201 Pathophysiology 201 Diagnostic Approach 201 Pivotal Findings 201 Symptoms 201 Signs 201 Laboratory and Ancillary Testing 203 Imaging 203 Electrocardiogram and Echocardiogram 203 Differential Algorithms 204 Critical Diagnoses 204 Emergent Diagnoses 204 Empirical Management 206 Specific Strategies 206 Methemoglobinemia and Sulfhemoglobinemia 206 Other Causes of Cyanosis 206 Patient Disposition 206 Admission 206 Discharge 206 References 207 15 Syncope 208 Perspective 208 Epidemiology 208 Pathophysiology 208 Diagnostic Approach 208 Differential Considerations 208 Pivotal Findings 209 Symptoms 209 Signs 210 Ancillary Studies 210 Diagnostic Algorithm 211 Empirical Management 211 References 215 16 Depressed Consciousness and Coma 216 Perspective 216 Epidemiology 216 Pathophysiology 216 Diagnostic Approach 216 Differential Considerations 216 Pivotal Findings 218 History 218 Physical Examination 219 Ancillary Testing (Refer to Table 16-2) 220 Laboratory Studies 220 Imaging Studies 222 Additional Testing 222 Diagnostic Algorithm 222 Empirical Management 222 Disposition 224 References 225 17 Confusion 226 Perspective 226 Epidemiology 226 Pathophysiology 226 Diagnostic Approach 226 Differential Considerations 226 Rapid Assessment and Stabilization 226 Pivotal Findings 227 History 227 Physical Examination 227 Laboratory Tests 228 Differential Diagnosis 229 Empirical Management 229 Disposition 230 References 231 18 Seizures 232 Perspective 232 Epidemiology and Classification 232 Pathophysiology 232 Diagnostic Approach 233 Differential Considerations 233 Rapid Assessment and Stabilization 233 Pivotal Findings 235 History 235 Physical Examination 236 Ancillary Testing 236 Laboratory. 236 Imaging. 236 Electroencephalography. 236 Management 237 Disposition 237 References 238 19 Dizziness and Vertigo 239 Perspective 239 Pathophysiology 239 Diagnostic Approach 240 Differential Considerations 240 Pivotal Findings 240 History 240 Past Medical History. 241 Physical Examination 241 Vital Signs. 241 Head and Neck. 241 Positional Testing. 241 Neurologic Examination. 242 Ancillary Testing 242 Radiologic Imaging. 242 Differential Diagnosis 242 Diagnostic Algorithm 242 Management 242 Disposition 246 References 247 20 Headache 248 Perspective 248 Epidemiology 248 Pathophysiology 248 Diagnostic Approach 248 Differential Considerations 248 Rapid Assessment and Stabilization 248 Pivotal Findings 248 History 248 Physical Examination 250 Ancillary Testing 250 Differential Considerations 250 Management 253 Empirical 253 Specific 253 Disposition 253 References 254 21 Diplopia 255 Perspective 255 Epidemiology 255 Pathophysiology 255 Diagnostic Approach 255 Important Historical Elements 255 The Examination 255 The Diagnostic Approach 255 1. Is the Diplopia Monocular? 255 Symptoms. 257 Signs. 257 2. Is the Binocular Diplopia a Result of a Restrictive, Mechanical Orbitopathy? 257 Symptoms. 257 Signs. 257 3. Is the Binocular Diplopia a Result of a Palsy of the Oculomotor Cranial Nerves (III, IV, or VI) in a Single Eye? 258 Symptoms. 259 Signs. 259 4. Is the Binocular Diplopia a Result of a Neuroaxial Process Involving the Brainstem and Related Cranial Nerves? 260 Symptoms. 260 Signs. 260 5. Is the Binocular Diplopia a Result of a Neuromuscular Disorder? 261 Symptoms. 261 Signs. 261 Diagnostics 262 Empirical Management 262 References 263 22 Red and Painful Eye 264 Perspective 264 Epidemiology and Pathophysiology 264 Diagnostic Approach 264 Differential Considerations 264 Pivotal Findings 264 History 264 Physical Examination 265 Visual Acuity 266 Visual Field Testing 266 External Examination 266 Extraocular Muscle Function 267 Pupillary Evaluation 267 Pressure Determination 267 Slit-Lamp Examination 267 Direct Funduscopic Examination 268 Bedside Testing 268 Ancillary Testing 268 Differential Diagnosis 269 Critical Diagnoses 269 Emergent Diagnoses 269 Urgent Diagnoses 270 Diagnostic Algorithm 271 Empirical Management 271 Irrigation 271 Pain Relief 271 Mydriatic and Cycloplegic Agents 271 Antimicrobial Agents 271 Other Protective Interventions 272 Specific Management 273 Special Considerations 273 Pediatrics 273 Trauma 276 Disposition 277 References 278 23 Sore Throat 279 Perspective 279 Epidemiology 279 Pathophysiology 279 Diagnostic Approach 279 Airway Assessment and General Appearance 279 Source of Pain Visualized on Examination 279 Viral versus Bacterial Pharyngitis 280 Special Considerations on History 281 Ancillary Testing 281 Imaging 281 Empirical Management 282 References 284 24 Hemoptysis 285 Perspective 285 Epidemiology 285 Pathophysiology 285 Diagnostic Approach 285 Differential Considerations 285 Rapid Assessment and Stabilization 285 Pivotal Findings 286 History 286 Physical Examination 286 Ancillary Testing 286 Diagnostic Algorithm 286 Differential Diagnosis 286 Management 286 Bronchoscopy 286 Interventional Angiography 286 Surgery 287 Disposition 287 References 288 25 Dyspnea 289 Perspective 289 Epidemiology 289 Pathophysiology 289 Diagnostic Approach 289 Differential Considerations 289 Pivotal Findings 289 History 289 Duration of Dyspnea. 289 Onset of Dyspnea. 289 Positional Changes. 289 Trauma. 290 Symptoms 290 Signs 290 Ancillary Studies 290 Differential Diagnosis 291 Critical Diagnoses 291 Emergent Diagnoses 293 Empirical Management and Disposition 293 References 297 26 Chest Pain 298 Perspective 298 Epidemiology 298 Pathophysiology 298 Diagnostic Approach 298 Differential Considerations 298 Rapid Stabilization and Assessment 298 Pivotal Findings 298 History 298 Physical Examination 300 Ancillary Studies 300 Diagnostic Table 306 Management and Disposition 306 References 307 27 Abdominal Pain 308 Perspective 308 Epidemiology 308 Pathophysiology 308 Diagnostic Approach 310 Differential Considerations 310 Rapid Assessment and Stabilization 311 Pivotal Findings 311 Symptoms 311 Signs 314 Ancillary Testing 314 Differential Diagnosis 315 Empirical Management 316 Disposition 316 References 317 28 Jaundice 318 Perspective 318 Epidemiology 318 Pathophysiology 318 Normal Bilirubin Metabolism 318 Abnormalities in Bilirubin Metabolism 318 Diagnostic Approach 318 Differential Considerations 318 Pivotal Findings 318 Symptoms 318 Signs 318 Laboratory Tests 319 Imaging 320 Diagnostic Algorithm 320 Empirical Management 320 Special Populations 322 References 324 29 Nausea and Vomiting 325 Perspective 325 Epidemiology 325 Pathophysiology 325 Diagnostic Approach 326 Differential Considerations 326 Rapid Assessment and Stabilization 327 Pivotal Findings 327 History 327 Physical Examination 329 Ancillary Studies 329 Differential Diagnosis 329 Pediatric Considerations 330 Management 332 Special Situations 333 Disposition 333 References 335 30 Gastrointestinal Bleeding 336 Perspective 336 Epidemiology 336 Diagnostic Approach 336 Differential Considerations 336 Pivotal Findings 336 Medical History 336 Physical Examination 337 Vital Signs. 337 General Examination. 337 Emergency Department Studies 338 Occult Blood and Guaiac Bedside Testing. 338 Clinical Laboratory Testing 338 Blood Bank 338 Electrocardiogram 338 Radiographic Imaging 338 Diagnostic Algorithm 338 Empirical Management 339 Resuscitation 340 Blood Product Transfusion 340 Nasogastric Aspiration and Lavage 340 Sengstaken-Blakemore Tube 340 Medications 340 Definitive Management 340 Consultation 340 Endoscopy 340 Colonoscopy 340 Angiography 340 Tagged Red Blood Cell Imaging 340 Disposition 341 References 342 31 Diarrhea 343 Perspective 343 Incidence 343 Definition and Categorization 343 Clinical Approach 345 Emergency Assessment and Stabilization 345 Secondary Survey 345 Characterization of the Diarrheal Syndrome 346 Acute Infectious Diarrhea. 346 Noninfectious Diarrhea. 347 Ancillary Testing 347 Empirical Management 347 Disposition 349 References 350 32 Constipation 351 Perspective 351 Epidemiology 351 Pathophysiology 351 Diagnostic Approach 351 Differential Considerations 351 Pivotal Findings 351 History 351 Physical Examination 352 Ancillary Testing 352 Diagnostic Algorithm 352 Empirical Management 353 Disposition 355 References 356 33 Acute Pelvic Pain in Women 357 Perspective 357 Epidemiology 357 Pathophysiology 357 Diagnostic Approach 357 Differential Considerations 357 Pivotal Findings 357 Symptoms 359 Signs 360 Laboratory Tests and Imaging 360 Diagnostic Algorithm 360 Empirical Management 361 References 364 34 Vaginal Bleeding 365 Perspective 365 Epidemiology 365 Pregnant Patients 365 Pathophysiology 365 Nonpregnant Patients 365 Pregnant Patients 366 Diagnostic Approach 366 Differential Considerations 366 Pivotal Findings (Symptoms, Signs, and Laboratory) 367 Symptoms 367 Signs 367 Ancillary Testing 367 Diagnostic Algorithm 367 Empirical Management 368 Disposition 369 References 370 35 Back Pain 371 Perspective 371 Epidemiology 371 Pathophysiology 371 Diagnostic Approach 371 Differential Considerations 371 Rapid Assessment and Stabilization 372 Pivotal Findings 372 History 372 History of Present Illness. 372 Where is the pain? 372 When did the pain start? 372 Are there any aggravating or alleviating factors? 373 Is there motor or sensory loss, bowel or bladder dysfunction? 373 Is there other pertinent history? 373 Past Medical History. 374 Physical Examination 374 Vital Signs. 374 Lower Back Inspection 374 Other Examinations, Including Neurologic Examination 374 Straight Leg Raise. 374 Ancillary Testing 374 Laboratory Tests. 374 Imaging. 374 Differential Diagnosis 375 Empirical Management 375 Disposition 376 Acknowledgments 377 References 378 II Trauma 379 One General Concepts 381 36 Multiple Trauma 381 Perspective 381 Epidemiology 381 Trauma Systems 381 Principles of Disease 382 Management 382 Out-of-Hospital Management 382 Emergency Department 382 General Principles 382 Primary Survey 385 Airway and Breathing. 385 Circulation. 385 Disability. 386 Exposure. 386 Secondary Survey 386 Pitfalls 387 Radiographic Evaluation 387 Laboratory Evaluation 387 Disposition 388 Special Considerations 388 References 390 37 Trauma in Pregnancy 393 Perspective 393 Principles of Disease—Changes of Pregnancy 393 Physiology 393 Cardiovascular 393 Some Alterations Mimic Shock. 393 Alterations That May Mask Hypovolemic Shock. 393 Some Alterations Can Exacerbate Traumatic Bleeding. 393 Pulmonary 393 Gastrointestinal 394 Anatomic Changes in Pregnancy 394 Changes in Laboratory Values with Pregnancy 394 Clinical Features of Trauma in Pregnancy 394 Blunt and Penetrating Trauma 394 Interpersonal Violence 395 Falls 395 Penetrating Trauma 395 Fetal Injury 395 Placental Injury 395 Uterine Injury 396 Diagnostic Strategies 396 Radiography 396 Plain Radiographs 396 Ultrasonography 397 Computed Tomography and Magnetic Resonance Imaging Scans 397 Special Procedures 397 Diagnostic Peritoneal Lavage 397 Management 397 Maternal Resuscitation 397 Primary Survey 397 Airway and Breathing. 397 Circulation. 397 Secondary Survey 398 Fetal Evaluation 398 Laboratory 399 Kleihauer-Betke Test and Fetomaternal Hemorrhage 399 Mother Stable, Fetus Stable 400 Mother Stable, Fetus Unstable 400 Mother Unstable, Fetus Unstable 400 Perimortem Cesarean Section 400 Disposition 401 Miscellaneous 401 Acknowledgment 401 References 402 38 Pediatric Trauma 403 Perspective 403 Principles of Disease 403 Clinical Features 403 Initial Assessment Priorities and Primary Survey 403 A—Airway and Cervical Spine Stabilization 403 B—Breathing and Ventilation 404 C—Circulation and Hemorrhage Control 406 D—Disability Assessment (Thorough Neurologic Examination) 406 E—Exposure and Thorough Examination 406 F—FAST and Family 406 Secondary Survey 407 Management and Diagnostic Strategies 407 General Management Principles 407 Physical Examination 408 Pain Control 409 Diagnostic Evaluation 409 Laboratory Studies 409 Radiology 409 Specific Disorders and Injuries 409 Head Injury 409 Perspective 409 Principles of Disease 409 Clinical Features 409 Specific Injuries 410 Concussion. 410 Scalp Injuries. 410 Skull Fractures. 411 Cerebral Contusions. 411 Epidural Hematoma. 411 Subdural Hematoma. 411 Diagnostic Strategies and Management 411 Radiology 413 Skull Radiographs. 413 Computed Tomography of the Head. 413 Spinal Injury 413 Perspective 413 Principles of Disease 413 Clinical Features 414 Radiology 414 Management 415 Cardiothoracic Injury 416 Perspective 416 Principles of Disease 416 Specific Disorders 417 Pneumothorax. 417 Open Pneumothorax. 417 Tension Pneumothorax. 417 Hemothorax. 417 Pulmonary Contusion. 418 Traumatic Diaphragmatic Hernia. 418 Cardiac and Vascular Injuries. 418 Commotio Cordis. 418 Abdominal Injury 418 Perspective 418 Principles of Disease 418 Clinical Features 419 Diagnostic Strategies and Management 419 Spleen Injury. 419 Liver Injury. 419 Renal Injury. 420 Penetrating Injury. 420 Radiology. 420 Disposition 420 Cessation of Care 420 References 422 39 Geriatric Trauma 424 Perspective 424 Background 424 Definition of Geriatric Trauma 424 Demographics and Epidemiology 424 Age as a Triage Criterion 424 Mechanisms of Injury 424 Distinguishing Principles of Disease 425 Decreased Physiologic Reserve 425 Comorbidities 425 Effect of Medications 425 Modifications to the Trauma Assessment of Older Adults 425 Primary Assessment and Resuscitation 425 Airway 425 Breathing 425 Circulation 425 Disability 426 Exposure 426 Secondary Assessment 426 Laboratory Testing 426 Imaging 427 Specific Disorders 427 Traumatic Brain Injury 427 Pathophysiology and Mechanisms of Injury 427 Assessment and Diagnosis 427 Treatment 427 Prognosis and Disposition 427 Vertebral Fractures and Spinal Cord Injuries 427 Central Cord Syndrome 428 Cervical Extension-Distraction Injury 428 Odontoid Fractures 428 Thoracic Trauma 428 Abdominal Trauma 428 Extremities 428 End-of-Life Decisions 428 References 430 40 Injury Prevention and Control 432 Perspective 432 Principles of the Disease of Injury 432 History of Injury Control 433 Methods of Prevention 433 Injury Control in Medical Practice 437 Injury Epidemiology and Documentation 437 Risk Factor Assessment 438 Biomechanical Risk Factors 438 Behavioral and Comorbid Risk Factors 438 Acute Care 439 Emergency Medicine Leadership: Advocacy of Public Policy 439 References 441 Two System Injuries 443 41 Head Injury 443 Perspective 443 Epidemiology 443 Principles of Disease 443 Anatomy and Physiology 443 Scalp and Cranium 443 Brain and Cerebrospinal Fluid 444 Cerebral Hemodynamics 444 Blood-Brain Barrier. 444 Cerebral Perfusion Pressure. 446 Biomechanics of Head Trauma 446 Direct Injury. 446 Indirect Injury. 446 Brain Cellular Damage and Death 446 Primary and Secondary Brain Injuries 446 Secondary Systemic Insults 447 Pathophysiology 447 Increased Intracranial Pressure 447 Brain Swelling and Cerebral Edema 447 Altered Levels of Consciousness 448 Cushing’s Reflex 448 Uncal Herniation. 448 Central Transtentorial Herniation. 448 Cerebellotonsillar Herniation. 449 Upward Transtentorial Herniation. 449 Clinical Features and Diagnostic Strategies 449 History 449 Acute Neurologic Examination 449 General 449 Glasgow Coma Scale 450 Pupillary Examination 450 Motor Examination: Posturing 450 Brainstem Function 450 Deep Tendon Reflexes and Pathologic Reflexes 451 Other Examination Findings 451 Management 451 Severe Traumatic Brain Injury 451 Out-of-Hospital Care 451 Emergency Department (Fig. 41-6) 452 Airway. 452 Hypotension. 452 Hyperventilation. 453 Osmotic Agents. 453 Barbiturates. 453 Steroids. 453 Hypothermia. 453 Cranial Decompression. 454 Seizure Prophylaxis. 454 Antibiotic Prophylaxis. 454 Ancillary Evaluation 454 Laboratory Tests. 454 Neuroimaging. 454 Disposition 454 Consultation. 454 Transfer. 454 Priority Management. 455 Moderate Head Trauma 455 Clinical Features and Acute Management 455 Disposition 455 Complications 455 Minor Head Trauma 455 Clinical and Historical Features 456 Imaging Studies 456 Ancillary Studies 457 Disposition 457 Patients on Anticoagulation. 457 Concussion. 458 Pediatric Head Injuries 459 Epidemiology 459 Pathophysiology 459 Clinical Features 459 Diagnosis and Management 459 Penetrating Head Injuries 462 Epidemiology 462 Pathophysiology 462 Clinical Features 462 Management 462 Complications after Head Injury 463 Neurologic Complications 463 Seizures 463 Central Nervous System Infections 463 Meningitis after Basilar Fractures. 463 Brain Abscess. 463 Cranial Osteomyelitis. 463 Medical Complications 463 Disseminated Intravascular Coagulation 463 Neurogenic Pulmonary Edema 464 Cardiac Dysfunction 464 Specific Injuries 464 Scalp Wounds 464 Skull Fractures 464 Clinical Assessment and Significance 464 Linear Fractures 465 Depressed Fractures 465 Basilar Fractures 465 Open Fractures 465 Diffuse Axonal Injury 466 Cerebral Contusions 466 Epidural Hematoma 467 Subdural Hematoma 467 Subdural Hygroma 469 Traumatic Subarachnoid Hemorrhage 469 Intracerebral Hematoma 469 Traumatic Intracerebe