ER Emergency Medicine

Mike Romano, John Sauve and Ryan Zufelt, chapter editors

Christophel' Kitamura and Michelle Lam, associate editors
Janine Huston, EBM editor
Dr. Simon Kingsley, staff editor

Initial Patient Assessment/Management ..... 2 Ophthalmology Emergencies ............. 42

Rapid Primary Survey (RPS) Ophthalmologic Foreign Body and Corneal
Resuscitation Abrasion
Detailed Secondary Survey
Definitive Care Dermatologic Emergencies ••.••••••.•••• 43
Ethical Considerations Life Threatening Dermatoses

Traumatology ........................... 6 Environmental Injuries . . . . . . . . . . . . . . . . . . 44

Considerations for Traumatic Injury Heat Exhaustion and Heat Stroke
Head Trauma Hypothermia and Cold Injuries
Spine and Spinal Cord Trauma Burns
Chest Trauma Inhalation Injury
Abdominal Trauma Bites
Genitourinary Tract Injuries Near Drowning
Orthopaedic Injuries
Life and Limb Threatening Injuries Toxicology .•••••••••••••••.••••••.•••• 48
Upper Extremity Injuries Alcohol Related Emergencies
Lower Extremity Injuries Approach to the Overdose Patient
Wound Management ABCs of Toxicology
Trauma in Pregnancy D1 -Universal Antidotes
D2- Draw Bloods
Approach to Common ER Presentations .... 19 D3- Decontamination and Enhanced
Abdominal Pain Elimination
Acute Pelvic Pain E- Examine the Patient
Altered Level of Consciousness (LOC) G - Give specific Antidotes and Treatments
Chest Pain Disposition from the Emergency Department
Epistaxis
Headache Psychiatric Emergencies ................. 56
Joint Pain Approach to Common Psychiatric Presentations
Otalgia Acute Psychosis
Seizures Suicidal Patient
Shortness of Breath Violent Patient
Syncope
Sexual Assault Common Pediatric ER Presentations ....... 57
Modified Coma Score
Medical Emergencies••••••.•••••••••••.• 30 Respiratory Distress
Anaphylaxis and Allergic Reactions Febrile Infant and Febrile Seizures
Asthma Abdominal Pain
Cardiac Dysrhythmias Common Infections
Chronic Obstructive Pulmonary Disease (COPD) Child Abuse and Neglect
Congestive Heart Failure
DVT and Pulmonary Embolism Procedural Sedation .................... 61
Diabetic Emergencies
Electrolyte Disturbances Common Medications ................... 61
Hypertensive Emergencies
Stroke References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Gynecology/Urology Emergencies......... 39
Vaginal Bleed
Pregnant Patient in the ER
Nephrolithiasis (Renal Colic)

Toronto Notes 2011 Emergency Medicine ERI

ER2 Emergency Medicine Initial Patient Assessment/Management Toronto Notes 2011

Initial Patient Assessment/Management

----(_-.,
A!lllfOich 1D die Criticellr II Pdent
1. Rapid Primary Survey [RPS)
2. RRuscitJdion [Dfml concwnntwith
RPS)
3. Deteilad Sacondary Survey
4. Definitive Care
1. Rapid Primary Survey (RPS)
• Airway maintenance with cervical spine (C-spine) control
• Breathing and ventilation
• Circulation (pulses, hemorrhage control)
• Disability (neurological status)
• Exposure (complete) and Envirorunent (temperature: control)
• Continually reassessed during secondary survey
IMPORTANT: always watch for signs of shock while doing primary survey (see Table 1)

A. AIRWAY
.._' I • first priority is to secure airway
,.l------------------, • assume a cervical injury in every trauma patient and immobilize with collar
Noisy breathing is obstructed breathing • assess ability to breathe: and speak
until prawn olherwi&a.
• can change rapidly, therefore reassess frequently

Airway Management
----(_-., • goals
Signs of Airway Obllrualian • permit adequate oxygenation and ventilation
• Agi1iltion, confusion, "universal • facilitate ongoing patient management
choking sign" • give drugs via endotracheal tube (ETT) if IV not available
• Respirmry dis1Jess • Note: start with basic management teclmiques before progressing to advanced (see below)
• Feiuruto IIPaek. dy$phonia
• Cymosis
I. Basic Airway Management (Temporizing Measures)
• protect the C-spinc:
• head-tilt (if C-spine injury not suspected) or jaw thrust to open the airway
• sweep and suction to clear mouth of foreign material
Medic:nona that c:u b• Deliqrld
•m 2. Definitive Airway Management
NAVEL • ETT intubation with inline stabilization of spine (Figure 1)
Naloxone [Nen:en) • orotracheal ± Rapid Sequence: Intubation (RSI) preferred
A1ropina • nasotracheal- may be better tolerated in conscious patient
Ventolin [Salbutamol)
Epinephrine
• relatively contraindicated with basal skull fracture
Lidoc:eins • does not provide 100% protection against aspiration
• surgical airway (if unable to intubate using oral/nasal route and unable to ventilate)
• cricothyroidotomy

----(_-., 3. Rescue or Temporizing Measures

lndit:lltiDna fur lntallilticm • nasopharyngeal airway
• Unable to pratec:t airwly [e.g. • oropharyngeal airway (not if gag reflex present)
Glasgow Coma Scale [GCS) < 8;
airway tmuma)
• "rescue" airway devices (e.g. laryngeal mask airway (LMA); Combitube•)
• lnlldequate axygenation with • transtracheal j c:t ventilation through cricothyroid membrane (last resort)
IIPontBneous !85pimlion [0 2
setumion with 1 02 or
Trauma requiring nubltian

•
rising
• Profound .tlack I
• Anticiplllory: in trauma, overdose, ...

•
congestive heart flliluru [CHF), No immldiate neld Immediate need
asthma. chronic obstructive I
pulmonary dileasa [COPO) and $/lloka
inhalation injury
• Anticipllled transfer of criticaUy iU
C·IIPine x-my
••
Apn&IC Breathing

l
I I
peti81111

Fiberoptic m or 0ra1m Oralm Omlm Nasalmororalm

..._,I nasel m or RSI

1
[:!: RSI) [no RSI) [:!: RSI)
,.l------------------,
Addld Equipmllllt 11111 Techniques In
llltuWicm
• Bougi• {usld liklegJiUwin)
• Retrograde intubation {ffi threaded
over a wirl inserted through skin and
out mouth)
I
••
Unable

Rescue devices or
I

•
Unable

Rescue devices or
I
••
lklable

Rescue or
I

• Lighted stylet {use light through skin cricothyroidotomy cricothyroido1Dmy cricothyroidotomy

111 detErmine if ffi in CO!Tilct place) • 11...: CleoriiiQ lhe C.Spine cli'lical -.sment. which ,..quim: 1) No midline tenderness 2) No focal neurol01,1ical delleits
• Fibreoptic in11Jbation- indiruct vision 3] No dlltracting factors 111ch .. intOJication, lllt8racl LOC or dimctiiiQ injuri..
using fibraop1ic cable
Figura 1. Approach to Endotracheal Intubation in an Injured Patient
m- andalrlchaliltDI illublliDn; RSI-IIpid sequancs illubllim
Toronto Notes 2011 Initial Patient Asaeument/Manqement Emergency Meclidne ER3

B. BREATHING
• Look
• mental status (anxiety, agitation, decreased WC), colour, chest movement (bilateral vs.
asymmetrical), respiratory rate/effort, nasal flaring
• Listen
• sounds of obstruction (e.g. stridor), breath sounds, symmetry of air entry, air escaping
• Fed
• flow of air, tracheal shift, chest wall for crepitus, flail segments, sucking chest wounds,
subcutaneous emphysema

Breathing Assessment
• measurement of respiratory function: rate, pulse oximetry, arterial blood gas (ABG), A-a gradient

Management of Breathing
• nasal prongs -+ simple face mask-+ oxygen reservoir -+ CPAP/BiPAP
• Venturi mask: used to precisely control Oz delivery
• Bag-Valve mask and CPAP to supplement ventilation

C. CIRCULATION

Definition of Shock
• inadequate organ and tissue perfusion with oxygenated blood (brain, kidney, extremities)
(see Table 2) \to,
Shock in a trauma patient is
Table 1. Major Types of Shock hemorrhagic proven otherwiae.

llypavalemic C.nliogenic Distributive {vaodilltian) Dbllruc:tive

Hamon1lage (IIXIII'nill and illbll'nlll) Myoc:ll'dial Ischemia Septic Cardiac tamponade
SIMI'II bums AnhytlmiiiS Anaphylactic Tension pnaumotho111X 't'
Hijl olllplt fistulas Congestive Heart Failure Neurogenic (spinal cord injury) Nmonary entolism &-!If Shack
Dehy!htion {diarrhea, DKA) Cll'diomyopallies Aortic stenosis SHOCKED
Cll'diac valve problems Constrictive Septic, SpinaVnaurovunic,
Hernonhagic
Clinical Evaluation Ob5buctive (e.g. blnsion pneumolhomc,
c.-diac tamponadll, pumonary
• early: tachypnea. tachycardia. narrow pulse pressure, reduced capillary refill, cool extremities BITiboliiiTI)
and reduced central venous pressure (CVP) Cardioqenic (e.g. blunt myocardial
• late: hypotension and altered mental status, reduced urine output injury, arrhythmia, Ml)
anaphylactiK
Endocrine (e.g. Addison's, myxedema,
Table 2. Estimation of Degree of Hemorrflagic Shock coma)
CIBS I II Ill IV Drugs

Blood Loss
%of blood volume
<750 cc
<15%
750.1500 cc
15-311%
1500.2000 cc
30-40%
>2000 cc
>411% ..... ''
Pulse <100 >100 >120 >140 Estimm.d Sysbllk: Blo.cl
Baed on Palhlon !If MDII Dlmll
Blood pressure Normal Ncrmal Decreased Decreased I'Bip.-ldtiPul•
Respinrtory 111111 20 30 35 >45 siP (mmllg)
Capillary ntil Normal Decreased Decreased Decreased Radial >80
Femoral >70
UriiiiiY output 30 ce/lr" 20 cC/lr" 10 cC/lr" None Carotid >60
Auid replacement Crystaloid Crystalloid Crystalloid + blood Crystalloid + blood

Management of Hemorrhagic Shock

• secure airway and supply 0 2
• TREAT TilE CAUSE OF TilE SHOCK Manqm18111
• control external bleeding RED
•directpressure Rest
• elevate extremities if no obvious unstable fracture Elavat81ha bleeding area above the
level of the
• consider vascular pressure points (brachial, axillary, femoral) Dirac! prauura on the blll8ding sitll
• do not remove impaled objects as they tamponade bleeding
• tourniquet only as last resort
• prompt surgical consultation for active internal bleeding
• infusion ofl-2 L ofNS/RL as rapidly as possible-+ 2large bore (14 gauge) IVs wide open
.... ',
• warm blood!IV fluids, especially for massive transfusions Fluid
• replace lost blood volume at ratio of 3:1 with crystalloid Give bolus until HR diiCrlllllllll,
output picks up, and p!dierrt stabilizn
• if inadequate response, consider ongoing blood loss (e.g. chest, abdomen, pdvis, extremities) -+ Maintenance: 4-2-1 rule
operative intervention required fir1t , Okg: 4CCI!qVhr
• indications for blood transfusion 1G-20kg: 2cc;/kg/hr
• severe hypotension on arrival remaining weight 1
• shock persists following crystalloid infusion replace ongoing lou• lll1d deficitli
(lllmll , 0'11 of body weight)
• rapid bleeding
ER4 Emergency Medicine Initial Patient Assessment/Management Toronto Notes 2011

• transfusion options with packed red blood cells (pRBCs)

• crossmatched if possible
Since only 30% of infused isotonic • type-specific (provided by most blood banks within 10 minutes)
cryllllllloid& ruiTIIIin& in inlnlvm:ul• • preferred to 0-negative un-crossmatched blood if both available
space, you must give 3x estimallld • 0-negative (children and women of child-bearing age)
blood IDA.
• 0-positive if no time for cross-match (males/postmenopausal women)
• anticipate complications with massive transfusions
• consider replacement of other blood products (plalelets, FFP) after 2-4 units pRBCs
• transfusion with fresh frozen plasma (FFP)
lnllllll af Any l'llllent • used for clinical evidence of impaired hemostasis
inSbacll • ongoing hemorrhage, PT >1.5x normal range
ABCs
IV fluids
Oxygen
Monitor(HR, BP. urinl, manlldion, ut.l D. DISABILITY
Control hemonbaQe • assess level of consciousness by AVPU method (see sidebox) or GCS

Glasgow Coma Scale (GCS}

• for use in trauma patients with decreased LOC; good indicator of severity of injury and
It' neurosurgical prognosis
Mllhod uf Aeleaintl • may be used for metabolic coma. but less meaningful
L-1 af ConsciousnHI
• most useful if repeated and used for monitoring of trend
AVPU • change in GCS with time is more relevant than the absolute number
AI art
• patient with deteriorating GCS needs immediate attention
Responds 1D Verbal stimuli
Responds 1D Painful stimuli • prognosis based on best post-resuscitation GCS
Unmponsivl • reported as a 3 part score: Eyes +Verbal+ Motor = Total (see Table 3)
• if patient intubated, GCS score reported out of 10 + T (T= tubed, ie. no verbal component)

Table 3. Glasgow Coma Scala

Unprovwn or Hermful T-lnlllnts fw EyasOp• Best Yalbll Response Bill Motor lllsponsa
Hemenbegl Shock Spontln!ously 4 Answers appropriatl!ly 5 Obeys commands 6
• position
• Steroids (used only in spilll cord To voice 3 Confused, disoriented 4 Localizes ID pain 5
injuryl
• MAST g11n11en!s To pain 2 words 3 Withdraws from pain 4
• Vuopressors
No response 1 lncCJIT1lll!hensible sounds 2 Decorticate (flexionl 3
No varbal respansa lleclllllbrate (axlllnsionl 2
. . . . .ii-Nwlljiiiiijftilil...... il
l'lliiiD will s.,ti: SIIICk
No response
NE.IA 2008; 358:877-87 13-15 =mild injury. !1-12 = mod81118 = sem injUJY
lllldorril8d,doublt-bindlrilll Sal Tlbll28 for modliad r.cs for infants 111d childm
l'llim: m pllilllllMllslplic shock
........ VIIQIIIIIIil (0.01 tu0.03
upnmal •mnpilaplrillii51D 1511Qper
mirWI in addition a E. EXPOSURE/ENVIRONMENT
mininun af 5UQ rl nllllpinlphri111. • undress patient completely and assess entire body for injury; logroll to examine back
o.au Mcr1Jij;y llle 28 days ilf1lr ilart al • digital rectal exam
irlu&illlll.
......_: No signilicart dill!tence helween 1he • keep patient warm with a blanket ± radiant heaters; avoid hypothermia
IIIII the II • warm IV fluids/blood
or 90dlys. HcMt., ilpililro Nth lisa • keep providers safe (contamination, combative patient)
-.1lplic lhol:t,IIIIOI!y IIIIIW1117Mir in lhe
group.
2. Resuscitation
• done simultaneously with primary survey
• attend to ABCs (see Table 4)
Folly Contrlindiclllelll • manage life-threatening problems as they are identified
• Blood at urelhn.l meatus
• Scrutal hematoml • vital signs qS-15 minutes
• High-riding pro1111!1 on DRE • ECG, BP and 0 2 monitors
• Foley catheter and nasogastric (NG) tube if indicated
• tests and investigations: CBC, electrolytes, BUN, Cr, glucose, amylase, INR/PTT,
toxicology screen, cross and type
Nil 1WI Conlreindbtion•
• Si!Jlificlnt mid-face 1niUR11
• BIHI skull frllcturu
Toronto Notes 2011 Initial Patient Asaeument/Manqement Emergency Meclidne ER5

Table 4. 2005 AHA CPR Guidelines

Stlp/Aclion Adult>Jvn I Child: 1-8 yan I Infant <1 yw
Airway Head tilt-chin lift
Breaths
Foreign-body
airway obstruction
Abdcminal thrust
2 breaths 111 second/breath
I Back slaps and chest thrusts

Cernpression In the centre Ill the chest, between Just below nipple line
landmarks
Cernpression 2 Hands: Heel of 1 hand, 2 Hands: Heel of 1hand with 2fingers
msthod: pU&h hard &econd hand on top sBCOnd on IDp, or
and fast and allow 1Hand: Heel of 1hand only
fur cCJIT1llele recoil
Ccmpression depth 11h ID 2inches About IJliD 1/z the depth of the chest
Compression rile 101Vmin
Compression- 3D ccmpressians ID 2ventiations
ventilation rllio
Compression· Hands·cmly CPR is preferred byslllnder is not t111ined or does not feel confident in their ability ID
CPR provide COIMintional CPR or if 1hB bystander is tained but choD&es ID use
llefilrillation lmmadiatll delibrilation fur all rescuers responding ID a sudden No delitrillation
witnessed collapse. CCJIT1llession before A8l is
considered if EMS arrival is >4-5 rrinutes aftsrthe cell

3. Detailed Secondary Survey

• done after rapid primary survey problems have been addressed
• identifies major injuries or areas of concern
• full physical exam and x-rays (e-spine, chest. pdvis -required in blunt trauma. consider
T-spine and L-spine)

HISTORY
• "SAMPLE": Signs and Symptoms, Allergies, Medications, Past medical history, Last meal,
Events related to injury

PHYSICAL EXAMINATION
Head and Neck
• pupils
• assess equality, size, symmetry, reactivity to light ..... ,,
• inequality/sluggish suggests local eye problem or lateralizing CNS lesion
• relative afferent pupillary defect (swinging light test) - optic nerve damage Dllmd, NeiHMCtlve
• extraocular movements and nystagmus Pupil, Think:
Focelmnslasion
• fundoscopy (papilledema, hemorrhages) Epidlnl hematoma
• reactivity/level of consciousness (LOC) Subdurlll hema!DRII.
• reactive pupils + decreased we -+ metabolic or structural cause
• non-reactive pupils+ decreased we-+ structural cause (especially if asymmetric)
• palpation of facial bones, scalp
Non-contrail held CT is lila bait
Chest imfll!ing modality for intracerabral injury.
• inspect for midline trachea, flail segment: rib fractures in places; if present look for
associated hemothorax, pneumothorax, and contusions
• auscultate lung fields
• palpate for subcutaneous emphysema
Sip af 111-.d lntr•Cfllni•l
Abdomen • Deteriorating LOC (hallmft)
• assess for peritonitis, abdominal distention, and evidence of intra-abdominal bleeding • Deteriorating ra.pimory pM!llm
• FAST (Focused Abdominal Sonogram in Trauma), diagnostic peritoneal lavage (DPL) or CT • Cushing reflex (high BP. low hellrt
• rectal exam for GI bleed, high riding prostate and anal tone (best to do during the log roll) rate, irregular mpindions)
• Latnlizing CNS signs (e.g. cranial
• bimanual exam in females as appropriate nerve pal$ie5, hemiparesis)
• SlizUI'II
Musculoskeletal (MSK) • illtel
• examine all extremities for swelling, deformity, contusion, tenderness, range of motion • NNand WA
• check for pulses and sensation in all injured limbs
• log roll and palpate thoracic and lumbar spines
• palpate iliac crests and pubic symphysis, pelvic stability (lateral, AP, vertical)
ER6 Emergency Medicine
,,.. ,
.llbovab"s wrm-
• Capabl• adults haY8 the right to
rafuu madiall traatmant
• May r.fus• whole blood, pRBCs,
platalllbi lll1d plalma evan lliflt-
saving
• Should be questioned directly about
tha us• of albumin, imrmrloglobuli'la.
hamophilic preparations
• Do not alow autologous transfusion
unless there is unlntenupted exira
corporul cin:ulation
• Ulllllly ask for the highest possible
quality of care the usa of the
above interventions (e.g. crystalloids
for volume expansion, attempts at
biDOdiiiS SUrQII'ff
• Patient will generally &ign h05pital
forms rel11sing medical stall from
liability
• Molt I CIIN involv1 childrln of
Jehovah's Witnesses; if lifit.saving
treatment is refuaad contacllld CAS
,,.. ,
High Rilk ....rill.
• MVC at high speed, resulting in
ejKiion from vehicle
• Motorcycl• collisions
• v.hicll vs. flldertrian cruhn
• FaD tram height >12ft [3.6 ml
Initial Patient AasessmenUManagementJTraumatology Toronto Notes 2011
Neurological
• GCS
• full cranial nerve exam
• alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities
• progressive deterioration of breathing pattern implies a failing CNS
• assess spinal cord integrity
• conscious patient: assess distal sensation and motor
• unconscious patient: response to painful or noxious stimulus applied to extremities
4. Definitive Care
• continue therapy
• continue patient evaluations and special investigations
• specialty consultations including OR as needed
• disposition: home, admission, or transfer to another setting (e.g. OR, ICU)
Ethical Considerations
Consent to Treatment: Adults
• Emergency Rule: consent is not needed when patient is at imminent risk from a serious injury
(e.g. severe suffering, loss oflimb, vital organ or life) AND obtaining consent is either: a) not
possible (e.g. patient is comatose); OR b) would increase risk to the patient (e.g. time delay)
• assumes that most people would want to be saved in an emergency
• any capable and informed patient can refuse treatment or part oftreatment, even if it is life-saving
• consider: is the patient truly capable? Does pain, stress, or psychological distress impair their
judgment?
• exceptions to the Emergency Rule: treatment cannot be initiated if
• a competent patient has previously refused the same or similar treatment and there is no
evidence to suggest the patient's wishes have changed
• an advance directive is available - e.g. do not resuscitate (DNR) order
• refusal of help in a suicide situation is not an exception; care must be given
• if in doubt, initiate treatment
• care can be withdrawn if appropriate at a later time or if wishes clarified by family
Consent to Treatment: Children
• treat immediately if patient is at imminent risk
• parents/guardians have the right to make treatment decisions
• if parents refuse treatment that is life-saving or will potentially alter the child's quality of life,
Children's Aid Society (CAS) must be contacted- consent of CAS is needed to treat
Other Issues of Consent
• need consent for HIV testing, as well as for administration of blood products
Duty to Report
• law may vary depending on province and/or state
• gunshot wounds, potential drunken drivers, suspected child abuse, various communicable diseases
• medical unsuitability to drive
Traumatology
• epidemiology
• leading cause of death in patients <45 yrs
• 4th highest cause of death in North America
• causes more deaths in children/adolescents than all diseases combined
• trimodal distribution of death
• minutes: lethal injuries, death usually at the scene
• early: death within 4-6 hours - "golden hour" (but decreased mortality with trauma care)
• days-weeks: death from multiple organ dysfunction, sepsis, etc.
• injuries generally fall into two categories
• blunt (most common): motor vehicle collision (MYC), pedestrian-automobile impact,
motorcycle collision, fall, assault, sports
• penetrating (increasing in incidence): gunshot wound, stabbing, impalement
Considerations for Traumatic Injury
• important to know the mechanism of injury in order to anticipate traumatic injuries
• always look for an underlying cause (alcohol, medications, illicit substances, seizure, suicide
attempt, medical problem)
• always inquire about head injury, loss of consciousness, amnesia, vomiting, headache and
seizure activity
Toronto Notes 2011 Traumatology Emergency Meclidne ER7

Motor Vehicle Collision (MVC}

• vehicle(s) involved: weight, size, speed, amount of damage
• type of crash (to assess location of possible injuries)
• lateraVT-bone and head-on: head. cervical spine, thoracic, abdominal, pelvic and lower
extremity
• rear-end: hyper-extension of cervical spine (whiplash injury to neck)
• roll over: energy dissipated, less likely severe injury ifvictim restrained by seatbelt, however
still significant potential morbidity
• location of patient in vehicle
• use and type of seatbelt
• lap belt: spine and abdominal injury
• shoulder belt: look for major vessel injury
• ejection of patient from vehicle/entrapment of patient under vehicle
• airbag deployment
• use of helmet in motorcycle or bicycle collisions
Pedestrian-Automobile Impact
.... ,,
• high morbidity and mortality
• vehicle speed is an important factor Vthicll ... Pldellrilll er.h
In adults look lor triad of injuries
• site of impact on car (waddle's triad):
• children tend to be run over 1. Tibi&-fibula or femur fnlctwe
• adults tend to be struck in lower legs, impacted again on car (truncal injury) and thrown to Z. TrQICIII injury
the ground (head injury) 3. Craniofacial injury

Falls
• 1 storey= 12 feet = 3.6 m
• distance of fall: 50% mortality at 4 stories and 95% mortality at 7 stories
• position in which patient landed and type of surface
• assess for shock, lower extremity, spine and pelvic fractures
Gunshot Wounds (GSW)
• typeofgun
• handgun injuries: low or medium velocity, extent of injury may be limited to a small area
• hunting and rifle injuries: high velocity, widespread injury
• shot gun: widespread tissue destruction
• type of ammunition (e.g. hollow point bullets)
• range of shot
• close range: massive tissue destruction, deposition of wadding into wound
• characterize route of entry, even or odd number of wounds and site of exit wound (if any) \•,
• GSW with hypotension: immediate transport to OR Cardiac box: sbllllll notch. nipples and
• hypotension indicates severe blood loss (>2 L blood loss in 70 kg patient is required to xiphoid process; injuries inside this
produce hypotension) lhould incmsaiUSpicion of Cllrdiac
injury.

Stab Wounds
• route/direction of entry, length of blade
• type of penetration (stab, slash, impalement)
• victim recollection and witness reports are often inaccurate and may not correlate with depth/
severity of wound
• ifblade in-situ, DO NOT REMOVE- it may be tamponading bleeding vessel (to be removed in OR)

Head Trauma
• see NS29
• 6096 oftrauma admissions have head injuries
• 6096 ofMVC-related deaths are due to head injury

Specific Injuries
• fractures (diagnosed by CT head, often not visible on x-ray)
A. skull fractures
• vault fractures
.... ,,
• linear, non-depressed Signs llf Bual Sladl fl'llcture
- most common Battle's sign {bruised mastoid process)
- typically occur over temporal bone, in area of middle meningeal artery (commonest Hamotympanum
Raccoon ayes (periorbital bruising)
cause of epidural hematoma) CSF Rhinorrhae./()toniiSI
• depressed
- open (associated overlying scalp laceration, torn dura) vs. closed
• basal skull
• typically occur through floor of anterior cranial fossa (longitudinal more common than
transverse)
• clinical diagnosis superior as poorly visualized on CT (Battle's sign. raccoon eyes, CSF
rhinorrhea/otorrhea, hemotympanum)
ER8 Emergency Medicine Traumatology Toronto Notes 2011

B. facial fractures (see Plastic Surgery. PL26)

• neuronal injury
• beware of open fracture or sinus fractures (risk of infection)
• unstable or displaced fractures (need semi-urgent plastics referral)
• severe facial fractures may pose risk to airway from profuse bleeding
• neuronal injury
A. diffuse
• concussion
• mild: temporary disturbance of neurological function, complete recovery
Warning Sig• af S.vwrlllll&d lnjmy • classical: temporary, reversible neurological disturbance, with temporary (<6 hrs) loss of
• GCS <8 consciousness, complete recovery
• Dell!riDrlling GCS • diffuse axonal injury
• Unequal pupils • mild: coma 6-24 hrs, possibly lasting deficit
• L.amralizing sip
N.B. Altered LOC is a hallmlllk of brain • moderate: coma >24hrs, little or no signs ofbrainstem dysfunction
injury. • severe: coma >24hrs, frequent signs ofbrainstem dysfunction
B. focal injuries
• contusions
• intracranial hemorrhage (epidural, subdural, intracerebral)

ASSESSMENT OF BRAIN INJURY

History
• pre-hospital status
• mechanism of injury

Physical Examination
• assume C-spine injury until ruled out
• vital signs
• shock (not likely due to isolated brain injury, except in infants)
• Cushing's response to increasing ICP (bradycardia, hypertension, irregular respirations}
• severity of injury determined by
l.level of consciousness (LOC)
• GCS :s;s intubate, any change in score of 3 or more = serious injury
2. pupils: size, anisocoria >1 mm (in patient with altered LOC), response to light
3.lateralizing signs (motor/sensory}
C.utlianCT"-dR.... • may become more subtle with increasing severity of injury

llllll
r.,....•
1lle lMcrl2001; 357:921i6;1391·1396
er lllld • .., ,..._ llilor
wilb mr• .. IMialawilg:
• re-assess frequently

Investigations
. .risk(fwllllliQioP
• labs: CBC, electrolytes, coags, glucose, tox screen
• GCSSCOII<15d2hlbrijly • CT scan (non-contrast) to exclude intracranial mass lesions
• &.p.c:tad opllllll dipru.d ltul fnlc:tn • C-spine imaging, often with CT head and neck to exclude intracranial mass lesions
• Allr sign ri belli tlwl f1ldln (hlmotympnJm,
"nr;coon'"""" Glurrherl Management
lilincmh-. illllll'l 191 • general
• Yamiti'G 0!2 episodes • ABCs
•
• ensure oxygen delivery to brain through intubation and prevent hypercarbia
. . . . risk !fw IJIIia ijny 111en • maintain BP
• Almlliuftlr >30 mil
• llqelaus mechllilm !pedntrim 111\Uby • treat other injuries, must treat hypotension, hypoxia (both contribute significantly to
mallllwbicil, OCcupllllljlctld from 111111111 mortality)
wllicle, fdfmm heiglt >311111arfiveslllrs) • early neurosurgical consultation for acute and subsequent patient management
.......... ildlftn... • medical
rllliiiiCi--. deliiiE lll'llesil, orwitniiiiSd • seizure treatment/prophylaxis
disorianlllion ill IJIIilriwith I GCS ICCAof 13-15. - benzodiazepines, phenytoin, phenobarbital
- steroids are of no proven value
• treat suspected raised ICP -+ consider if head injury with signs of increased ICP:
•
Tr111tm11nt af ln-ldiCP
- raise head of stretcher 20° ifpatient hemodynamically stable
- intubate and hyperventilate (100% 0 2) to a pC02 of 30-35 mmHg
• Elevate head of bed - mannitollglkg infused as rapidly as possible
• Mannitol - consider paralysing meds if agitated/high airway pressures
• Hyperventilate - maintenance of cerebral perfusion pressure is critical
• Paralyzing agenl.t58dating agenl$
• surgical
See also Neumsurqert NS6
Disposition
• neurosurgical ICU admission for severe head injuries (HI)
• in hemodynamically unstable patient with other injuries, prioritize most life-threatening
injuries and maintain cerebral perfusion
• for minor head injury not requiring admission, provide 24-hour HI protocol to competent
caregiver, follow-up with neurology as even seemingly minor HI may cause lasting deficits
Toronto Notes 2011 Traumatology Emergency Medicine ER9

Spine and Spinal Cord Trauma "-{_9,

eau.r E"'JOII' with One of
• assume cord injury with significant falls (> 12 ft), deceleration injuries, blWlt trauma to head, 1118 FoiiDwlng Cl'llllrlll
neck or back • Midline tandarnass
• spinal inunobilization (cervical collar, spine board during patient transport only) must be • Neurological symptoms or signs
• Significant distracting injuries
maintained until spinal injury has been ruled out (Figure 2) • Hllld injury
• vertebral injuries may be present without spinal cord injury; normal neurologic exam does not • Intoxication
exclude spinal injury • Dangerous macllanism
• cord may be injured despite normal C-spine x-ray (SCIWARA = spinal cord injury without • History of altered LDC
radiologic abnormality)
• injuries can include: complete/incomplete transection, cord edema, spinal shock

History
• mechanism of injury, previous deficits, SAMPLE
• neck pain, paralysis/weakness, paresthesia

Physical Exam
• ABCs
..... ',
• abdo: ecchymosis, tenderness Naill: Patients with penetrating trauma
• neuro: complete exam, including mental status {especially gunshot 111d knife wounds)
Cll1 alia hllva spinal cord injury.
• spine: maintain neutral position, palpate C-spine for tenderness, step-otf, log-roll, then palpate
thoracic and lumbar spine; assess rectal tone
• extremities: check cap refill, suspect thoracolumbar injury with calcaneal fractures
... '9l------------------.
,
Investigations Of tha investigations, the IIIIBnll C-spina
• labs: CBC, electrolytes, creatinine, glucose, coags, cross and type, tax screen lf-111'( is the single most important
• imaging film. 95% of radiologically visible
• full C-spine x-ray series for trauma (AP, lateral, odontoid) are found on 1llis film.
• thoracolumbar x-rays
• AP and lateral views
• indications: ..... ',
• patients with C-spine injury CIIUda Equina Syndrome can occur
• Wlconscious patients (with appropriate mechanism of injury) with any spinal cord injury bllow
• patients with neurological symptoms or findings T10 vertebrae. Look for incontinence,
• patients with deformities that are palpable when patient log-rolled anteriar thigh pain. quadriceps
• patients with back pain weakness. abnormal sacral sensation,
decreased rectal tone 111d vuiable
• patients with bilateral calcaneal fractures (due to fall from height) reflexes.
- concurrent burst fractures of the lumbar or thoracic spine in 10% (T 11-U)
• consider CT (for subtle bony injuries), MRI (for soft tissue injuries) if appropriate

Suapac:tad C-spine Injury

•• based on mech111ism of ir1ury (e.g. MVC, fllll, sports)

+
History: midline nack pail, numbness or pansthasia, pn1111nce of dirtnu:ting pail, patient haed-injurad, n..e...-. e..,m. ....__1111 NEXUS
pllliant intoxicated, lOS$ of con1ciousnll$$ or pall history of spinal mobility di1order '-tilt Cllblllln I'IMI wllh 'hma
PhpicaiiiiWII: posterior neck spasm, tenderness or crepitus, any neurologic deficit or NEJM 2003; 341(26):251"-
autonomic dysfunction, altered mental state l'llpole: To com11111 tile clili:ll IJII(Dnrlnct II
tile Can.tiln C.Spine Rule (CCRiand the Nltionll
I
• •
No Yes Udllllion Sludy
INEXUSI Law-llit Critliriii!NLCJ.
Sllllr. TI1IITI pnllniJ (n=12131 in stJIJia
I C-1pine cleared I 1. Plain Hll'f', 3 viiiWI
2. CT8CII1 if:
conditioll were bybolhthe
CCR snd If£ by 384 physicians hlbll radiogrlplv.
• Inadequate plain film survey Z\of1hnl patimhld I C-spin1 injury.
• Suspicious plain Om findings llldl: Conlplllld 1111118 If£. lhl CCJIMS mora
C-spine claarad I • To bBttar dalinaate injuries sean on plain Oms
• Any clinical suspicion of atlanto-axial dislocation
.... 199.4 "¥1. 90.7\) and1111n !l*lic
• High clinical suspicion of injury despite nonnal x-ray vs. 38.8"1 Iller excusion o1 inddeminlle-
Norm11j Th1llllllblr ofmiuld pdlllll would bll far 1111
• To include C1-C3 when head CT is indicated in tr-..ma
j+-
• •
Flexio!Vextension films Neck pain CCR snd 1&!artie tt.C. The range of motion-
not Mltmld ilme CCR C1181ialy blctus8
pilysicilns were no1 con-lur1lbk! will lhe procedure
H Nonnalfilms
I I Abnonnal films

•
snd lhis ny
I
11111itiuity111
RamBin immobilized, !p1Cili:ilyof1111 CCII in pn1cticl.
spina sarvica s..m.y. The CCII il s..... 1111111 If£ inllart
Remain immobilized, and stable pllillniJ Mh IIIINnl. The u• 111111 CCR
Abnormal i Abnonnal
I consult spine se!Vice Clllrtajk i1 bwar lldionlrf lila

MRI I+- neurological

axam
+-

C-spine claarad
I
Figura 2. Approach to Clearing tlla C-spina
ER10 Emergency Meclidne Traumatology 1'oroDio 2011

Can Clear C·spine if:

• no posterior midline cervical tenderness
..Milt (lilllprC.. . .- ; ; 151 • no evidence of intcW.cati.on
. . . . .Trwll .....loflnCd:ll...
• oriented to person, place. time and event
• no focal neurological defidt8
• no painful dJ.stracting Injuries (e.g. long bone#)
AgaO!liS,_a
(I

U.UIIIIdlrilnr" Management of Cord Injury

(I
• immobilize
l'nllhllils • evaluate ABCs
•i. • treat shock: (maintain sBP >100 mmHg)

.........,
-IIH!dr.r.tt
.. • insert NG and Foley catheter
• high dose steroids: methylprednisolone 30 mg/kg bolus, then SA mglkglhr drip. !tart within
6-8 brs ofInjury (controvenial. and recently has less support)
• complete imaging of spine and consult spine service if amiable
(I • continually reassess high cord Injuries as edema can travel up cord
lt!irtiJI)Iiilllillll • ifcervical cord lesion. watch for respiratory insufficiency
(I
.....1 • low cervical transection (CS-Tl) produces abdomins.l breathing (phrenic innervation of
ArriUiDty •-vtn
(I diaphragm still intact)
Dri!JIIInatllir.kplill • high cervical cord injury (above C4) may require intubation and ventllation
(I
• beware of hypotension (neurogenl.c shock)
.......
AlllntIll • treatment: warm blanket. 'fre:ndelenbergposition (occaaionally), volume infusion, consider
.... .....
vasopresson

Approach to C.Spine X·Rays

1111111tncllllr-.ld7
>5'111fllnd ril#f • 3-view C-spine series is the screening modality of choice
...... 1. lateral Cl-Tl ± swimmer's view (Figure 3, see Table 5 for interpretation)
• lateral view is best. identifies 90-95% of Injuries
1•--1 2. odontold view (open mouth or oblique submental view) (see Figure 4)
'llqanilaMlllihl'ism; • enm1ne the dens fur fi:a.ctures
• - beware ofartifact (horizontal or vertlcal) caused by the radiologl.calsbadow of the
• M\t splld (> liiiiMt
• MIIDril!d--wlicles
roba;.,. teeth overlying the dens
- ifunable to rule out fracture, repeat view or consider CT or plain film tomography
• Bqdt tdlilln • examine laters.l aspects ofCl and spacing relative to C2
3.APview
tslrciiiiiHIII MVC .W.:
iml • alignment of spinous processes In the midline
•11br llftrgltnd • spacing ofspinous proce88es should be equal
•RGIDwr • check vertebral bodies and facet dlsl.ocatl.ons

_ . . NctimllllilllllllrllnaPiil Supine Oblique VIews

JUM..I001; 216:1841·1848 • rarely used
• better visualization of posterior element fractures Oamina. pedicle, facet joint)
• good tD assess patency of neural foramina
• can be used to visualize the C7-Tl junction

Tabla 5. lllterpratltion of l..atllral Viaw: Tha ABCS

1. Anlllrior vartlbrallile
2. l'ostlrior 'tWIIbnllline
(antJrlor maraln olaplnal canal)
3. l'ostlrior barthl' of fiiC81s
4. Llmillr fusion line
(pollerior margin of 1pilll CIDII)
5. f'llllaior iipiloua Ina
(alq dPI of IIPMUI 1RC88188)
Flgar8 3. Un11 of Crmtour 01 1
Lmral C.Spina x-Ray
A _.ICY 11d.Aig11111t
• Mist a C1 1D C7-TI jnliln; if nat. dllwrMwd 1rBc1ian d thcUdn. swilllllll"s viaw. obliques.
II' CT SCII'I needed
• Linea of CIIIIClll'- in chictan <8 ,.-" of age: Cllll88 jlbyliolagic aubUartion of C2 on C3, and C3 on C4, but the
spind.ninallina is rnai1111in..
• d spinau& 111'DC811811- suggests pas1llilr liglrnlldllus diiiUIDJn
• Widrii;J r1 facal joirt$
• lhd IIIIIIJID.occipit:!ll joint
• Lina axtanding inferiorlyfrom clivus ahiUd tnmect odanlllid
• AllantD-IXiallllii:UII1ion -widening of pradnal space (ncrmal: <3 mm in adui1J, <5 nm in chtlnln) inclcates inillY
ofC1 ar C2
B 111111111
.l2 o Hail#lt, wicllland llhlpa at IIICh vertebral body
j • l'ediclas, facats, and ilrillla &h!Ud IPfiR" • ana - dDiilling ratlllion
fi
.ii!
E
c c:.tilll
o lnlllvlltllbl'll disc &pleas - wadging lllleriady ar poslaillty suggast& lllltlllnl campiiS&ion
:
S SaltTIISUII
• r1 reliqJIIII'jllgelll (no1TT181: <7 rrm at C1-4,1111'f be wide in chidren <2 yrs an apiraticnl or relmlndullll
8piC88 (nonnel: <22rmut C6-T1, <14 mm in chlrhn <5 '/II)
Toronto Nota 2011 TraUIIllltology .Em.c:lzeocy Medicine ERll

Saqualaa af C-spina Fracturu

• deaeased descending sympathetic tone (neurogenic/spinal shock) responslble for most sequelae
• autonomic dysretl.exia: in patients with spinal cord inJurles at or above the T6lem
• common signs and symptoms: pounding headache, naaal congestion, feeling of apprehension
or anxiety, visual changes, and marked increue in systolic and diastolic blood pressure
• common triggers
• urinary system.: bladder distention, urinary tract Infection, and kidney stones
• GI causes: fecal impaction or bowel distention
1. Dana
• treatment: monitoring and controlling blood preslllll'e. prior to addressiDg CllllBative issue 2. Cl Lateral MaR
• cardiac 3.C2
• no autoregulation, falling BP, decreasing HR. vasodilation
• management: give IV fluids ± vasop:ressors
• respiratory
• no cough reflex (risk of aspiration pneumonia)
• no intercostal muscles ± diaphragm movement
lateral m-
To c'- th!IJH8'(
of Cl
lhll:
A. The denl ia centnld belween lhl
B. Cl and C2 1n align-' llltarwly
C. The
j
f
syn111etrical illizi 0
• management intubate and maintain vital capacity
• gastrointestinal Figunt 4. C.Spiae X-Ray; Dduntoill
• ileus, vasodilation, bile and panaeati.c secretion continues (>lUday): risk of asplration, GI View
stress ulcers
• management: NG tube may be required fur sw:tioning. feeding, etx:.
• renal
• hypoperfusl.on -+ give IV fluids
• kidney still producing urine (bladder can rupture ifpatient not urinating)

...... ,
• management: Foley catheter may be required (measure urine output)
• skin
• vasodilation, heat loss, no thermoregulation, atrophy (risk ofskin ulcera)
• muscle 20'1. Ill C.lpin1 frac:luiBIID
• ftaccidity. atrophy, decreued venous return
• penis 10 ensu11111uncic Md •m•r
ICCDm!*lild by othar spilll frlctures.
1pine
x-rays n nDIIIIII before proc.IMilg
•priapism to OR.

Chest Trauma
• twotypes
A. found and managed in 1° survey
B. found and managed in 2° survey
\,,
Tra111111 to lhl ches!IICQiu!Qfor 50% of
trmnadllllthL

A. l.Jt..Thraatenlng Chest InJuries Found In 1° Survey (see Table 6)

Tabla 6. l.ife·lllreetening Cllast lnjuriaa Fauad ia 1° Sunray
• Anxiety, stridor, lanl111111a,
allarad III8IDIIUIIII
• Aplaa. cyanosil
• Respil'ltary dislma,
• Clinical diaplil lllclr,alrdia. dislandad nack.
• 0118-W11Y Vlllva c:ausing vails, cyanasis,llyJTIII8by
of air in plaual of chest wal malian
l!piiC8 • Tlll:haal daviltion r11R1f fmm
pnaui11Dibarlx
• Percussion
• Do nrt wait fer ABG to • Daliitive liway lllllllglllllll
in11meta
• RSIDMI Fll hirilla with
IIIYI'CIDIC!fll prior to inbJIItian
• NIIHldawaphic • Needle 1lalcoatDnty -large
diacJiasis bara n11lllla, 2nd ICS mid
cllwicul.-lile, ftlllawed by
chest tube il 5th ICS. lllllliar
IIXi'-vhl
...... ,
80'1. Ill all chill in;.i• can b&lllllnqal
niii-IU111iCBIIyo with li111JI8 1118111UI'M
IUch • inbation. chilli: lub18, IIIII
pain conlrOI.
\,,
3-lny IMI far Ope1 l'nlllnlltiiDIU
p.........
Alcrws 1irto - • lllring tha
expil'l!llrV pl1ale I• that YGU don't Gfl
I laaian ,..lftlothiiiU) but a•ll ibalf

• LnlatBnllllbsanceli lnllth to aiDw ldeqLIIIII br81111s dwing lhl

aollldl iiiiPil'l!llrV pima.

• Gunshot or CJiher wtml • Air-tight dressing l8lled on

MllllwllllllcdlaiD
• >1500 cc l*lod loss il chalt
cavity
(hde >2/31racheal dimeter) 3sides
± axitwtuld • Cheat1ube
• bruh SCU!ds • Sll!liiV
• PaiD, flat neck. veins, shock. • U..lly any allle1o da • Restare blood wlume
• lnlllerll dulneu tupine ClCII - entire 1111!1 • Cheat1uba
' .Abslft lnllth IOUnds. lJIIII8IIli mdioapllque as • Tlun:otamv if:
hypabmilll blood Sjl1!flds out IM!f • >1500 cc total biDDd loa
pastrriar tluncic CIYily • cc.1r conti1118d
drainaga
ER12 Emergency Medicine Traumatology Toronto Notes 2011

T1ble 6. Ufe-Threltening Chest Injuries Found in 1a Survey (continued)

It' Physical Exam lnVIIIigllions
DDx of Lh Thra...ning Cl-.st lnjurin
Filii Chast • Paradoxical movement Dl • ABG: decreased • 02 + fluid therapy + pain
HOT 1mt FAT CHEST o Fre&-ftoating segment of chest flail segment increased pC0 2 con1rol
Hamothoru* wall due to >2 ril fractures, o Palpable crepitus of ribs • CXR: rib fractures, lung • Judicious fluid therapy
Open pneumolhoru.
Ta111ion pnaumothoru.* each ill 2 sites o Decreased air entry on contusion in absence of systemic
• Underlying lung contusion affected side hypotension
flail chest {cause Dl morbidity and • Positive pressure ventilation
Airway obllruc:tion mortlllity) • ± intubation and ventilation
Tamponade*
Cllntusion: pum-rv. myocardial Canlillc Tamponade • Penetrating wound {usually) • EchocardiDIJliTI • IVftuids
Hernia: 1nlumltic, dilphragmltic o Clinical diagnosis o Beck's 1riad: hypotansion, • Bedside ultrasound • Paricardiocantasis
ESophngalll perforltion o Pericardia! fluid accumulation distended neck veins, {FAST} • Open thoracDI:omy
Tracheobronchial disruptiorv' impairing ventricular function muffled heart sounds
Traumatic injury/TllOr'IICic Aorta o Tachycardia, tachypnea
Ruptura* o Pulsus paracloxus
*Rapidly Liflllhr'81111ning • Kussmaul's sign

B. Potentially Life-Threatening Chest lniuries Found in 2!' Survey (see Table 7)

Kullam•uf• Sign C...:
Constrictive pericarditis
Right ventricular myocardial iThlrction
Tricuspid mnosis
Cardiac Tamponade
..
Ruptured diaphragm is more often
diagnosed on 1he left side, as liver
concaall right sida dafect.
Aartic Tau: ABC WHITE
X-ray faaluras of Aortic lllar
daprassld l.rt mainstlm Bronchus
pleural Cap
Wid& mldiallinum (most consislllntl
HemathOiliX
Indistinct aortic lmuclda
Tracheal deviation to right 5ide
Esophagus (NG tubal deviatad to right
(Note: pment in 85% Df cases, but
cannot rule out)
• need to have high index of suspicion, usually dependent on mechanism of injury
Tabla 7_ Potentially Uf•Thralltllning Chest Injuries Found in 2a Survay
Pulmon.., Colltulion
Ruptured Dii!phl'lgm
Aarlicleu
• 90% tear at subdavian
{near ligamentum arteriosurn), corr1lfainls Ill chest pain,
most die at scene
• SSvageable Wdiagnosis
made rapidly
• Blunt trauma to chest
• Interstitial edema impairs
and gas
axchange
• Blunt trauma to chest or
abdomen {e.g. high lap belt in
MVC)
• Usually penl!lnlting trauma
{pain out Dl proportion to
degree Dl
• Sudden high 1peed decBieration •
{e.g. MVC, fall, airplane crash),
dyspnea, hoarseness • See sidebar for CXR features
{fraquently absent)
• Decreased femoral pulses.
differential arm BP {arch 1elr)
• Blunt trauma to chest {usually
in setting Dl multi-system
treuma therafore
to diagnose)
• Physical examination: overlying
injury, e.g. fractures, chest wall
contusion
o CXA: areas of opacification
ofllll'(l within 6 hours
of trauma
• CXR: abnormality Dl
dil!plngrn/lower lung
fields,ING tube placement
o CT scan and endoscopy-
sometimes helpful for
diagnosis
o CXA: mediastinal air {not
always)
• Esophagram {Gastrograffin)
• Flexible esophagoscopy
CXR, CT scan. • Thoracotomy {may treat
transesophageal echo {TEE), other severe injuries frst)
acrtography (gold standard)
o ECG: arrhytlmias,
ST chroges
o Patients with anormal ECG
and normal hemodynamics
never get dysrhythmia
• Maintain adequate ventilation
• Monitor with ABG, pulse
oximeter and ECG
• Chest physiotherapy
• Positive pressure ventilation
Wsevere
• Lllparutomy for diaphragm
repair end because Dl
associated intrHbdominal
injurias
• Early repair {withil 24 hrs)
improves outcome but all
require repair
• Antiarrhythmic agents
• Analgasia

rt•, C. Other Potentially Life-Threatening lniuries Related to the Chest

If l'nltrating N..:k T111uma pn1. .nt.
DONT:
• Clamp structures (can damage nerves)
• Probe
• Insert NG tuba {leads to bleeding)
• Ramova WlllpllrVirnplllad objact
Penetrating Neck Trauma
• includes all penetrating trauma to the three zones of the neck (Figure 5)
• management injuries deep to platysma require further evaluation by angiography, contrast CT
or surgery
• do not explore penetrating neck wounds except in the OR
'IbroDlo Nota 2011 Emeqmcy Medidne ER13

Airway Injuries
• always maintain a high index ofsuspicion
• larynx
• history: mangulation, clothes line, direct blunt trauma, a.ny penetrating injury
involving platysma
• triad: hoarseness, subcutaneous emphysema, palpable fracture crepitus
• other symptoms: hemoptysis, dyspnea, dysphonia
• investigations: CXR, cr scan, arteriography (ifpenetrating)

_..
• IDllJlll8eiii.ellt
• airway - Ill81l8ge early because ofedema
• C-apine may also be injured, consider mechanism of injury
• surgi.cal- tracheotomy vs. repair Z'Dnal \
• trachea/bronchus I
• frequently missed
• history: deceleration, penetration, increased intra-thoracic pressure; complaints ofdyspnea, Z.. Ill: Superior •If*! Df nec:k
Z.. II: Midportion al nack. (cricoid to
hemoptysis the angle af mandible)
• examination: subc:uta.neous air, Hamman's sign (crunching sound synchronous with heart beat) Z..l: a- of nec:k (lhllracic ii'W
• CXR: mediastinal air, penistent pneumathoru: or penistent air leak after chest tube inserted ID cricoid cartlaga)
fur pneumothorax
Figure 5. Zon• of tile Neck In
• management surgical repair if>1/3 circumference Tr111111

Abdominal Trauma
• two mechani&ms
• blunt: usually causes soll.d organ injury (spleen injury is most common)
• penetrating: usually causes hollow organ injury or liver injury (most common)

BWNTTRAUMA
..... ',
• results in two types ofhemorrhage S.dbllt •ni•rias.., c-•
• Ralroperi1D1111I dulldanal truna
• intta-abdominal bleed
• retroperitoneal bleed • lnlrllpllrilllnell bowallnlni8Ciion
• MalaniBric injll'(
• adopt high clinical suspicion ofbleeding in multi-system trauma • L·spiolainjury

History
• mechanism of inJury, SAMPLE history .... ',
Physical Exam 11.....,11 far Faler IIIII NG Nlll11
• often unreliable in multi-system trauma Alnlllllinlll ,,_..
• slow blood loss not immediately apparent uncon..-::iou.
• other injuries may mask symptoms willl nUiipla injuriaa who cannot void
• serial eumlnations are required lpDnllnaousfy.
COIDalrdclll-= blood 11t1118 meaiUI,
• abdomen .. ..-::chymatic 1crDtlall, or • '"higll-
• inspect: contusions, abrasions, seatbelt sign, distention riding" pniS1atl on DRE (r'llr'DOnlda
• auscultate: bruits. bowel sounds iJ nliealed to rule out
• palpate: tenderness, rebound tenderness, rigidity, guarding a ul'fllnl war or bladd.-1.
• DRB: rectal tone, blood, bone fragments. prostate location N6 ...,.: u.ed to dscomp!IIM1h8
• placement ofNG, foley catheter should be considered part of the abdo exam llolliiCh IRI prmci'nllllllllll bawel.
• other systems to assess: CVS, respiratory (possibility ofdiaphragm rupture), pelvis, back. neuro COIDalrdclll-= facial frae1lnl ar
as it pertains to abdo sensation, GU ba11aJ llkl.l frac:tul8i IU.ped8d.

Investigations
• labs: CBC, electrolytes, coags, cross & type, glucose, creatinine, CK.lipase, amylase, liver
..... ',
enzymes. ABG, blood EtOH.Jl-hCG, U/A, tax screen
• imaging: see Table 8
Crbril far Paililll._..
• >10 ccpsi*Jod
• BIB, blcllril. foreign ll'llhlrill
Tillie I. lm111ing i1 Al11laminel Tn1m1 • RBC caunt >I 00,000 x 1OS,t
• WBC >500 x 10'1\, emylaa > 1751U

X-Ray Chest (lootilg fir under diaplngm, diaph111g1Bic Saft tissue mt wei visualilld
hernia. ai'.ftlid lewis!, peMs. 1hlncic, lurmar spines
cr. . Most apecific tart Radillion 8Xplll118 2Dx mn thmlHIY
t.lnot use lwmodynlllic ins1llblity
Diqlllllli: ,....... Most S8IISi1iva I8St t.lnot tart fa' nlll'apelitlnNII bllllld or
LMII(DPLJ Tesls fir Dnl-pllii:Dneal bllllld diaphiiiQIIIID:. , .
C..nllt distivJjsh lethal from bivialllleed
Ralullt can 111ka up to 1hr
......._.:FAIT ldllllifia pnl&lll1ct/llbsln:a af frae til il pari1alaal t&Yily NOT used til ilantify specific llf'llll" quria
(FGCUI8d Abdamilll RAPID IIXllll: lass lim 5minute& If patin hils asci11s. FAST wil be fBisely
Sanag11m far T1111m1d C..lllsa IXII'IIins pwicardium nl pilunll cavitias positivl.l
ER14 Emergency Medicine Traumatology Toronto Notes 2011

• imaging must be done if

• equivocal abdominal examination, suspected intra-abdominal injury or di5tracting injuries
• multiple trauma patient resulting in unreliable physical exam (altc:rc:d sensorium,
e.g. secondary to drugs, alcohol, head trauma. or distracting injury; spinal cord injury
resulting in abdominal anesthesia)
• unexplained shock/hypotension
• multiple trauma patients who must undergo general anesthesia for orthopaedic,
neurosurgic:al, or other injuries
• fractures oflower ribs, pelvis, spine
.._,, • positive FAST
.. Management
l.aplrmmr 11 M•ndaiiii'J if • general: ABCs, fluid resuscitation and stabilization
............ l'raumll•nd: • surgical: watchful wait vs.laparotomy
• ShDt:k
• l'lritonilis • solid organ injuries: dc:ctsion based on hemodynamic stability, not the specific injuries
• Eviscemion • hemodynamically unstable or persistently high transfusion requirements: laparotomy
• Frle air in abdomen • hollow organ injuries: laparotomy
• Blood in NG tube, Foley catheter, or • even if low suspicion on injury: admit and observe for 24 hours
on racllll exam

.._,, PENETRATING TRAUMA

"Rulli Dllbinla" far •tab waunda:
• 1/3 do not penslniiB paritoll&lll cavity
• 113 penellate but are harmless
• 1/3 CIIU$8 injury requiring IIUrgery
• high risk of gastrointestinal perforation and sepsis
• history: size of blade, calibre/di5tance from gun, route of entry
• local wound exploration under direct vision may determine lack of peritoneal penetration (not
reliable in inexperienced hands) with the following exceptions:
• thoracoabdominal region (may cause pneumothorax)
• back or flanks (muscles too thick)

Management
• general: ABCs, fluid resuscitation and stabilization
• gunshot wounds -+ always require laparotomy

Genitourinary Tract Injuries

• see Urology. U32

Etiology
• blunt trauma - often associated with pelvic fractures
• renal contusions (minor injury- parenchymal ecchymoses with intact renal capsule)
• renal parenchymal tears/laceration: non-communicating (hematoma) vs. communicating
\•, (urine extravasation, hematuria)
G1011 hematuria 1111gg811J bladdlr • extraperitoneal rupture of bladder from pelvic fracture fragments
injury.
• intraperitoneal rupture ofbladder from trauma and full bladder
• anterior (bulbous) urethral damage with pelvic fractures
• ureter: rare, at uretero-pelvic junction
• penetrating trauma
• damage to: kidney, bladder, ureter (rare)
• acceleration/deceleration injury
• renal pedicle injury - high mortality rate (laceration and thrombosis of renal artery, renal
vein, and their branches)
• iatrogenic
• ureter (from instrumentation)

History
• mechanism of injury
• hematuria (microscopic or gross), blood on underwear
• d)15uria. urinary retention
• history ofhypotension

Physical Examination

.... ,, • abdominal pain, flank pain, costovertebral angle (CVA) tenderness, upper quadrant mass,
perineal lacerations
• DRE: sphincter tone, position of prostate, presence ofblood
In the case of gross hematuria. the GU • scrotum: ecchymoses, lacerations, testicular disruption, hematomas
syst8m is invntig11t1d from distaltD • bimanual exam, speculum exam
proximal ii.e. urethrogram, cystugram, • extraperitoneal bladder rupture: pelvic instability, suprapubic tenderness from mass of urine or
etc:.)
extravasated blood
• intraperitoneal bladder rupture: acute abdomen
Toronto Notes 2011 Traumatology Emergency Medicine ER15

Investigations
• urethra: retrograde urethrography
• bladder: urinalysis, CT scan, urethrogram,± retrograde cystoscopy,± cystogram (distended
bladder +post-void)
• ureter: retrograde ureterogram
• renal: CT scan (best, ifhemodynamically stable), intravenous pyelogram (IVP)

Management
• urology consult
• renal
• minor injuries - conservative management
• bedrest, hydration, analgesia, antibiotics
• major injuries -admit
• conservative management with frequent reassessments, serial urinalysis, ± reimaging
• surgical repair (exploration, nephrectomy): e.g. hemodynamically unstable or continuing
to bleed >48 h, major urine extravasation, renal pedicle injury; all penetrating wounds
and major lacerations, infections, renal artery thrombosis
• ureter
• uretero-uretostomy
• bladder
• extraperitoneal
• minor rupture: Foley drainage x 10-14 days
• major rupture: surgical repair
• intraperitoneal
• drain abdomen and surgical repair
• urethra
• anterior: conservative, if cannot void -+ Foley or suprapubic cystostomy and antibiotics
• posterior: suprapubic cystostomy (avoid catheterization) ± surgical repair

Orthopaedic Injuries
• see Ortho.paedics (Shoulder, Knee, Wrist, Ankle)
'1:'
Goals of ED Treatment Ill Frac:tu-
• identify injuries accurately and address potentially lifellimb threatening problems appropriately
SOlARTAT
• reduce and immobilize fractures (cast/splint) as appropriate Sit&
• provide adequate pain relief Open vs. closed
• arrange proper follow-up if necessary Leng1t1
Articular
History lloiDion
Translation
• useSAMPLE
• mechanism of injury may be very important Type {a.g. 1111:.1

Physical Examination
• Look (inspection): "SEADS" Swelling, Erythema, Atrophy, Deformity, Skin changes (e.g. bruises)
• Feel (palpation): all joints/bones -local tenderness, swelling, warmth, crepitus, joint effusions,
subtle deformity
• Move: joints affected plus above and below injury - active ROM preferred to passive
• Neurovascular status: distal to injury (BEFORE and AFTER reduction)

LIFE AND LIMB THREATENING INJURIES (see Table 9) ""' I

• threat to life is usually due to blood loss (e.g. up to 3 Lin pelvic fractures, 1.5 L per long bone
fracture) a.u- fvr E•rgent Orthop..UC
Consultalian
• threat to limb is usually due to interruption of blood supply to distal part of limb or to • IYfldroma
susceptible part of bone • Irreducible dislocation
• Circulatory compromise
• Opan fnlcbn
Table 9. Life and Umb Threatening Ortllopedic Injuries • Injury requiring surgiclll repair
Ule Tlll'lllllning Umb Tlln111bning
Major pelvic fraclires Fracture/dislocation of artie {llllar AVN)
Traumatic amputations Crush injuries
Massiwlcng bona injJri111 (bawara of fat emboli) Compartment syndrome
Vascular iljury proximal to knBII{albcw Opanfr.lctum
Dislocations of knefo'hip
Fractures above knee/elbow
ER16 Emergency Medicine Traumatology Toronto Notes 2011

Open Fractures
• communication between fracture site and external surface of skin - risk of osteomyelitis
When Dealing with an Open Fracture,
• remove gross debris, irrigate, cover with sterile dressing - formal irrigation and debridement
Remember "STAND" often done in the OR
Splint • control bleeding with pressure (no clamping)
Tetanus prophylaxis • splint
Antibiotic
Neurovascular status (before and after)
• antibiotics (1st generation cephalosporin and amino glycoside) and tetanus prophylaxis
Dressings (to cover wound) • must secure definitive surgical care within 6-8 hours

Vascular Injuries
• realign limb/apply longitudinal traction and reassess pulses (e.g. Doppler probe)
• surgical consult
• direct pressure if external bleeding

Compartment Syndrome
Vascular injury/compartment syndrome
is suggested by "The 6 Ps":
• increased interstitial pressure in an anatomical "compartment'' (forearm, calf) with little room
Pulse discrepancies for expansion, resulting in decreased perfusion and potential muscle/nerve necrosis
Pallor • excessive pain which is worse with passive stretching and refractory to analgesia is the hallmark
Paresthesia/hypoesthesia sign early on; also look for "the 6 Ps" (see side bar)
Paralysis
Pain (especially when refractory to
• requires prompt decompression - remove constrictive casts, dressings; fasciotomy may be
usual analgesics) needed emergently
Polar (cold)

UPPER EXTREMITY INJURIES

• anterior shoulder dislocation
• axillary nerve (lateral aspect of shoulder) and musculocutaneous nerve (extensor aspect of
forearm) at risk
• seen on lateral view: humeral head anterior to glenoid
• reduce (traction, scapular manipulation), immobilize in internal rotation, repeat x-ray,
out-patient follow-up with ortho
• with forceful injury, look for fracture
• Colles' fracture (Figure 6)
• distal radius fracture with dorsal displacement from Fall On an Outstretched Hand (FOOSH)
• AP film: shortening, radial deviation, radial displacement
• lateral film: dorsal displacement, volar angulation
• reduce, immobilize with splint, out-patient follow-up with ortho or immediate orthopedic
referral if complicated fracture
• if involvement of articular surface, emergent orthopedic referral
• scaphoid fracture (see Figure 7 for review of carpal bones)
• tenderness in anatomical snuffbox, pain on scaphoid tubercle, pain on axial loading of thumb
1. Dorsal tilt • negative x-ray: thumb spica splint, re-x-ray in 1 week± bone scan
2. Dorsal displacement
3. Ulnar styloid fracture
• positive x-ray: thumb spica splint x 6-8 weeks, re-x-ray in 2 weeks
4. Radial displacement • risk of avascular necrosis (AVN) of scaphoid if not immobilized
5. Radial tilt • outpatient ortho follow-up
6. Shortening

Figure 6. Calles' Fracture

LOWER EXTREMITY INJURIES
• ankle and foot fractures
• see Ottawa Ankle and Foot Rules (Figure 8)
• knee injuries
• see Ottawa Knee Rules (Figure 9)
• avulsion of the base of 5th metatarsal
• occurs with inversion injury
• supportive tensor or below knee walking cast for 3 weeks
• calcaneal fracture
• associated with fall from height
• associated injuries may involve ankles, knees, hips, pelvis, lumbar spine
Metacarpal
bones (1-5)

© Elisheva Marcus

Figure 7. Carpal Bones

Toronto Nota 2011 Trallllllltology .Em.c:lzeocy Medicine ER17

\•,
Rlutne ''" Spii'Die
• IINit:M pain
• IINit:M firilar damaga tD vassals
and niiMitl
• IINIC811 rilk Ill' inadwnlllntly
converting • clallad frll:ture into 1n
op•fnlelure
• Faclibrtu
LATBIAL VIEW MEDIAL VIEW
An ankle raclog!IPhic l8liel il requi'ed only if there il any pain il maleolar mne llld any of lheee findi11111:
1. bone llndarness at A
or
2. bema tandamassllt B ......
rna. ai.Ankii . . IMfalt,.....
ArzmllfriiiiiMI.WII IIIIIIID Emili

or .llfJ Zll3; 321(131&1;411

3. ir.hility to be..- waight both iiTIIIadiBWy and il IRIIIIQIII1C'f
IIIIIiliirlillilg 15,58'1
Afuot 11rie1 i1 only if U.. ilany pain in midfuot l!lne md any of lheee fioldinp: l8flliiri¥n lpiCiicily r1111a Dlllwl rill IIMs
1. bona taldamass at C flr..w61g frii:Uel Gltht nile ...tniclfuDt
or ....: 1111-paolad lbhodl1liJ rlaMQIIM
2. bone IBndllmiiU 111: D flllllablaiilg I filii neaD!IIIIalilb 'Mth
or I hl:bn 111111 dlllllrial Dba 0.011 l'ur bdh IIIB
3. ir.hility to bear waight bDth immlldiBWy and i1 amargancy rilllnlll'id-illt
.......
F'111f8 a. DUnn Anlda Rulas jiMia llllmlllll inllnlrllt• ..w6lg
,t,daJUdhm Stillltt.lll../NoM 1994; 211 ;121-832 frlnllllfiiiiButil...t mi!UoGiwlh 1
riMriii!IIDIIIII•...nliyriM. n.
1111 rllNs ils1nnwrt "" l'llllc8111a lllll'ia' rl
A knlllHIJ Ulmilllti• is nqund 11111r far acute pMillnts willl ana ar man Df:
1111-.ylllf.,.....
• Age 55 years Dr alder
• Tanda1111SSat haed offibjja
• llcla!Bd tand.-n811 of patella•
• blbility to flex 1o !Ill"
• blbility to bill' both immediately and in the emergency (faur
"no .bon,...,_Gfm.. ott.tt.. potllll
lllllllflrwelahti'Mce onto 8ICII 1oww lrm llglldeD olllmplng

F'111re 9. DUnn ICiae Halas

,t,daJUd hm: StillIII. II.JW( 1987;

Wound Management
Goals of ED Treatment
• identify InJuries and stop any active bleeding- direct pressure
• manage pain
AHie 'lhllhllt .t c...t.llne
• 'WOUild examination and exploration (history and physical)
• cleansing ± antibiotic and tetanus prophylaD RICE
lllllt
• repair and dressing let
ea.-ion
Tetanus Prophylaxis Elevation
• both tetanus toxoid (Td) and immunoglobulin ('I'IG) are safe (and indicated) in pregnaru:y

Table I D. Galdellnaa hr Tat••• Prophylaxla hr Weundl

Nan TIIIBau "'-W111ndl
..
.....
..._. U.. ••• Duration
reP noa a. will!••
Td liG
......,
lh:llllil or <3 dose8
3or111018.nonefor>10years
Yea
Yes
No
No
Y8l
Yes
Y8l
No
....
. . . .Wilt

.
Fact 1-0
3 or 111018. 5to 10 years 9 No No Yas No Not.Jailt 4-0
3or11'1111!, <4yeaugo No No Yes No -Wit 3-4 10
1 Wllllll >& lanJ oM, >1 an dllp.. JU1CUa.wt1, aUialll, WIIIIIIIIIIUq fnRn niaia, tiUih 'MIIIII, U..,fml1lnl. Wlllliiii:IIDlrW!da! wi1h *'.
,._
,........,.
4-0 1
tt'A
I tn1u1 imruJa 250 UID. . . .
Solnt: /MMI2001; 401RRIZ)..1-5Z. NB.I'IIiml111111ni1 thtnpy may 1111111 IIDnll
i1 fir ..... parilll rllirll
Bruises
• non palpable = ecchymosis
• palpable collection (not swelling) = hematoma following blunt trauma
......
...
,
• assess for coagulopathy (e.g. liver disease), anticoagulant use
.o.n.tivH ta ........
• fiSSU8gU
• Steri8biPI*
• Slap!•
ER18 Emergency Meclidne Traumatology 1'oroDio 2011

Abruions
• partial to full thickness break in skin
• management
Whn NOT to Ule local anlllthetie with
!IPNplml: • clean thoroughly; ±local anesthetk. with brush to prevent foreign body impregnation (tattooJng)
Ean. Noee. Fi9n. ,._ IIIII HOie • antiseptic ointment (Polysporm• or Vaseline•) for 7 days for facial and complex abrasions
tl'lni•J • tetanus prophylaxis (Table 10)
Lacerations
I{.•, • see also Plastic Sw:ge:cy. PL6
lliffln•lllild Diaa•lli• of C.l•ltis
• consider every structure deep to a laceratlon injured untll proven otherwise
Necntizing Ftllciitis • In band InJury patients, Include following In history: handedness, occupation, mechanism of
Gat gqrene Injury, previous history of Injury
CUIIIIB!UIIIIIIInx • physical exam
Vecci1ia '11Cci111ion • think about underlying anatomy
-.et bil8 (hypereellliiMt'fl • examine tendon function actively against reaiatance and neurovascular status distally
Al:ulagaut
DVT • clean and explore under local anesthetic; look fur partial tendon injuries
Fixld*ua....cion • x-ray or ultrasound wounds if a foreign body Ia suspected (e.g. shattered glass) and not
IC&waJaki'• found when exploring wound (remember: not all foreign bodies are radiopaque), or if
QIUIIJIRiaJm suspect intra-IU"ti.cular involvement
• management
• disinfect skin/use ste:dle techniques
It' • Irrigate copiously with normal saline
FuluiR Ill NH..ming Faciilil • analgesia± anesthesia (Figure 10)
llflctilll • maximum dose oflidocaine:
ABCDE • 7 mgllcg with epinephrine
• 5 mgflcg without epinephrine
A- Anaerobic, Alll'llbic, MM. • In clilldren, topical anesthetics such as LET (lidocaine, epinephrine and tetracaine) and In
Antibiatice nlfrlcttry
1- lactaial aynargilllic QMQitln&, selected cases a short-acting benzodiazepine (midazolam or other agents) for sedation and
Blood miDI h9lar than norm.. amnesia are useful
C- CIIIUitis, C111pilus, IIIII • secure hemostasis
eo•opethy • evacuate hematomas, debride non-viable tissue, remove hair and remove foreign bodies
D- D&mllllQIIIIIJIII1&, D*v in • ± propbylectic antibiotics
preuntalion almost fatll
E- Eiythema with IPQIIding Edema • suture unless dtlayed presentation, a puncture wound. or mammalian bite
• take into account patl.ent and wound factors when considering suturing
• advise patient when to have sutures removed

Digital
arteriBa

Palmar digital n8MII

Flgera10. Digital Block- Local Anelltllllla of Dlgn.

Cellulitis
I{.•, • see also Plastic SuQ:'ecy. PL12
&.1y irrigdion and dabridanun • localized Infection of the dermis
are 1ha most imparlllnt fllclln in • bacterial (S. aureus, GAS, H. injlf.renzae. occasionally PseudomotUU spp., MRSA) infection of
deer1181ing inflelion. skin and subcutaneous tissues
• look fur "rubor, calor, dolor, tumour" (erythema, warmth. pain, swelling)
• have high Index ofsuspicion in patients who are immunocompromised (e.g. HIV; DM),
vasculopaths, IV drug users
• treat with immobilization and elevation of infected area. antibiotics, analgesics. and close
follow-up
• antibiotics for mild cellulitis: PO cephal.exin or cloxacillin
• ifMRSA: PO clindamycin, doxycycline, TMP-SMX; IV vancomycin ifbateremic

I{.•,
Wllic• . _ _ 111111 AnlllialiCI'I
• Evidence all'(ltlmic ln1111le.g.
calulilill
0 hmunDCOI'IVfllllisad pllillll
• l'ltillllt at risk for endol:ll'ditis
Abscess
• may be associated with a retained foreign body
• look for warm, swolle.n. painful, erythematous fluctuant masses
• ensure absence of systemic symptoms and presence ofsubcutaneous air In simple abscesses
• anesthetize locally
• treat with indsion and drainage ± antibiotics - apply warm compress, give analgesics
Toronto Notes 2011 Traumatology/Approach to CommonER Presentations Emergency Medicine ER19

Trauma in Pregnancy
• priorities: Airway, Breathing, Circulation

Hemodynamic Considerations
• near term, inferior vena caval compression in the supine position can decrease cardiac output ..... ,.. ,
by 30-40% (see Maternal Physiology, Obstetrics, OB3)
• use left lateral decubitus (LLD) positioning or hip bolster to alleviate compression and The best 1relltment for 1ha fvlus 1ha
increase blood return ifBP is low IIIICIM netment of 1h1 mo1hw.
• BP drops 5-15 mmHg systolic in 2nd trimester, increases to normal by term
• HR increases 15-20 beats per minute by 3rd trimester

Blood Considerations
• physiologic macrocytic anemia of pregnancy (Hb 100-120)
• WBC increases to high of20,000

Shock
• pregnant patients may lose 35% of blood volume without typical signs of shock (ie. tachycardia,
hypotension)
• the fetus may be in •shock" due to contraction of the uteroplacental circulation
• fetal HR changes are an early warning of maternal circulatory compromise

Management Differences
• place bolster under right hip to stop inferior vena cava compression
• fetal monitoring (continuous tocographic monitoring if possible viable fetus >20 weeks)
• early obstetrical consult
• do not avoid necessaryx-rays, but shield as much as posssible
• consider need for RhoGAM if mother Rh negative

Approach to Common ER Presentations

Abdominal Pain
Rule Out Life-Threatening Causes
• CVS: MI, aortic dissection, ruptured AAA (tearing pain)
• GI: perforated viscus, hepatic/splenic injury, ischemic bowel (diffuse pain) I

• gynecologic: ectopic pregnancy IIIII Flap

• Exlr8mas of aga
Additional Differential Diagnosis • Unstable vital signs
•Fava"
• GI: appendicitis, divertic:ulitis, bowel obstruction, hepatitis, cholecystitis, pancreatitis • Sign.tsymptoms of shock
• urinary: cystitis, pyelonephritis, ureteral calculi • Rapid onset savara pain
• genital
• female: pelvic inflammatory disease (PID)/salpingitis, tuba-ovarian abscess, ovarian torsion,
ovarian cyst, endometriosis
• male: testicular torsion, epididymitis
• other: diabetic ketoacidosis (DICA), Herpes Zoster VllUS (HZV), intra-abdominal abscess, Abdamlnal AIHument In all
pneumonia, lead poisoning, porphyria. sickle cell crisis, psychiatric •OuUram.
DR.GEIM
History and Physical Examination Distention
• determine onset. course. location and character of pain: PQRST Rigidity
Guarding
• broad differential, including GU, Gyne. GI, respiratory, and CV systems EvisceratiorVEcchymosis
• recent/remote abdominal trauma/surgeries Rebound lllndemess
• general appearance, vitals, ABCs Massas
• respiratory, CVS
• abdomen and back: CVA tenderness, ecchymoses, stigmata ofliver disease, DRE, pelvic exam
(females), genital exams (males)
..... ,,
• extremities: differential pulses, psoas/obturator sign
If both AST and ALT elevated,
AST > All indicllbls polllntiallllcohol
Investigations rUrted hlpatic disi8US
• do not delay consultation if patient unstable All > AST indicllles viral hepatic
• CBC, electrolytes, glucose. LFTs, amylase, BUN/creat, U/A, +others if indicated: ECG, pathology
troponins If ALP lind GGT elevated, 1hink
biliary traa
• AXR: look for calcifications, free air, gas pattern, air fluid levels
• CXR upright: look for pneumoperitoneum (free air under diaphragm)
• U/S: biliary tract, ectopic pregnancy, AAA, free fluid
• CT: trauma. AAA, pancreatitis, nephro/urolithiasis, appendicitis and diverticulitis
ER20 Emergency Medicine Approach to Common ER Preaentations Toronto Notes 2011

...... ,
•t-----------------,
Management
• NPO, IY, NG tube, analgesics
Old IIQ"I, pr.gnancy (T3), lll1d chronic • growing evidence that small amounts of narcotic analgesics improve diagnostic accuracy of
carticiNilllnlid u1e can blunt parilllneal physical exam of surgical abdomen
findings, so hava suspicion • consult as necessary: general surgery, vascular, gynecology, etc.
of intrabdomi1111l in these
individuals I
Disposition
• admission: in addition to a surgical abdomen, admission is sometimes required for workup of
abnormal findings on investigation, IV antibiotics, pain control, etc.
• discharge: patients with a negative lab and imaging workup who improve clinically during their
Unllllble petien!lllllould not be sent stay; instruct the patient to return if severe pain, fever, or persistent vomiting develop
for imaging.

Acute Pelvic Pain

Etiology
• gynecological
• 2nd most common gynecological complaint after vaginal bleeding
• ruptured ovarian cysts - most common cause of pelvic pain, follicular cyst most common type
• ovarian torsion - rare, 50% will have ovarian mass
All woman of childb811t'ing IIQ"B assumed
• leiomyomas (uterine fibroids) - especially with torsion of a pedunculated fibroid or in
1D be pregnant untH provan Dlherwise. pregnant patient (degeneration)
• ectopic pregnancy- ruptured/expanding/leaking
• spontaneous abortion - threatened or incomplete

..... •,•t-----------------, • infection - PID, endometritis, tuba-ovarian abscess

• dysmenorrhea and endometriosis
• non-gynecological
Gynecol'lliclll C.uses .t' P.m.: Pain: • GI - appendicitis, constipation, bowel obstruction, gastroenteritis, diverticulitis, IBD, IBS
av.illl1 Cyst • GU - cystitis, pyelonephritis, ureteric stone
Dysmenorrhe1 • other - porphyria, abdominal angina, aneurysm, hernia, zoster
MittelshmaR
Endometriosis
av.i1111 Torsion History and Physical Exam
lbrine Fibroidl/neopllsm • determine onset, course, location and character ofthe pain
Adnexal Neoplasm
• associated symptoms: vaginal bleeding, bowel or bladder symptoms, radiation
P1D + Cervicitis
• vitals
• gynecological exam
• abdominal exam

..... •,•J-----------------, Investigations

• fl-hCG for all women of childbearing age
illhe prefamld imaging • CBC and differential, PTT/INR
madllity illhe ll55essment of ecute • pelvic and abdominal U/S - evaluate adnexa, look for free :O.uid in the pelvis or masses, evaluate
pelvic pain. thickness of endometrium
• doppler flow studies for ovarian torsion

Management
• general: analgesia, determine if admission and consults needed
• gynecology consult if history and physical suggestive of serious cause
• other consults as indicated - general surgery, urology, etc.
• specific:
• ovarian cysts
• unruptured or ruptured and hemodynamically stable- analgesia and follow-up
• ruptured with significant hemoperitoneum - may require surgery
• ovarian torsion - surgical detorsion or removal of ovary
• uncomplicated leiomyomas, endometriosis and secondary dysmenorrhea can usually be
treated on an outpatient basis, discharge with gynecology follow-up
• PID: requires broad spectrum antibiotics

Disposition
• patients requiring IV therapy or surgery should be admitted
• patients to be discharged should be given clear instructions for appropriate follow-up
Toronto Notes 2011 Approach to CommonER Presentations Emergency Medicine ER21

Altered Level of Consciousness (LOC)

Definitions
• altered mental status - collective, non-specific term referring to change in cognitivt: function,
behaviour, or attentivt:ness
• delirium - acute. transient. fluctuating, potentially revt:ISible organic brain disorder presenting
as altered LOC and attentiveness (see P§Ythiatry. PS 17)
• dementia - insidious, progressivt:, organic brain disorder with change in memory, judgment,
personality and cortical function (see Psychiat:cy. PS18)
• lethargy- state of decreased awareness and alertness (patient may appear wakeful)
• stupor - unresponsiveness from which the patient can be aroused
• coma -a sleep-like state, not arousable to consciousness (Figure 11)
• use the GCS to evaluate LOC (see Initial Patient Assessment and Management, ER2)

C11111a (GCS :sBJ

(MaJorttvf -I (Minllltty]

... ...
I Toxic,/Metabolic I Primary CNS Dii8UII/Tra.Jma J It'

M-
E-
T -
Major organ failure
Electrolyte/Endocrine
Toxi'1t11'11!111erature
.
Billl!nl Cerebral
I
.
Brainstem
Polaillle C..n of Co1111
AEIDUTIPS
Acidosis/Alcohol
Epilepsy
A-
B-
Acid disorders
a.e disordtn {affecting I (affecting RAS)
I lnt.ction
Dxyven (hypoxiai/'Dpialllli
D- decreased DX'(9an laval I Uremia
L-
I -
l.actab
Insulin/Infection (sepsis) ... ... ... ... TempenrturW'JI'IIIIIMI (especially head)
Insulin (too littlll or too much)
C- Canliac;lhyperCalcemia I
Diflusa traumafiSchemia II Diffuse lesion I Compression
• Supn(lnfratentorial
Direct
• Brainstem
Psychogenic;,ll'oisoning
Strub
tumour irnrct or
• Sub/epidural hemorrhage
hemetoma

Figure 11. Etiology of Co11111

..._, !
MANAGEMENT OF ALTERED LOC
,.-----------------.
In general. GCS under 8, intublllll, but
History ability to protect aiiWIIy is pri'nr{
• obtained from family, friends, police, paramedics, old chart, etc. consideration!
• onset and progression
• abrupt onset suggests CNS hemorrhage/ischemia or cardiac cause
• progression ovt:r hours to days suggests progressive CNS lesion or toxic/metabolic cause
• preceding events
• it is essential to determine patient's baseline LOC preceding deterioration 't'
• antecedent trauma, seizure activity, fever E'llll1181ian of ColllllaM htient
• past medical history (e.g. similar episode, depression, avt:rdose) FW.Na
Noggin
Physical Examination e.g. raccoon eyes and Battle's sign
• ABC's, vitals including temperature, cardiac, chest, respiratory, abdominal exam, and the (bruising of the mastoid process)
"five Ns" (see sidebar) appears about 8 hours after trauma
• complete neuro exam, in particular examination of the eyes, look for medic alert bracelet Neck
C-11Pin1, 11111ropnic shock. nuchal
Investigations rigidity
• rapid blood sugar, CBC, electrolytes, Cr, BUN, LFTs, glucose, serum osmolality; ABGs, coags, ENT
troponins, U/A Otorrhea, rhinorrhea, tongue biting,
• ECG, CXR, CT head odour on bnlatl1. hematympanum
• drug levt:ls of specific toxins if indicated Na1dlls
Inspect lor track marb
Diagnosis
Neurological
• administer appropriate univt:rsal antidotes Concentrate on GCS. respiration,
• thiamine 100 mg IV if history ofEtOH or patient looks malnourished posture, 11111V1111111t. pupils, rwfl-
• one ampule DSOW IV if low blood sugar 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 movt:ments and motor findings, ifpresent, are usually asymmetric It'
• look for focal or lateralizing abnormalities Uninnal Antldatea
• toxic-metabolic coma DDNT
• dysfunction at lower levels of the brainstem (e.g. caloric unresponsivt:ness) Dextrose
• respiratory depn:ssion in association with an intact upper brainstem (e.g. equal and Oxv!lln
n:activt: pupils; see exceptions in Table 11) Naloxone 2 mg
Thiamine 100 mg
• extraocular movements and motor findings are symmetric or absent
ER22 Emergency Medicine Approach to Common ER Preaentations Toronto Notes 2011

• essential to re-examine frequently - 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")

Tabla 11. 1Dxic - Mllblbolic Caus• Df Fixad Pupils

Dlatlld Dillllld 1D Normal
AnOllia Hypothermia Dlolinergic Bgllllts (e.g. organophosliJIIIBsl
Anticholimrgic aganls (e.g. atropine, TCAsl Barbiturates OpilllliS (e.g. hanlin), except nneparidine
Methanol (llRI Antipsychotics
Cocaine
Opioid
Anllhebmines
Halklcinogens

Disposition
• readily reversible alteration ofWC: discharge if adequate follow-up care available
• ongoing decreased WC: admit to service based on tentative diagnosis
• transfer patient if appropriate level of care not available

Chest Pain
Rule Out Life-Threatening Causes
• CVS: acute coronary syndrome/acute MI, pericarditis/cardiac tamponade, aortic dissection
Uh Th111•rma c:auq• Gf Chid Pllin • respiratory: pulmonary embolism (PE)/pneumothorax (tension or spontaneous)
PET MAP • GI: esophageal rupture/pneumomediastinum
Pulm01111ry embolism
Elophageall14l!Ln
Tamponade Additional DHferential Diagnosis
MVangina • cardiac: stable angina
Aortic diuection • respiratory: pneumonia
PnlllmllhDriiX • GI: peptic ulcer disease (PUD), pancreatitis, cholecystitis, esophagitis, reflux, esophageal spasm
• MSK: rib fractures, costochondritis, zoster, etc.
• psychogenic/anxiety (diagnosis of exclusion)

Initial Resuscitation and Management

• 0 2 , IV; cardiac monitoring. CXR (portable if unstable), ECG

History
• must evaluate cardiac risk factors (DM, HTN, hyperlipidemia, smoking, family history)
• classic presentations (but presentation seldom classic)
Signs 1nd Symptoms llf Ml • aortic dissection: syncope with sudden severe tearing pain, often radiating to back, ± focal
PUlSE pain/neuologic loss in extremities secondary to major vessel ischemia
l'lrliltent chut pain • pulmonary embolism: pleuritic chest pain {75%), dyspnea, anxiety, tachycardia, PERC SCORE
Upset stomach • pericarditis: anterior precordial pain, pleuritic, relieved by sitting up and leaning forward
ljghlheadldn111 • acute coronary syndrome (ACS): retrosternal squeezing/pressure pain, radiation to arm/
Shortness of brellh
Ela:M$iv8 $W$11ing neck, dyspnea, nausea/vomiting. syncope
• esophageal: frequent heartburn, acid reflux, dysphagia, relief with antacids
• ACS more likely to be atypical in females, diabetics, and >80 years
..... , Physical Examination
• vitals (BP in both arms, but unreliable indicator of dissection)
PERC IICIIfl fur PE
Age >50 yam • palpate chest wall for tender points, but be aware that 25% of patients with acute MI have chest
HR >100 bpm wall tenderness
Dtsllt on RA <94% • consider a diagnosis of MSK disease only if more serious causes excluded and palpation fully
Prior hiiiDry DIITJPE reproduces pain and symptoms
Recent 1rlluma or surgery
Hemoptysis • cardiac exam, respiratory exam. peripheral vascular exam
Exogenous estroqen
Clinical signs sugpsting Dill Investigations
Sco111 1for each question; a scare • CBC, electrolytes
Ml m1111s palilnt hu < 1.6'1 chanc• • serial cardiac enzymes
having I I'E and IVOid5 further • normal CK-MB does NOT rule out MI
investigation. • troponin I more sensitive (but positive later than CK-MB; can have false positives in renal
failure, must follow for 8 hrs post onset of symptoms)
• ECG (see Table 12)
• always compare with previous
• PE and acute MI may have normal ECG in up to 50% of cases
• consider 15-lead ECG if hypotensive or ifECG shows inferior MI or AV node involvement
Toronto Notes 2011 Approach to CommonER Presentations Emergency Medicine ER23

• CXR
• always compare with previous
..... ,
• PE (see DVT, ER34) Signs of PE on CXR
• 50% completely normal
W...marll's sign: abrupt bparing of
• atelectasis, elevated hemidiaphragm, pleural effusion
a vasal on chntfilm.
• aortic dissection (see sidebar ER12 for features)
• change from previous CXR is the most accurate finding Hutpllln's hump: a Wlldga-shaped
infillnl1e that abuts the pleun1.
• CXR is normal in 20% of thoracic dissections
• pneumothorax
• may need inspiration and expiration views ..... ,
• ABGs - normal in 20% of patients with PE, therefore do not perform
• D-dimer, V/Q scan or helical cr, venous leg Doppler, if PE suspected (see sidebar for Wells' W.O.' Sctn far PE
Score) Previ011s Hx of DVT/emboli + 1.5
• negative D-dimer rules out PE in low probability patients HR >1DD +1.5
• patients with intermediate or high probability Wells' score require imaging Recant immobility or Sx + 1.5
Clilical signs of DVT +3
Disposition AIIBmllta llx lass likalylhan PE +3
IMmoptysis +1
• patients at risk of developing dysrhythmias should be admitted to a monitored bed Cancer +1
• consult cardiology for patients with ACS; obtain a cardiothoracic surgery consultation for
Low probability = D-2
patients with valwlar lesions by echocardiogram, esophageal rupture, or aortic dissection
Intermediate probability = Z·&
• discharge is appropriate for patients with a low probability of life-threatening illness due to High probability = > 6
resolving symptoms and negative workup; instruct the patient to return ifthey develop SOB or
increased chest pain
Table 12. Common Ufe Threatening ECG Changes
..... ,
Pathology ECG Finllnp lmporlllnt to laok far reciprocal cllqes
in STEM I in order to differantiata from
Dy!rtlylhmia pericarditis Idiffuse elevations!.
a) Torsade de Poinl85 Ventricular complaxss in L.pWard1liJinling 111d downward-pointing contiiiiUm (250-350 bpm)
b) Ventricular tachycardia 6 or more consecutive premature ventricular beats (15G-250 bpm)
c) Ventricular ftult8r Smooth silll WBVB pattam of similll' amplitude (25G-350 bpm)
d) Ventricular fibrillation Enatic ECG tracing. no identifiable waves
lm...ct-. Trutmllll: of Ac:..-111
Conduction BEMOAN
a) 2nd degree heart block PR ilteMI slllble, some DRS's dropped Bate-Blockade
(Mobitz Type II) EnoXllpllrin
b) 3rd degree hell'! block Total AV dissociation, but stable P.P and R.ft intervals Morphine
c) Left buncle branch block Prolonged QRS complex (>0.12s) Oxygen
RSR' in V5 or V6 ASA
Monophasic I and V6 Nitroglycerin
May see ST elevation
to inlelpn!l, new LBBB is considered STEMI equivalent

-·-g_
a)STEMI ST oiiMIIion in leeds associated with injured area of heart and reciprocal lead changes (depression)
Melilbolic
a) Hyperblemia Tall TWllvas
PWBVB flattening
QRS complex widening and flattening
b) Hypokalemia U Wllves appear
Flattl!ned T waves
Digillli1 Toxicity Gradual downward curve Ill ST
At risk far AV blocks and ventricular iTilabilily
Syn!Rm•
a) Brugada RBBB with ST elevation in Vl, V2 and V3
Susceptible to deacly allhythmias, includilg V. Fib.
b) Wellens Marbd T waw irrwr&ion in V2 and V3
LBft anterior descanding coronary stllnosis
c) Long ar Syndrome ar ilteiwllanger than \.i of cardiac cycle
Predisposed to ventricular arrhythmia

ACUTE MYOCARDIAL INFARCTION

• see Cardiology. C25

Management
• immediate stabilization
• oxygen 4Umin
• IV access
• cardiac monitors
• STATECG
• cardiac enzymes (CK, Troponins)
• ASA 162-325 mg chewed
• nitroglycerin 0.3 mg SL q5min x 3 (IV for CHF, H1N, unresolved pain)
• morphine 2-5 mg IV q5-30min if unresponsive to NTG
• metoprolol5 mg slow IV qSmin x 3 if no contraindication (beware in inferior wall AMI)
I!R24 Emergency Medicine
,, ,
Tlrombocytopenic palient8 - 1111
n11orbable packa to avoid risk of
re-blaeding CIW&ad by pulling out the
removable pack.
,, I
Compllcadons Df N...l Packing
Hypoxemia
Toxic-shock syndroms
Aspimion
l'hlrynoeal fibrosi.tstanosis
Alar/sepllll necrosis
Note: up to 5% of pllient8 with
subarachnoid hamonhaga llava a nonnal
CT scan; 1111pact SAH with a n1gsliw
CT. perform a lumbar puncture.
DDx Sullarub11111d Hamoll'hage
BATS
Berry aneurysm
Arteriovenous malfonmltiorVAduh
polycystic kidney disa1111
Trauma
Stroke
Approach to CommonER Preaentations Toronto Notes 2011
• low molecular weight heparin 1 mg/kg SC bid (30 mg IV STAT post TNK infusion)
• thrombolytics or primary percutaneous coronary intervention (PCI)
• agents include t-PA, r-PA, Streptokinase, and TNK
• evaluate indications and contraindications prior to use
• other - antiarrhythmics, cardioversion, defibrillation, transthoracic pacing, angioplasty
• cardiology consult
Epistaxis
• see Otolar_ytl&Olo&.v. OT27
• 90% of nosebleeds stem from the anterior nasal septum (at Kiesselbach's plexus located in
Little's area)
• can be life-threatening
Etiology
• most commonly caused by trauma (digital, blunt, foreign bodies), but can also be caused
by barometric changes, nasal dryness, chemicals (cocaine, Otrivin•), or systemic disease
(coagulopathies, hypertension, etc.)
Investigations
• CBC, PT/PTT (if indicated)
• x-ray, CT as needed
Treatment
• aim is to localize bleeding and achieve hemostasis
• first-aid: ABC's, lean forward, pinch soft part of nose for 20 minutes
• assess blood loss: vitals, IV normal saline, cross match 2 units packed RBC if significant
• determine site of bleeding: use topical anaesthetidvasoconstrictor to facilitate; use nasal
speculum and good lighting
• attempt to control the bleeding
• first line: Otrivin• or cocaine
• second line: cauterize with silver nitrate (one side of septum only!)
• ifthese fail, or if bleeding is posterior --+ nasal packing (must monitor for complications)
• ifpacking fails, consult ENT
Disposition
• most patients can be discharged after ensuring vitals are stable, bleeding is controlled and
patient has appropriate follow-up
• educate patients about prevention (e.g. humidifiers, saline spray, topical ointments, avoiding
irritants, managing hypertension)
• admission may be required for severe cases
Headache
• see also Neurolo&.v, N39
Etiology
o the COJDJDOD
• common migraine (no aura)/classic migraine (involves aura)
• gradual onset, unilateral/bilateral, throbbing
• nausea/vomiting, photo/phonophobia
• treatment analgesics, neuroleptics, vasoactive meds
• tension/muscular headache
• never during sleep, gradual over 24 hours
• posterior/occipital
• increased with stressors
• treatment modify stressor, local measures, NSAIDs, tricyclic antidepressants
• thedeadly
• subarachnoid hemorrhage (SAH) (see Neurosurgery. NS17)
• sudden onset, increased with exertion
• "worst" headache, nausea and vomiting, meningeal signs
• diagnosis: CT, LP (5-1 0% of patients with SAH have negative initial CT)
- sensitivity of CT decreases with time and is much less sensitive by 48-72 hr
• management: urgent neurosurgery consult
• increased ICP
• worst in morning, supine, or bending down
• physical exam: neurological deficits, cranial nerve palsies, papilledema
• diagnosis: CT scan
• management consult neurosurgery
Toronto Notes 2011 Approach to CommonER Presentations Emergency Medicine ER25

• meningitis (see Infectious Diseases. ID6)

• flu-like presentation initially (fever, nausea/vomiting, malaise), meningeal signs, purpuric
rash M.nmgitk
• altered level of consciousness and confusion Da ncrt delay IV antibialil:s fur LP.
• perfonn CT to rule out increased ICP then do LP for diagnosis
• treatment: early empiric antibiotics (depending on age group), steroid therapy
• temporal arteritis (not immediately deadly but causes great morbidity)
(see QphthalmolollY, OP38)
• unilateral scalp tenderness, jaw claudication, visual disturbances
• labs: elevated ESR
• temporal artery biopsy is gold standard for diagnosis
• treatment: high-dose steroids immediately ifTA suspected

Disposition
• admit 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
• 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 Pain
• see Rbeumatoloi:Y

Rule Out Life-Threatening Causes

• septic joint (see Ortho.paedics. OR8)

Differential Diagnosis
• articular pain
• monoarticular It'
• infectious: bacterial, viral, fungal C.usn .r Joint l'llin
• hemarthrosis: trauma/fracture, anticoagulants, bleeding diatheses SOFTER TISSUE
• crystal induced: gout, CPPD, hydroxyapatite Sepsis
• inflammatory: seropositive, seronegative Osmaarthrilil
Fraduras
• neoplasm Tendon/muscle
• degenerative: osteoarthritis Epiphyseal
• polyarticular R.fi!T'Id
• infectious: Lyme disease, bacterial endocarditis, septicemia, gonococcus, viral
• post-infectious: rheumatic fever, reactive arthritis, enteric infections Ischemia
• inflammatory: seropositive, seronegative arthritides
Seronegative
• degenerative: osteoarthritis Unrte
• non-articular Extr&-articular rflaumatism
• musculoskeletal {e.g. palymyalgia]
• localized: tendonitis, bursitis, capsulitis, muscle sprain
• generalized: :fibromyalgia, PMR
•other
• neurologic: spinal stenosis/spondyl.olithesis, degenerative disc disease, cauda equina
syndrome, neoplasm, thoracic outlet syndrome, Charcot joint
• vascular: intermittent claudication

History and Physical Examination

• determine onset, course, location, character of the pain (OPQRST) and recurrence
• determine which joint or joints are involved
• associated symptoms: fever, constitutional symptoms, skin lesions, conjunctivitis, urethritis
• patterns ofjoint involvement: polyarticular vs. monoarticular, symmetric vs. asymmetric
• inflammatory symptoms: prolonged morning sillfness, sillfness and pain ease through the day,
midday fatigue, soft tissue swelling
• non-inflammatory symptoms: sillfness short lived after inactivity, short duration stiffness in the
morning, pain increases with activity
• assess ROM, presence of joint effusion, warmth
• watch for: localized joint pain, erythema, warmth, swelling with pain on active ROM, inability
to bear weight, fever as these may indicate presence of septic joint

Investigations
• x-ray, CBC, ESR, CRP, WBC, INR/PTT, blood cultures, urate
• joint aspirate send for: WBC, protein, glucose, Gram stain, crystals
ER26 Emergency Medicine Approach to CommonER Preaentations Toronto Notes 2011

Management
• septic joint: IV antibiotics ± joint decompression and drainage
• antibiotics can be started empirically if septic arthritis cannot be ruled out
• crystalline synovitis: NSAIDs at high dose, colchicine with in first 24 hours, corticosteroids
• do not use allopurinol, as it may worsen acute attack
• acute polyarthritis: NSAIDs, analgesics {acetaminophen ± opioids), corticosteroids local or
systemic
• hospitalization is required in the presence of(l) significant, concomitant internal organ
involvement; {2) signs of bacteremia, including vesiculopustular skin lesions, Roth spots,
shaking chills, or splinter hemorrhages; (3) systemic vasculitis; (4) severe pain; (5) severe
constitutional symptoms; (6) purulent synovial fluid in one or more joints; or
(7) immunosuppression
• osteoarthritis: acutely: NSAIDs, acetaminophen
• soft tissue pain: allow healing with enforced rest ± immobilization
• nonpharmacologic treatment: local heat or cold, electrical stimulation, massage
• pharmacologic: oral analgesics, NSAIDs, muscle relaxants, corticosteroid injections, topical
agents

Otalgia
Differential Diagnosis (see also OT6)
• local
• infections: AOE, AOM, OM with effusion, mastoiditis, myringitis, malignant otitis in
diabetics, herpes simplex/zoster, auricular cellulites, external canal abscess
• others: trauma, neoplasm, foreign body, cerumen impactions, Wegener's
• determine onset, course, location and character of pain
• otorrhea, aural fullness, hearing loss, pruritis
• Q-tip use, hearing aids, headphones
• associated symptoms: fever
• observe for otorrhea, palpation ofouter ear, otoscope to see bulging erythematous TM, perforation

Investigations
• consider audiogram ifhearing loss

Management
• debridement and antibiotics for cerumen and infection

Seizures
• see Neurology. N8

Definition
• paroxysmal alteration of behaviour and/or EEG changes resulting from abnormal, excessive
activity of neurons

Categories
• generalized seizure (consciousness always lost): tonic/clonic, absence, myoclonic, atonic
• partial seizure (focal): simple partial, complex partial
• causes: trauma, intracranial hemorrhage, structural abnormality, infection, toxins/
drugs, metabolic disturbance (hypo/hyperglycemia, hypo!hypernatremia, hypocalcemia,
hypomagnesemia); primary seizure disorder
• differential diagnosis: syncope, pseudoseizures, migraines, movement disorder, narcolepsy/
cataplexy, myoclonus

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)

Physical Examination
• injuries to head and spine and bony prominences (e.g. elbows), tongue laceration, aspiration,
urinary incontinence
...._,,
Investigations
Min. Wollwp In In Adull wdll Ill • known seizure disorder: anticonvulsant levels
Timl SlizuN • Accu-Chek·
CBC 1111d diff • first time seizure: CBC, serum glucose, electrolytes, BUN, creatinine, Ca, Mg; consider
8ectrolytes including Ca. Mg. P0 4 prolactin, fi-hCG, tox screen
Head CT
• initial: CT; x-ray if suspected extremity injuries. Definitive: MRI, EEG
Toronto Notes 2011 Approach to CommonER Presentations Emergency Medicine ER27

Table 13. Management of Status Epilepticus

Time (mi•l Slips
6-5 Give axygen; ensure ade!J.Ia'le ventilation
Monilllr. vital signs, oximetry
Establish IV access; obtai! blood samples for glucose level, CBC, electrolybls, toxins, and anticonwlsllnt IMis
fi.9 Giva 50 ml 50% glucose (preceded by thiamine 100 mg IM in adultsl
111-ZD IV lorazepam 0.1 ITigllqj at 2 mg{min or IV diazepam 0.2 at 5mg{min
Diazepam can be repeated if seizures do not stop after 5 min; if diazepam is used to stop the status, then r,ilenyloil
..... ,,
should be administered pr0f11llly to prevent the of status
If adminiQring phenytoin, patient must
2110 If status persists, administer 15-20 of intravenously no faster than 50 m!Vmin in adults and be on a cardiac monitor as anhytluniu
1mw1qj/min in clildren and/or hyputB!IIion 11111y occ:ur.
>60 If status does not stop after of phanytoil, giva additional doses of 5 mg/kg to a maxinal dose of
If status pnisls, then giva 20 mlrkg of at 100 mjfmin When is given after a
benzodiiiZEpine, ventilatory assistance is usually required
If status persists, then give general anaesthesia (e.g., pentobarbilllll. Vasopressors or fluid volume are usually
necessary. Electroencephalogram should be manitorad. Neuromuscular blockade may be needed.
Adllptad form: Ctd'sEs:!erltirlsDf.&fe*ite, 7tfuditian, Tabla 12H Used with panrillion.

Disposition
• the 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 re: ability to drive
• warn regarding other safety concerns (e.g. no swimming, bathing children alone, etc.)

Shortness of Breath
• see Re$pirolQgy and CardiQlQgy ..... ,,
Etiology
• categorized into one oftwo groups: respiratory or cardiovascular C.•n of Acute DIYJIMI
• respiratory system dyspnea: discomfort related to disorders of the central controller (brain), the Cllnliovncular: acul& Ml, CHF, cardiac
ventilatory pump (ventilatory muscles, peripheral nerves), and the gas exchanger (alveoli and tamponade.
pulmonary capillaries) Ra•iratory: bronchospaiiTI, pulm01111ry
• cardiovascular system dyspnea: cardiac diseases (acute ischemia, heart failure, systolic embolism, pnlllrllOthorax. infection
dysfunction, valvular disorders, pericardial diseases), anemia, and deconditioning (bronchitis, pneumonia), upper airway
obstruction (upimion, 11111phylaxis).
History/Physical
• acute SOB is often due to a relatively limited number of conditions. Associated symptoms and
signs are key to the appropriate diagnosis
• substernal chest pain with cardiac ischemia
..... ,,
• fever, cough and sputum with respiratory infections
Collll'lindiclllilln ta 1011% DXJtllln
• urticaria with anaphylaxis C01 rvt111inn (1.g. COPD).
• wheezing with acute bronchospasm
• dyspnea may be the sole complaint and the physical examination may reveal few abnormalities
(e.g. pulmonary embolism, pneumothorax)
• chest tightness may be indicative of bronchospasm
• a sensation of rapid, shallow breathing may correspond to interstitial disease
• a sense of heavy breathing is typical of deconditioning
• vitals including pulse oximetry
• wheeze (airway) vs. crackles (parenchymal), JVP, and murmurs

Investigations
• CBC + differential (hematocrit to exclude anemia), electrolytes, consider ABG
• CXR (hyperinflation and bullous disease suggestive of obstructive lung disease, or changes in
interstitial markings consistent with inflammation, infection or interstitial fluid)
• serial cardiac enzymes and ECG if considering cardiac source
• CT chest usually is not indicated in the initial evaluation of patients with dyspnea, but
can be valuable in patients with interstitial lung disease, occult emphysema, or chronic
thromboembolic disease (PE)
Disposition
• the history and physical examination lead to accurate diagnoses in patients with dyspnea in
approximately two- thirds of cases; the decision to admit or discharge should be based on the
underlying disease process identified
• consideration for intubation should be early in C02 retainers (e.g. COPD)
• if the decision to discharge is chosen, provide appropriate discharge instructions to return in
case of returning/worsening SOB
ER28 Emergency Medicine Approach to CommonER Preaentations Toronto Notes 2011

Syncope
..... , ------------------------------------------------------
9·t-----------------, Definition
S Types If Syncap1 • sudden, transient loss of consciousness and postural tone with spontaneous recovery
1. Vasomotor • usually caused by generalized cerebral or reticular activating system hypoperfusion
2. Canliac
3.CNS
4. Metabolic
Etiology
5. Psychogenic • cardiogenic: arrhythmia, outflow obstruction (e.g. PE, tamponade, tension pneumothorax,
pulmonary liTN), MI, valvular disease
• non-cardiogenic: peripheral vascular (hypovolemia), vaso-vagal, cerebrovascular disorders,
CNS, metabolic disturbances (e.g. EtCH intoxication)
ICl
History
c - ot Syncope by 5ys1am • gather details from witnesses, and clarify patient's experience (e.g. dizziness, ataxia, or true
HEAD, HEART. VeSSElS syncope)
Hypoxii/Hypoglycamia
Epilapry
• distinguish between syncope and seizure (see N9}
Anxiety • some patients may have myoclonic jerks with syncope - NOT a seizure
Dysfunctional brainstem • signs and symptoms during presyncope, syncope and postsyncope
lllllrt attack • past medical history. drugs
Embolism (PE] • think anatomically in differential; pump (heart}, blood (quality}, vessels, brain
Aortic obstruction • sudden loss of consciousness with no warning or prodrome is cardiogenic until proven
lhylhm disturbance
Tachycardia otherwise
Vasovagal
Situational
Physical Examination
Subclavian stall • postural BP and HR
ENT (glossophllryngelll nallflllgia] • cardiovascular, respiratory and neuro exam
low systemic VUCUIIII" nllli51mlca • physical findings in the elderly patient who falls (I HATE FALIJNG):
Sensitive carotid sioos
• Inflammation of joints (or joint deformity)
• Hypotension (orthostatic blood pressure changes)
• Auditory and visual abnormalities
• Tremor (Parkinsoris disease or other causes of tremor)
• Equilibrium (balance) problem
• Foot problems
• Arrhythmia, heart block or valvular disease
• Leg-length discrepancy
• Lack of conditioning (generalized weakness)
• Illness
• Nutrition (poor; weight loss)
• Gait disturbance

Investigations
• ECG (tachycardia, bradycardia, blocks, WPW, long QT interval), bedside glucose
• as indicated: CBC, electrolytes, BUN, creatinine, ABGs, Troponin, Ca, Mg.
• consider drug screen

..... ,
Which 1'811111111 wllh Syncope should
be AllmittR?
ThO&B 11 risk of complicaliona:
• Older thin 60-70 years
• Significant cardiac risk factors
• Racurrant syncopa
• Sarious undlllying il.,eu
Management
• ABCs, IV, <l:2. monitor
• examine for signs of trauma caused by syncopal episode
• cardiogenic syncope: admit to medicine/cardiology
• non-cardiogenk syncope: discharge with follow-up as indicated by cause
Disposition
• decision to admit is based on etiology
• most patients will he discharged
• on discharge, instruct patient to follow up with family physician
• educate re: avoiding orthostatic or situational syncope
• patients with recurrent syncope should avoid high-risk activities (e.g. driving)

..... ,
Lagally raquirad to rapart sexual
if victim is < 16 years of age to
Children's Aid Sociaty (CAS].
Sexual Assault
Epidemiology
• 1 in 4 women and 1 in 10 men will be sexually assaulted in their lifetime
• it is estimated that only 796 of rapes are reported
General Approach
• ABCs, treat acute, serious injuries
• ensure patient is not left alone and provide ongoing emotional support
• set aside adequate time for exam (usually 1.5 hours)
Toronto Notes 2011 Approach to CommonER Presentations Emergency Medicine ER29

• 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 hrs since assault
• label samples immediately and pass directly to police
• offer community crisis resources (e.g. shelter, hotline)
• do not report unless victim requests (legally required if <16 years old)

History
• ensure privacy for the patient - others should be asked to leave
• questions to ask: who? how many? 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
• gravity, parity, last menstrual period
• contraception use
• last voluntary intercourse (sperm motile 6-12 hours in vagina, 5 days in cervix)
• medical history - acute injury/illness, chronic diseases, psychiatric history, medications,
allergies, etc.

Physical Examination
• evidence collection is always secondary to treatment of serious injuries
• 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, tom 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 ifpresent or aspiration of saline irrigation
• immediate wet smear for motile sperm
• air-dried slides for immotile sperm, acid phosphatase, ABO group
• others
• fingernail scrapings
• saliva sample from victim

Investigations
• VDRL -repeat in 3 months if negative
',.,
• serum m.t 11f Suultlly TranMIIIW lhu•
• blood for ABO group, Rh type, baseline serology (e.g. hepatitis, HIV) After Suual AluuH
Gonorrhea: 6-1
Chlamydia: 4-17%
Management Syphilis: 0.5.J'J(,
• involve local/regional sexual assault team HIV:<1'1(,
• medical
• suture lacerations
• tetanus prophylaxis
• gynecology consult for foreign body, complex lacerations
• assumed positive for gonorrhea and chlamydia
• management: azithromycin 1 gPO x 1 dose (alt: doxycycline 100 mg PO bid x 7 days)
and cefixime 400 mg PO x 1 dose
• may start prophylaxis for hepatitis B and HIV
• pre and post counselling for lllV testing
• pregnancy prophylaxis offered
• levonorgestrel 0.75 mg PO STAT, repeat within 12 hours (Plan B•)
• psychological
• high incidence of psychological sequelae
• have victim change and shower after exam completed

Disposition
• discharge if injuries/social situation permit
• follow-up with MD in rape crisis centre within 24 hours
• best ifpatient does not leave ED alone
ER30 Emergency Medicine Approach to CommonER Presentationa/Medical Emergencies Toronto Notes 2011

..... ,
...-----------------,
Haw do you g.t • p.ti...t who Is
Ki:OIIIJianilld lly ...,. pllrlner . . _
witho.t lrDUiing lutpician?
Order 11'1 x-ray.
DOMESTIC VIOLENCE
• women are usually the victims, but male victimization also occurs
• identify the problem (need high index of suspicion)
• suggestive injuries (bruises, sprains, abrasions, occasionally fractures, burns or other injuries;
often do not match up 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)
• if disclosed, be supportive and assess danger
• order an x-rayto secretly get patient alone to question re: abuse
• patient must consent to follow-up investigation/reporting (unless for children)

Management
• treat injuries
• ask about sexual assault and children at home
• document findings
• safety plan
• follow-up: family doctor/social worker

Medical Emergencies
Anaphylaxis and Allergic Reactions
..... , Etiology
• exaggerated immune response classically IgE mediated, sensitization then re-exposure
• anaphylaxis: a severe hypersensitivity reaction affecting at least two organ systems (e.g. GI,
Most c - Trigg.,. hlr
"-.phyluis derm,resp)
• l'e!liciUin • urticaria: a hypersensitivity reaction causing an itchy skin eruption
• Stings • angioedema: swelling that occurs in the tissue just below the surface of the skin, most often
• Nuts around the lips and eyes
• Shellfi$11 • anaphylactoid reaction: non-IgE mediated, may occur with first exposure {e.g. radio contrast
dyes); presentation and treatment same as for anaphylaxis

History and Physical Examination

• general- marked anxiety, apprehension, tremor, cold sensation
• skin - generalized urticaria, edema, erythema, pruritus
• GI - abdominal pain, nausea, vomiting, diarrhea (most allergens are ingested, therefore GI
symptoms common)
• respiratory- nasal congestion, sneezing, coryza, cough. hoarseness, sensation of throat
tightness, dyspnea, stridor, wheeze
• eyes - itch, tearing, conjunctival injection
• cardiovascular - hypotension, tachycardia, weakness, dizziness, syncope, chest pain, arrhythmia,
MI

Management

..... ,
• remove causative agent; secure ABCs
• epinephrine
...-----------------, • on scene- epi-pen {injectable epinephrine) if available
• moderate signs and symptoms (minimal airway edema, mild bronchospasm, cutaneous
Trallnllnt
• Airwlly contral reactions)
• Epinljlmrlll • adult: 0.3-0.5 mL of 1:1000 solution 1M epinephrine
• Establish IV 1nd give fluids • child: 0_01 mUkg/dose up to OA miJdose 1:1000 epinephrine
• Steroids • severe signs and symptoms (laryngeal edema, severe bronchospasm and shock, severe
• Anti-llistamines
hypotension)
• epinephrine via IV or ETT starting at 1 rnl ofl:10,000 (0.1 mg) in adults; 0.01 miJkg in
children
• cardiac monitoring, ECG
• diphenhydramine (Benadryl•) 50 mg IM or IV q4-6h
• methylprednisolone 50-100 mg IV {dose depending on severity)
• salbutamol (VentoJin•) via nebulizer if bronchospasm
• glucagon (for those on !}-blockers with resistant hypotension and/or cardiac disease) 5-15
qlminiV

Disposition
• monitor for 4-6 hours in ED (minimum) and arrange: follow up with family physician in
24-48hours
• can have second phase (rebound) reaction up to 48 hours later, patient may need to be supervised
• 3-day course of.
• H 1 antagonist (cetirizine 10 mg PO od)
• H 2 antagonist (ranitidine 150 mg PO od)
• corticosteroid (prednisone 50 mg PO od)
Toronto Notes 2011 Medical Emergencies Emergency Medicine ER31

Asthma
• see Res.pirology, R7
• chronic inflammatory airway disease with episodes of bronchospasm and inflammation
resulting in reversible airflow obstruction
', ,
Beware of tna silent asthmaticI This is
a medical ernervency and may require
Investigations 11111111111111C'f intubelion.
• 0 2 sat
• pealdlow meter
• ± ABG (only in life threatening exacerbations)
• CXR if diagnosis in doubt or concerns of pneumonia. pneumothorax, etc.
',,
5 &MIIIw Elemenlll tm Hi.tory
Tabla 14. Asthma Assessment and Management • C111111 of 8XIIclllbation
• Previous EIVICU visib
Classifications tistory and Pllysical Exallination Mlnagemant • Previous intubations
• Tming af I'ICIITI st1roid UN
llllpimary Amlt • Exhausll!d, confused, diaphoretic, o 1011% Oz, cardiac monitor, IV access • Frequency of artllma medication usa
lmmilant • Silent chest, ineflective respiratory effort o Intubate (consider pr&-induclion with ketamine)
• DBCI8il&edHR • puffs OR nebuliz:sr 5 mg continually
• sat <90% despite supplemeniBI • Anticholilergics: MDI puffs q20 minx 3
OR nebulizer 0.5 mg q20 minx 3
• IV steroids: methylprednisolone 125 mg,
hydrocortisone 500 mg
Severe Asthma • Agitated, diaph01'81ic, laboLI'IId respirations o Anticipall need for intubation Tre.tmlnt of Asthm•
• Difficulty speaking in lull santences o Similar to above menagement (jl-agonist may be less ASTHMA
• No relief from frequent; q15-20 min) (beta-agonim)
• sat <90%, FEV1 <511% o Magnesilm sLJphate 2g IV STeroids
Hydration
Modandl Allhma • SOB at rest, cough, congestion, chest tiltltness o Oz to achieve Oz-sat >90% Muk!02)
• Nocturnal symptoms o puffer of neb q1h concurrent infection)
• Inadequate raliul from jl-agonist • St.oid&: pradni50ne 4()..60 mg PO
• FEV1 50-80'lo • Anticholilergics (Atrovent)
Mild Asthma • Exertional SOI!Icough some nocturnal •
symptoms • Monitor FEV1
• Good response to • Consider steroids (nebLJized or PO)
• FEV1 >80%

Disposition
• P-agonist MDI regular use (2-4 puffs q2-4h) until symptoms controlled then pm
• prednisone 30-60 mg/dayfor 7-14 days with no taper
• inhaled steroid
• follow-up with primary care physician

Cardiac Dysrhythmias
• see Cardiology. Cl2

Bradyarrhythmlas and AV Conduction Blocks

• AV conduction blocks
• 1ot degree - prolonged PR interval (>200 msec), no treatment required
• 2nd degree
• Mobitz I - gradual prolongation of PR then dropped QRS, usually benign
• Mobitz II - PR constant with dropped QRS, can progress to 3rd degree AV block
• 3rd degree - P unrelated to QRS, PP and RR intervals constant
• atropine and transcutaneous pacemaker (TCP)
• ifTCP fails consider dopamine, IV
.
',,
Atropine is unlikaly to wor1c. in 3nl
dlgrM hllllt block.
• long term treatment for Mobitz n and 3 degree block - internal pacemaker
• sinus bradycardia (rate <60 bpm)
• can be normal (especially in athletes)
• causes: vagal stimulation, vomiting, myocardial infarction/ischemia, increased ICP, sick
sinus node, hypothyroidism, drugs (e.g. P-blockers, CCBs)
• treat if symptomatic (hypotension, chest pain)
• acute: atropine ± transcutaneous pacing
• sick sinus: transcutaneous pacing
• drug induced: discontinue/reduce offending drug
ER32 Emergency Medicine Medical Emergencies Toronto Notes 2011

...... ,
•t-----------------,
Supraventricular Tachyarrhythmias (narrow QRS)
• sinus tachycardia (rate >100 bpm)
If 1111 patiant tachyanhythmia • causes: increased sympathetic tone, drugs, fever, hypotension, anemia, thyrotoxicosis, MI,
is unmble, perform immediabl PE, emotional, pain, etc.
canliovmion. • treat underlying cause, consider if symptomatic
• regular rhythm

...... ,
...-----------------,
Clini:lll Flllllmla Df lnltUility
• Hypotension (.SP <90)
• CHF or pulmonary edema
• Clmt pain
• Altered LOC (may indiuta lhock)
......
.,
.----------------.
If patient hu Wollf-Parkinson·White
and is in Afib usa lllliodarona or
procainamide. Avoid AV nodal blockinq
agent5 {adenosine, digoxin, diltiazam,
u 1his can inci'IISII
conduction through bypan bact.
• vagal maneuvres (carotid massage, Valsava), adenosine 6 mg IV push, if no conversion give
12 mg, can repeat 12 mg dose once
• rhythm converts: probable re-entry tachycardia
• monitor for recurrence
• treat recurrence with adenosine or longer acting medications
• rhythm does not convert: atrial flutter, ectopic atrial tachycardia, junctional tachycardia
• rate control (diltiazem, and consult cardiology
• irregular rhythm
• probable atrial fibrillation, atrial flutter or multifocal atrial tachycardia
• rate control (diltiazem,
Atrial Fibrillation
• most common sustained arrhythmia; no organized P waves, irregularly irregular heart rate,
narrow QRS (typically)
• etiology: HTN, CAD, thyrotoxicosis, EtOH (holiday heart), valvular disease, pericarditis,
cardiomyopathy, Sick Sinus Syndrome
• treatment principles: stroke prevention, treat symptoms, identify/treat underlying cause
• decreases cardiac output by 20-30% (due to loss of organized atrial contractions)
• acute management

.,
• if onset of AFib is >24-48 hrs: anticoagulate 3 wks prior to and 4 wks after cardioversion or
do transesophageal echo to rule out clot
...... ._________________ • if symptomatic or first presentation - cardiovert
• electrical cardioversion: synchronized DC cardioversion
Usa 1ha CHADS2 score from Tabla 3, • chemical cardioversion: amiodarone, procainamide, flecainide, propafenone
(if decreased LV function use amiodarone)
• long term management: rate or rhythm control, consider anticoagulation (CHADS2)

Ventricular Tachyarrhythmias (wide QRS)

• ventricular tachycardia (VT) (rate usually 140-200 bpm)
• definition: 3 or more consecutive ventricular beats at >100 bpm
• etiology: CAD with MI is most common cause
• treatment: sustained VT (>30 seconds) is an emergency
• hemodynamic compromise: DC cardioversion
• no hemodynamic compromise: DC cardioversion, lidocaine, amiodarone, procainamide
• ventricular fibrillation - call a code blue, follow ACLS for pulseless arrest
• torsades de pointes
• looks like VT but QRS 'rotates around baseline' with changing axis and amplitude
(twisted ribbon)
• etiology: prolonged QT due to drugs (e.g. quinidine, TCAs, erythromycin, quinolones),
electrolyte imbalance (hypokalemia, hypomagnesemia), congenital
• treatment:
• IV Mg. temporary overdrive pacing, isoproterenol
• correct cause of prolonged QT
• discontinue cardioversion if hemodynamic compromise

Chronic Obstructive Pulmonary Disease (COPD)

..... •,..----------------.
Nlell til Rule Out willl COPD
• progressive development of irreversible airway obstruction, typically caused by smoking
Eacelbalion • acute exacerbation: episode of increased dyspnea, coughing, increase in sputum volume or
• Pneumothorax purulence
• CHF axacarbation
• AcuteMI History and Physical Examination
• l'nelrnonia and oilier infectious CBU88S • worsening dyspnea or tachypnea
• Pulmonary embolus • acute change in frequency, quantity and colour of sputum production
• trigger: pneumonia, urinary tract infection, PE, CHF, Ml, drugs

Investigations
• CBC, electrolytes, ABG, CXR, ECG, PFTs
Management
• keep 0 2 sat 88-92% (beware of C02 retainers, but do not withhold Oz if hypoxic)
• ipratriopium is bronchodilator of choice, add salbutamol
• steroids: prednisone 40 mg PO (tapered over 3 weeks)
• antibiotics: TMP-SMX, cephalosporins, respiratory quinolones (if signs of infection)
• ICU admission iflife-threatening with ventilation (chance of ventilation dependency)
• lower threshold to admit if co-morbid illness
Toronto Notes 2011 Medical Emergencies Emergency Medicine ER33

Disposition
• can use up to 4-6 puffs qid ofipratropium and salbutamol for exacerbations
• continue antibiotics if started and give tapering steroids

Congestive Heart Failure

• also see Cardiology, C32

Etiology It'
• decreased myocardial contractility: ischemia, infarction. cardiomyopathy, myocarditis Cau111 of CHF Exacerbmon
• pressure overload states: hypertension. valve abnormalities, congenital heart disease
FAIWRE
• restricted cardiac output: myocardial infiltrative disease, cardiac tamponade Forvot medication
• volume overload AnhytllrnWAnamill
lsch1111illl'lnfarcti onllnflction
Causes of Exacerbation or Precipitants (e.g. too much all)
Upregulation of cardiac output
• cardiac: acute myocardial infarction or ischemia, cardiac tachyarrhytlunias (e.g. atrial (p1111J111ncy, hyperthyroidism)
fibrillation), uncontrolled hypertension 1111111 fllilunl
• medications: non-compliance with or change in cardiac medications, NSAIDS, steroids Embolilm (pulmonary)
• dietary: increased sodium intake
• increased cardiac output demand: infection, anemia, hyperthyroidism, pregnancy
• other: pulmonary embolus, physical overcxc:rtion, renal failure
..... ,,
History/Presentation Hotpitll Mlnagement lequir.d if:
• left-sided heart failure • Acute Ml
• dyspnea, decreased exercise tolerance, paroxysmal nocturnal dyspnea, orthopnea, nocturia, • Pulmo111.ry edema or severe
respiratory distress
fatigue, possibly altered mental status, syncope, systemic hypotension • Sevn complicating medical illnass
• in severe cases pulmonary edema: severe respiratory distress, pink frothy or white sputum, (a.v. pnaumonia)
rales, S3 or S4 • Anasarca
• right-sided heart failure • Symptomatic hypo1ension or syncope
• Raflactory to oUipltiant therapy
• dependent edema, jugular venous elevation, hepatic enlargement, ascites • Thromboerilolic compliclllions
• patients often present with a combination of right-sided and left-sided symptoms requiring interventions
• Clinically significant arrhythmias
Physical Examination • Inadequate social support for safe
• vitals: tachypnea, tachycardia, hypo- or hypertension, hypoxia outpatient m8111.Q8ment
• l'lniltent hypoxia requimg
• respiratory: crackles (acute), wheeze (chronic) IUJiplllllllllllll oxygm
• cardiac: laterally displaced apex, S3 or S4, jugular venous distention, hepato-jugular reflex
• abdominal: hepatomegaly, ascites
• peripheral vascular: peripheral or sacral edema, weak peripheral pulses, pulsus altemans
(alternating weak and strong pulse), cool extremities
..... '_._, ______________
CHF an CXR
Investigations Pulmonary Vllscular rvdistribution
• labs: CBC, electrolytes, AST, ALT, bilirubin, creatinine, BUN, cardiac enzymes, BNP (brain Perihilar inliltnnn
natriuretic peptide) lntamitilll edema, Karley B lin1111
AIVIIOiar edema, bilateral infillrltas
• chest X-ray (see side bar) May see cardiomegaly, pleural effusions
• ECG: look for Ml, ischemia
• in CHF: LVH, atrial enlargement conduction abnormalities
• ABG: if severe or refractory to treatment
• hypoxemia, hypercapnia and acidosis are signs of severe CHF
• echocardiogram: not usually used in emergency evaluation, previous results may aid in
diagnosis
• may be precipitated by arrhythmia (e.g. sudden onset AFib) - correct if new

Management (acute)
• ABC, may require intubation if severe hypoxia
• sit upright, cardiac monitoring and continuous pulse oximetry It'
• saline lock IV; Foley catheter (to follow effectiveness of diuresis) Aculll Traltnlllnt af CHF
• 100% mask LMNOP
• if poor response may require CPAP, BiPAP, or intubation Llsix (furos1111ide)
• drugs Morphine
• nitro 0.3 mg SL q5min PRN ±topical nitro patch (0.2-0.8 mg/hr) Nitroglycerine
Oxygen
• if not responding or ischemia: 10-200 f!g/min IV; titrate Position (sit upright)
• diuretic if volume overloaded (e.g. furosemide 40-80 mg IV)
• morphine l-2mg1Vpm
• ifhypotensive: dobutamine (2.51Jg!kg/min IV) or dopamine (5-10 f!glkg/min IV), titrate
up to sBP 90-100
• ASA 160 mg chew and swallow
• treat precipitating factor
• cardiology or medicine consult
ER34 Emergency Medicine
It'
Biak hctun for VTE
THROMBOSIS
Trauma, travel
HRT
B1crwtional drugs (IVDUI
Old (age >601
Maignancy
Birth control piU
Oblsily, obmlrics
Surgery, smoking
Immobilization
Sickness (CHF. MI. nephrotic
syndmme, Vlllculilis)
... ',
,._________________
PERC ICO,. for PE
AQe >50 y&II'S
HR >100bpm
02 ut on RA <94%
Prior history DVT/PE
Recent trauma or surq&r(
Hemoptysis
Exog-us estrogen
Clinical signs suggesting DVT
Score 1 for each qullllion; ascon
QIB m1111ns patient has < 1.6% chence
havilg aPE and avoids further
investigation.
.._,,
,._________________
Weill Sllora for PE
Previous Hx of DVT/emboli
HR >100
Recent immobility or Sx
Clinical signs of DVT
Alternate Dx less likely than PE +3
Hemoptysis
Cancer
Low probability = G-2
lntarmedilta probability =
High probability = >6
.._,,
511'!(; of patients with symptomatic
proximal DVT will develop PE, ofUn
within da'(IID wsek& of the IMIIIl
Medical Emergencies Toronto Notes 2011
DVT and Pulmonary Embolism
----------------------
• see also R18
Risk Factors
• Vircltow's triad
• alterations in blood flow (venous stasis)
• injury to endothelium
• hypercoagulable state (including pregnancy, use of OCP, malignancy)
• most significant risk factors (see side bar for complete list)
• major surgery or trauma or prolonged hospitalization
• permanent immobilization and age
• malignancy, other hypercoagulable state
• prior venous thromboembolism
History/Presentation
• DVT: calf pain. leg swelling/erythema/edema, palpable cord on exam; can be asymptomatic
• PE: dyspnea. pleuritic chest pain, tachypnea, hemoptysis, cyanosis, hypoxia, fever
• presence of risk factors and family history ofvenous thromboembolic disease
• clinical signs/symptoms are unreliable for diagnosis and exclusion ofDVT/PE; investigation
often needed (see Figures 12 and Figure 13}
• calculate the PERC score to assess the need for PE work-up before assessing the likelihood of a
PE (Well's criteria}
Investigations (Figures 12-14)
• ECG and CXR are useful to look for other causes (e.g. ACS, pneumonia)
• D-dimer is only useful ifit is negative in low risk patients
• Ultrasound has high sensitivity and specificity for proximal clot but only 73% sensitivity for
DVT below the knee
• CT angiography has high sensitivity and specificity for PE, may also suggest other etiology
• V/Q scan useful when CT angio not available, or patient unable to tolerate IV contrast (e.g.
renal failure, allergy)
Management of DVT/PE
+1.5 • LMWH unless patient also has renal failure
+1.5 • dalteparin 200 IU/kg SC q24h or enoxaparin 1.5 mg/kg SC q24h
+1.5 • warfarin started at same time as LMWH (5 mg PO daily initially)
+3 • LMWH discontinued when INRhas been therapeutic (2-3} for 2 consecutive days
+1 • early ambulation with analgesia is safe if appropriately anticoagulated
+1 • IVC filter or surgical thrombectomy considered if anticoagulation is contraindicated
• consider thrombolysis if extensive DVT or PE causing hemodynamic compromise
• often can be treated as outpatient, may require analgesia for chest pain (narcotic or NSAID)
• admit if hemodynamically unstable, require supplemental O:z, major comorbidities, lack of
sufficient social supports, unable to ambulate, need invasive therapy
• long term anticoagulation
• ifreversible risk factor: 3-6 months ofwarfarin
• idiopathic VTE: may need longer term warfarin (5 yrs or more)
•i
SuspiiCted (symptomatic) acute DVT
Compression U/S
...
• • •
Normal Inconclusive or inadequate study DVT present
.
Repeat U/S in 5 days Venography or MRI Trelltment
• I
...
I
...
• • • •
DVTpresant DVTabsant DVT present Negative for DVT
Tralllment Nonatment Traatment Nonatment
Figure 12. Approach to Suspected DVT
Toronto Notes 2011 Medical Emergencies Emergency Medicine ER35

Determine need to investigate Clllil:ll Crillril. ,.._..

via PERC score

• •
. . . . . . . . . illilerglnlr illplmllll
Puoilivl :.1/8 I l'lliiiD with Sulpldld I'UIIIIIIJ EIIWI•
J7hmmblllemolt2004; Z(81:1Z47-55.
Walls criteria PE excludad ,_..ec To. . pWnonllly embolsm (1'£) rule-
I aut crillria !PEIIC) tlllt em b1 Ulld 111111 bldlill,

l
a ]IMI'B -wsti1g fur PERt. Also, il p!MII!
awr-1Bstinu far Pf. wtidl ilcua th•!Hln IBit

•. •
reds i1 rue poilives.

tram 3148 ER pllilrD MY!Id lor pilllihll PE

<500 ng{mL >500 nglml Spiral CT pulmonary
111 diMIIup RJit.autcritlril. ThlllppiiCition allllt
angiog111m {CT-PA)

•. •.
I dMbped rules- inwstiQifld i114271ow-risk
PE excludad pdenls 11111382 'le1'fliiW risk Pl1ierD.
buill: Eigllt....mblll Will incl1111d i11 bbi
Negatiw <50Y'Ifl, pulse <100
>84\. no unillllll'llleg tw*g. no 1-.noptysia,
PEexcludad PE confirmed no l1l*lt t1un1 or Sllgefy; no prior PE or DVT.
no honnonallllj IIIIIIIIIIQIIIMIICOIII-
UIId ID Ml«<l PE.In lawiislt 111d V11V IDwiilk
Figure 13- Approach to Suspected PE J)ltilnls. 1111 aa bid 1switMy all& and 1001.
IIIII aspacificily al 'lland 15\
Detsrmine clinical probllbiity af PE respedt.letf.

.
via Wall's (high, moderab or low)

V/Uscan
s..-y: lor PE 11111' nat hi
1iMinble f II eijJt fldDrs in the P8IC IIIli
nagelivl.

•
Normal V/U scan
and any clinical
...
Low probability V/U
scan and low clilical
I
...
High probability V/U
scan and high clinical
•
All other combimdions
af V/U scan 111sults and

.
probability of PE

PE excluded
.
probability of PE

PE excluded
.
probability of PE

PE confirmed
.
clinical probability of PE

Pulmonary angiogrem or
sariallower IIX!nmity
venous utlnsounds

Figure 14. VJQ.Based Algorithm for Suspected PE

Diabetic Emergencies
• see also Endocrinolog)T, Ell

Diabetic Ketoacidosis (DKA)

• severe insulin deficiency resulting in hyperglycemia (11-55 mmol/L), dehydration and 1'1-.cipUiing fllelor• in DICA
electrolyte abnormalities The 5·r.
• history and physical examination - often young, type 1 DM, may be first presentation of lrnction
undiagnosed DM (may occur in small percentage of type 2 patients) Ischemia
• early symptoms: polyuria, polydipsia, malaise lrnll:lion
lntoxiclllion
• late signs and symptoms
ln•ulil missed
• anorexia, nausea, vomiting, dyspnea (often due to acidosis), fatigue
• abdominal pain
• drowsiness, stupor, coma
• Kussmaul's respiration
..... ,..-----------------.
,
• fruity acetone breath
• investigations 4 crlterill far DICA Dx: hyparglycemia,
• CBC, glucose, electrolytes, BUN/creatinine, Ca, Mg, phosphate, urine glucose and ketones metabolic acidosis, hyperketonemia,
Qlonurill_
• ABG
• ECG (MI possible precipitant; electrolyte disturbances may predispose to arrhythmia)
• management
• rehydration
• bolus of NS, then high rate NS infusion (but beware of overhydration and cerebral
edema, especially in pediatric patients)
• potassium
• essential to avoid hypokalemia: replace KCl (20 mEq/L if adequate renal
function and initial K <5.5 mmol/L)
• use cardiac monitoring if potassium levels normal or low
• insulin
• critical, as this is the only way to turn off gluconeogenesis/ketosis
• do not give insulin ifK <33 mmol/L
• initial bolus of5-10 U short-acting/regular insulin (or 0.2 U/kg) IV in adults
(controversial- may just start with infusion)
• followed by continuous infusion at 5-10 U (or 0.1 Ulkg) per hour
• add DSW when blood glucose <15 mM to prevent hypoglycemia
• bicarbonate is not given unless patient is at risk of death or shock (typically pH <7.0)
ER36 Emergency Medicine Medical Emergencies Toronto Notes 2011

Hyperosmolar Hyperglycemic State (HHS)

• state of extreme hyperglycemia (44-133.2 mmoUL) due to relative insulin deficiency; increased
counter-regulatory hormones, gluconeogenesis, and dehydration (due to osmotic diuresis) in
type 2 DM, high mortality (approaches 50% even with optimal management)
• history and physical examination
• mental disturbances, coma, delirium. seizures
• polyuria
• nausea, vomiting
• investigations
• CBC, electrolytes, creatinine, BUN, glucose, Mg, phosphate, urine glucose and ketones

•..,
...
•ABG
• ECG
• management
Cerlbral 1dem11 may ocrur • rehydration with NS (total water deficit estimated at average 100 cc/kg body weight)
hyperosmolalily 1reated too • 0 2 and cardiac monitoring, frequent electrolytes and glucose monitoring
IIIKJM1ively, • insulin as required
• identify and treat cause

..... , Hypoglycemia
.. • very common ED presentation
• management focus
DRill Inducing Hypoglycemill
Insulin Sulfa abx • treatment ofhypoglycemia
Sulfonylur1u Cotrimazol1 • investigation of cause (most often due to exogenous insulin, alcohol, sulfonylureas)
Ethanol AmpiciUin • history and physical examination
Salicylates Trtracycline • last meal, known diabetes, prior similar episodes, drug therapy and compliance
Acetaminophen Amphetamines
NSAIDS Cocaine
• liver/renal/endocrine/neoplastic disease
agoni5ts Pyridoxine • depression, alcohol or drug use
lithium ACE-I • management
Calcium Theophylline • IV access and rapid BG
MAOI Quinine
Coumadin
• DSOW 50 mL IV push, glucose PO if mental status permits
• if IV access not possible, glucagon 1-2 mg IM, repeat x 1 in 10-20 min
• 0 2, cardiac, frequent BG monitoring
• thiamine 100 mg 1M
• full meal as soon as mental status permits
• if episode due to long acting insulin, or sulfonylurea&, watch for prolonged hypoglycemia
due to long t 112 (may require admission for monitoring)
• search for cause

Electrolyte Disturbances
• see Ne.phrology and Endocrinology
Tabla 15. Elactralyta Dilturbanca&
Elactralyta C111111111 Caul• Symplllms Treatment Spacial Clllllidaratians
Distwlllnce
llypamllnlmia lnadBIJlal! Hz(! intake (elderly/disabled) Lethargy, weakness, initabiity, 111d Salt restrict 111d give free water No more then 12 in 24 hrs drop
or inappropriate excretion of Hz(! edema. Seizures and coma occur i1 Na (0.5 mmoiiiJlrl due to risk of
(diurutie5, li, Dl) with 58IIIJ8 elevation& of Na cerebral edelllil, seizure&, death
levels (> 158 mmollt)
Hyp-m=mia Hypo-08111olll' (dilutional e.g. CHF. Acute: Neurologic symptoms 2" Watur11181rict Limittlllal rise to 8 mmolll in 241111
cirrhosis, ascites) and hyper-osmolar to cereml edema, IVa. decreased Acute: correct rapi!ly 3'l6 NaCI (0.5 mmoVIJhr as plllierrts are
(usually glucose) LDC, depressed reflexes at risk of central pontine myelinolysis
Chronic: IV NS + furosemide
Rhllbdornyolysis, insulin deficiency, Nausea, palpitations, mJscle stiffness, Prutect nell'!: Ca gluconate ECG: Peaked/Narrow T wave, decreased
mlblbolic acidosis anrflaxill Shift Kinto cells: R, Pwave, prolonged PR intarval, widening
Vantol in of QRS, AV block. Vfib
Mstabolic alkalosis, insulin, diurutics, Nausea, vomiting. fatigue, K·Durf'l, Ksparing diu181ics, ECG: Uwaves most ftattenac11
anorexia cral!1)5, constipation IV solutions with 20-40 mEq KCI iwerted Twaves, prolonged ar.
Ventolin pll' liter over 3-4 hours depressed ST
May need to restore Mg
Hyper.fTH and malignancy account Multisystem including CVS, Gl Isotonic saline+lasix if hypervolemic Patients with more severe or
for approx. 90% of cases (pms), renal (stones), Bisphosphonates, dialysis, chelation symptomatic hypercalcemia n usually
rheumatological, MSK (bones), (BlTA or oral phosphate) dehydmted and require saline hydration
psychiatric (moans) as i1itialthe18f1V
Hypocalcemia IB1rog111ic, low Mg. liver dysfunclicn Llr{ngosparn, hypenellexia, Acute (ionized Ca <0.7 mMl requires Prolonged QT interval cen arise leadi1g
1" hypo-PTli pnsthesia, tebrly, Chvostek"s and immediate treetment IV calcium to anhythmia es can uppll' airway
Trousseau's sign gluconate 1·2 g in 10·20 mils obsbuclion
followed by slow infusion
Toronto Notes 2011 Medical Emergencies Emergency Medicine ER37

Hypertensive Emergencies .... ,,

Hypertensive Emergency (Hypertensive Crisis)
• definition: acute elevation of systolic and diastolic BP (sBP >200, dBP > 120) and associated Sia- of Rulli Depletion
Increased heart nrte
acute end-organ damage (CNS. renal. CVS. haem, pregnancy related) Postural changes in vital signs
• hypertensive encephalopathy: cerebral hyperperfusion due to blood pressure in excess of the Decreased urine output (normal:
capacity for cerebral autoregulation
• signs and symptoms: headache, nausea, vomiting, mental status changes (lethargy to Hypertensive
Dec1'81Sed .tin 1utgor
coma), fundoscopic changes, over hours can lead to coma and death Sunkan l'f8S
• acute renal failure: can be either the cause or effect of a hypertensive emergency Dry mucous membnnel
• diagnosis: proteinuria, RBCs and RBC casts in urine, elevated BUN and creatinine Decreased capiUary l'lfill
• treatment: IV calcium channel blockers, ± emergent ultrafiltration
• cardiovascular: Ml, CHF, thoracic aortic dissection
•left ventricular failure (LVF): decreased LV function due to increased afterload, increased
oxygen demand and decreased coronary blood flow
- signs and symptoms: chest pain, SOB
- treatment: avoid diazoxide, hydralazine. minoxidil as these drugs increase oxygen
demand
• thoracic aortic dissection (see C48) HELLP Syndnlmo (saen only in

Hemolytic anemia
Pregnancy Induced Hypertension {PIH) see Obstetrics, OB14 EIIYIIted Livw anzymas
• watch for HTN, abdominal pain with severe nausea and vomiting, seizures, proteinuria, lDw P111181et count
thrombocytopenia, increased AST, clonus, and hyper-reflexia
• initial treatment: lower BP, check reflexes, consider MgS04 if at risk for developing
eclampsia, and assess risk to mother and fetus (e.g. deliver)
• antihypertensives: hydralizine 5mg doses in 15 min intervals when dBP >105 or sBP >160,
until dBP 90-100; consider IV labetalol as an alternative
.... ,_._, ______________ __,
Catecholamine-Induced Hypertensive Emergencies
• etiology: discontinuation of short-acting sympathetic blocker (e.g. clonidine. propranolol), c.t.cholamint lnduc:ad Hyll'rtpsiva
pheochromocytoma, sympathomimetic drugs (cocaine, amphetamines, phencyclidine}, MAOI Emorgenciel
Avoid use of non-selective Jl-blockers
in combination with sympathomimetic& or tyramine-containing foods (cheese, red wine) as thay inhibit Jl-madiatad vasodilation
• treatment: immediate goal of IV therapy is to reduce the mean arterial pressure (MAP) by 25% and leave a-adrenergic vasoconstriction
in 30-60 min (5-10 min for aortic dissection) then a gradual reduction in MAP over the next 6 unopposed.
hrs to 160/100
• BP should NOT be lowered rapidly in patients with major cerebrovascular event
• decreasing BP too fast may extend or worsen stroke
• if dBP >120, aim to reduce dBP by 20% in the first 24 hrs
• treatment may be initiated in the ED followed by prompt admission to ICU for continuous
.... ,...-----------------,
,
BP monitoring
• re-administer sympathetic blocker if due to withdrawal (e.g. clonidine. propranolol)
EmorlfliiiCY
N/V
Hypertensive Urgency S.izur8
• definition: severely elevated blood pressure (usually sBP >180, dBP > ll5) with no evidence of Headache Dr altEred mental status
end-organ damage Cushing response
• most commonly due to non-adherence with medications
• treatment: gradually reduce pressure over 24-48 hours to a level appropriate for the patient .... ,..._----------------,
,
• goal is to differentiate hypertensive emergencies from hypertensive urgencies
Evidllnco of Eftd.Orgu Domogo
History and Physical Examination CNS: headache, focal neurological
signs, seizures
• prior hypertensive crises CVS: angina, CHF, bllck pain (110rtic
• antihypertensive medications prescribed, adherence, and BP control dissection}
• MAOIs, substance use, use of stimulants or withdrawal from sedatives including EtOH ln..: hematuria, oliguria
• blood pressure measurement in all limbs Eyes: papilladam1, retinal hemorrhages
• fundoscopic exam (hemorrhages, papilledema, etc.), gross motor examination

Investigations
..... ,,
• CBC, electrolytes, BUN, creatinine, urinalysis Wrth CNS manife5tations of SlMire
• peripheral blood smear - to detect microangiopathic hemolytic anemia hypertension. it is often difficult to
• CXR- if SOB or chest pain diffaruntiatu caUAI rulalionlhips
• ECG, troponins, CK - if chest pain hypartsnsion could ba secondary to
primary cnb111l event (Culhing efl8ct}].
• CT head - if neurological findings or severe headache

Treatment of Hypertensive Emergencies

• see Table 16
ER38 Emergency Medicine Medical Emergencies Toronto Notes 2011

...... ,
•t-----------------,
Teble 16. Most Commonly Used Agents for the Treatment of Hypertensive Crisis
DIUII DIISI88 Onsll of Durllion Advlne Special
Most commonly used agants for Actian of Action Effects• lnlkltians
hypllllllnsiw crisis .,. illmllol and
nitroprusside. VASODilATORS
Sodium 0.25· 10 Immediate 3-5 mil NN. muscle twitching, Most hypertensive emergencies
Nitroprusside sweating. cyanide (esp CHF. aortic di$$eclion)

.. ,
...... (VliSCular 1mooth intaxication, COIOIIII'( Use in combination with
musde dilator) steal syndrome (e.g. esmalol)
1st line in aortic dissection
D111111 ht Inc- Adrn•glc Caution with high ICP and
Stimuldllll azcrtemia
MAOis
TCAs Nicardipine (CCB) 2 mg IV bolus, 15-30 min 40 min Techycllllia, headache, Most hypertensive emergencies
Amphataminas then 4 m!Vkwbr IV flushing. local phlebitis Caution with acute CHF
Cocaine (e.g. encaphalopathy, RF.
eclampsia. sympathetic
crisis)
Fenoldopam 0.05-0.1 fJlllll/k3'min IV <5 min 8-10min Techycllllia, headache, Most hypertensive emergencies
Mesylate nausea, flushing Caution with glaucoma
(dopamile (e.g. acute RF)
receptor
antagonist)
Enalapril (ACEI) 0.62S.1.25 mg IV q6h 15-30 min 12-24 hr Theoretical filii in pressure Acute LV lililure
in high renin states nat Avoid in acute Ml, pregnn:y,
seen in studies acute RF
Nitroglycerin S.20 11w'min IV 1·2mil 3-5 mil Hypotension, bradyclldia, MVl'uhlonary edema
haadache, lightheadedness,
diz2iness
llythlazine S.10 mg IVIIM qZIInin 5·20 min In Dizziness, lhlwsiness, Eclllmpsia
(max2Dmg) headache. tachycardia.
Na rell!ntion
ADRENERGIC INHIBITORS
Lablllalal 20mg1Vbolusq10min 5-10min Vomiting, scalp tingling, Most hypertansiw ernergencies
or 0.5·2 mg/min in throat, dizziness, (esp. edampsia)
nausea, heart block, Avoid in acute CHF, HB >1st
orthostatic hypotension degree
Esmolal 250-500 !IIJikW'min 1·2 mil 11)..20 min Hypotension, nausea. Aortic dissection, acute Ml
1min, then 50 fiG"kkrmin bronchospasm SVT dysrhythmias, perioperativa
for 4 min; repeat HTN
Avoid in acute CHF,
HB >1st degree
Phentolamine 5-15 mg qS-15 min 1-2mil 3-10 min Tachycllllia. headache, Catecholamine excess
...... ,
•.J-----------------. 'Hypotansian n.y occur will! Ill afthala agan1J
flushing (e.g. pheo)

If patient presents within 4.5 llours of

onsll of disabling neurological dlficits
greater than 60 minutes with no signs Stroke
of 1'11101ution, thay 11111y be Cllldidllte for
11Yombolysi5. Do brief ISSe55111enl and
order Slit CT held. • see Neurology. N44
• can be ischemic (80% of all strokes) or hemorrhagic
Elu:lulian far tPA:
Suspected sublrechnoid hemorrhlllga
Previous irtrecrenilll hemorrhlllae History
Cerebral infarct or held injwy • consider acute stroke if acute neurological deficit (focal or global) or altered LOC
within thl past 3 months • more likely to be hemorrhagic if: nausea, vomiting, headache, change in LOC, seizure
Recent pericarditis
Major surgery within the past 14days • common symptoms of stroke: abrupt onset of hemiparesis/monoparesis, visual loss/field deficits,
Gl or urinary hemorrhlllga within the past diplopia, dysarthria, ataxia, vertigo, aphasia, sudden decrease in LOC
21 days • determine time of symptom onset for consideration of thrombolytic therapy
Recent lumbar punctura or arterial • DDx includes hypoglycemia, Todds paralysis, peripheral nerve injury, Bell's palsy, tumour
puncture It noncornpressible silll
Pllient is pregnant
rnmHg systolic, Physical Examination
110mmHu diutDiic • vitals
Bleeding diathesis • if decreased LOC: assess for ability to protect airway
Prolonged m (more then 40 seconds)
• rule out trauma, infection, meningeal irritation
oriNR >1.4
Piltlllt count < 100,000 • search for cardiovascular causes of stroke
Blood giLK:ose <2.8 or >22 mmolll • ocular fundi (retinopathy, emboli, hemorrhage) and pupils
Intracranial hemormage on CT/or III'QI • CVS (murmurs, gallops, AFib)
volume infllm
Seizu11 Ill onllll CIIUSing d8ficit • PVS (auscultate for carotid bruits)
Previously ADL dependent (clinical
judgmsnt)
Toronto Notes 2011 Medical Emergendea/Gynecologic/Urologic Emergencies Emergency Medidne ER39

• neuro
• mental status, WC, cranial motor function, sensory function, cerebellar function,
gait, deep tendon reflexes
• confirm presence of stroke syndrome, and distinguish from stroke mimics (seizure, systemic
infection, brain tumour, positional vertigo, Bell's palsy)
• establish neurological baseline should patient improve/deteriorate
..... ,,
Table 11. Stroke Syndromes
Dlffwre..._ .t UlliN D._,
llegiDI of S1rol!l Straka Syndrama
¥11RILMNDile-
Anterior Cerebral Artery Primarily fronlllllobe function affected
Altared mantlll status, impaired judgment, cootralaterallower axtJarity weakness and
hypoesthesia, gait apraxia tUUr dlicil PJPI
Rdws lraelsed
Midcle Cerebral AriBry Contralllteral hemiparesis (arm and face weakness > leg weakness! and hypoesthesia, ipsilllteral r. ircnlled
hemianopsia. gaze pret.alce to side of lesion fllciajRn Alllrt
:!: agnosia, receptive/expressive aphasia Ablnl\riillli
Affects vision am
Posterior Cerebral Artery

Vertebrobasilar Almry
Homonymous hemianopsia, cortical blindness, visual agnosia, mental status, inpaired memory
Wide variety of CN, cerebellar and brainstem deficits: Vl!rligo, nystagmus, diplopia, visual field
..... ,,
deficits, dysphagia, dysarthria, facial hypoeslhesia, syncope, ataxia
Loss of pain illd tempalilture 5ensation face and conlr.llateral body
1 c.-., Enllllli tr..
Atrial Fib
till ....

Ml
Investigations Endocarditis
V.Werdisa11111
• CBC, electrolytes, blood glucose, coagulation studies, ± cardiac biomarkers, ± toxicology screen llilllted cniamyaplllhy
• non-contrast CT head: look for hemorrhage, ischemia Left heart myxoma
• ECG ± echocardiogram: rule out atrial fibrillation, acute MI as source of emboli Prosthllic Valves
• other imaging: carotid dopplers, CfA, MRA as appropriate

Management
• quickly detennine if patient is eligible for thrombolysis (need acute onset less than 4.5 hours
c-•
It'
from drug administration time AND compatible physical findings AND normal Cf with no Aculll Ataxia
bleed) - not much time to do all of this (often requires designated stroke team) UNABLE TO STAND
• ABCs with RSI if GCS :5':8, rapidly decreasing GCS, or inadequate airway protection reflexes Underlying weakness (mimic mxial
• IV ± cardiac monitoring Nu1ritianal nuoplllhy (Yitamil Bu
• judge fluid rate carefully to avoid overhydration (cerebral edema) as well as underhydration deficiency)
Artlliti.,tvuc...
(underperfusion of the ischemic penumbra) BnU..migraine
• BP control: only treat severe hypertension (sBP >200, dBP >120, mean arterial BP >140) or neuronitis
hypertension associated with hemorrhagic stroke transformation, cardiac ischemia, aortic
dissection, or renal damage; use IV nitroprusside or labetalol Trauma [past-concussive)
• cerebral edema control: hyperventilation, mannitol to decrease ICP if necessary Dlher (rare genetic or metabolic
• consult neurosurgery, neurology as indicated disaasa)
Stroke {ischemia or hemorrhage)
Toxins [drugs, toluene, mercury)
Medications Alcahal
• acute ischemic stroke: thrombolytics (rt-PA, e.g. alteplase) if within 3 hours of symptom onset Neaplasmtparanaaplastic syndrome
with no evidence of hemorrhage on cr scan Demyelillltian [Miler Fistler, Gu•in
• antiplatelet agents: prevent recurrent stroke or stroke after TIAs, e.g. aspirin (1 11-line); 8111'6, MS)
clopidogrel. ticlopidine (2nd-line)

Gynecologic/Urologic Emergencies
Vaginal Bleed
• see Gptecolog)T, GY6 and Obstetrics, OB20

Etiology
• pregnant patient
..... ,,
• 1st/2nd trimester pregnancy: ectopic pregnancy, abortion (threatened, incomplete, complete,
Vaginal bleeding can be life thremnlng.
missed, inevitable, septic), molar pregnancy Always start with ABCs and ensure your
• 2nd/3rd trimester pregnancy: placenta previa, placental abruption, premature rupture of J)ltient is stable.
membranes, preterm labour
• either: trauma, bleeding cervical polyp
• postpartum
• postpartum hemorrhage, uterine inversion, retained placental tissue, endometritis
• non-pregnant patients
• dysfunctional uterine bleeding, uterine fibroids, pelvic tumours, trauma, endometriosis, PID,
exogenous hormones
ER40 Emergency Medicine
,, ,
Need Jl-hCG <::1200 to see interuterine
chllnges on hnsvagilllll LVS.
,, ,
Cl-ilying milcarlilge (allertlon):
MiiMII - non-viable inlraut8rine
prapncy
111.-..t.ned - viii!U intnlut.in1
prapncy with os clond
Inevitable - os closed, no products of
conception pll$$ed
lncampJ.Ie- products of concaption
partially uxpalled
Compll&e - products of concaption
completely expelled
Septic -any of llbova with of
infection (usually incompletll)
hc•rent- >3 spon!IIIICIUII abortions
(recurrent P!e!llllllCV loss)
,, ,
Vaginal bleeding (and its underlying
causes) can be • vary emotionally
1ilxing presentation lor patients.
Ensure approprill18 support il provided.
Gynecologic/Urologic Emergencies Toronto Notes 2011
History
• menstrual history, sexual activity, contraception, history ofPID
• pregnancy details
• determine amount ofblood
• urinary, GI symptoms
Physical Examination
• look for signs of hypovolemia
• pelvic examination - NOT if suspected placenta previa (ultrasound first)
• speculum exam
• if pregnant use sterile speculum
• bimanual examination
• if pregnant use sterile gloves
• if patient is near term with possible rupture of membranes and without other indications
defer bimanual examination {infection risk)
Investigations
• IJ-hCG test fur all patients with child-bearing potential
• CBC, blood and Rh type, quantitative !J-hCG, PTT, INR
• type and cross if significant blood loss
• 1st/2nd trimester/non-pregnant
• ultrasound (U /S) - intrauterine pregnancy, ectopic pregnancy, traumatic injury, foreign body
• must correlate U/S findings with IJ-hCG ifU/S is non-diagnostic (transvaginal ultrasound
will not see gestation in uterus if IJ-hCG < 1200 - must repeat)
• 2nd/3rd trimester pregnancy
• U/S if no fetal heart tones, no documented intrauterine pregnancy or unknown lie of
placenta
• non-stress test to assess fetal well-being during work up of mother
• DIC panel if placental abruption - CBC, PTT, INR, fibrinogen
• postpartum
• U/S for retained products
• P-hCG if concerned about retained tissue
Management
• ABCs
• pulse oximeter and cardiac monitors if unstable
• Rh immune globulin for vaginal bleeding in pregnancy and Rh-negative mother
• 1st/2nd trimester pregnancy
• ectopic pregnancy: definitive treatment with surgery or methotrexate
• intrauterine pregnancy, no concerns of coexistent ectopic: discharge patient with obstetrics
follow-up
• U/S indeterminate or >1000-2000 IU: further work-up and/or gynecology consult
• abortions: if complete, discharge if stable; for all others, acquire gynecology consult
• 2nd/3rd trimester pregnancy
• placenta previa or placental abruption: obstetrics consult for possible admission
• postpartum
• uterine inversion: replace uterus immediately, may require operative management
• postpartum hemorrhage: extraction of placenta if retained, hysterectomy if uncontrolled
bleeding
• retained tissue: D&C
• endometritis: IV antibiotics
• non-pregnant
• dysfunctional uterine bleeding (prolonged or heavy flow ± breakthrough bleeding and
without ovulation, a diagnosis of exclusion)
• <35-40 years of age: Provera• 10 mg POx 10 days, warn patient of a withdrawal bleed,
discharge if stable
• if unstable, admit for IV hormonal therapy, possible D&C
• >35-40 years of age: uterine sampling necessary prior to initiation of hormonal treatment
to rule out endometrial cancer, U/S for any masses felt on exam
• structural abnormalities: fibroids or uterine tumours may require excision fur diagnosis/
treatment. U/S for workup of other pelvic masses, Pap smear/biopsy for cervical lesions
Disposition
• the decision to admit or discharge should be based on the stability of the patient, as well as the
nature ofthe underlying cause; consult gynecology fur admitted patients
• if patient can be safely discharged, ensure follow up with family physician or gynecologist
• instruct patient to return to emergency fur increased bleeding, presyncope
Toronto Notes 2011 Gynecologic/Urologic Emergencies Emergency Medidne ER41

Pregnant Patient in the ER

--------------------------------------
Tabla 18. Complications of Pregnancy
Mltlrllll
First Pregnmcy failure Ectcpic pregnancy
1-14wks • Sponlzroeous abortion Anemia
• Fetal demise Hyperemesis gravidllllm
• Gesliltional trophoblastic disease
Second Disorders of felal growth GIISialional diab818s
• IUGA Ah D:ompatibility
• Oligcllpolyhylhmnios
Third Vasa previa Preterm labourJPPAOM
28-40 wks PreeciBI!1lSia/eclall1lSiB
Placenta previa
Placental abruption
Uterine rupture
DVT

Nephrolithiasis (Renal Colic)

..... I
.
Epidemiology and Risk Factors
• 10% of population (twice as common in males) Kidney Stann
8'"' Ca
• recurrence 50% at 5 yrs 1'"' S1ruvitB
• peak incidence 30-50 years of age 1'"' Uric acid
• 75% of stones <5 mm pass spontaneously within 2 weeks, larger stones may require consultation

Clinical Features
• urinary obstruction -+ upstream distention of ureter or collecting system -+ severe colicky pain
• may complain of pain at flank, groin, testes, or tip of penis
• writhing, never comfortable, nausea, vomiting, hematuria (90% microscopic), diaphoresis,
tachycardia, tachypnea
• occasionally symptoms oftrigonal irritation (frequency, urgency)
• fever, chills, rigors in secondary pyelonephritis

Differential Diagnosis of Renal Colic

• acute ureteric obstruction (other causes)
• UPJ obstruction
• sloughed papillae
• clot colic from gross hematuria
• extrinsic (e.g. tumour)
• acute abdomen - biliary, bowel, pancreas, AAA
• gynecological- ectopic pregnancy, torsion/rupture of ovarian cyst
• pyelonephritis (fever, chills, pyuria, vomiting)
• radiculitis (Ll) -herpes zoster, nerve root compression

Investigations
• screening labs
• CBC -+ elevated WBC in presence of fever suggests infection
• electrolytes, Cr, BUN -+ to assess renal function
• urinalysis: R&M (WBCs, RBCs, crystals), C&S
• imaging
• non-contrast spiral CT is the study of choice
• abdominal ultrasound may demonstrate stone or hydronephrosis
• strain all urine -+ stone analysis

Management
• analgesics, antiemetics, IV fluids
• urology consult may be indicated, especially if stone >5 mm, or if patient has signs of obstruction
or infection ,._________________
..._. I

• a-blocker helpful to increase stone passage in select cases

lndiclllillns for Admission to Hlllpital
• lntnlclabJ. pain
Disposition • Fever (suggests infection I
• most patients can be discharged • Single kidney willllnllral obstruction
• ensure patient is stable, has adequate analgesia, and is able to tolerate oral medications • Bilateral obstructing stones
• lntnlclabJ.
• may advise hydration, calcium supplementation, and limitation of protein, sodium, oxalate and
• Compromi1ed renal function
alcohol intake
ER42 Emergency Medicine
AlWAYS assess visullacuity i1 both
ayes when a patient prasants to the ER
111 ophthalmologic compllint.
..._,,
Alrf rrtiology of red ayes may alao
pment with blun.d vision.
..._,,
Dlbu Opbthlllmalqic Em.,..ncills
(S.1 Ophtbalmo!oPY OP5)
lnfwctiaua-Red ll'fB (Table 19),
andoplrthalmitis, cellulitis
Trau11111 - rutinal detachment, globe
ruptura, orbital blow-out hcturas,
chemical bums
Autoimm-- Giant cal artsritis
,, ,
Contr•lndlcatl- lD Pupil DilatiDn
• Shallow lntlrior chamb.-
• lril-wpported lens implant
• Pomntial niUI"Diogicelllbnonmality
ruquiring pupillary uvlluation
• Caution with CV dis8111- mymatics
can cause tachycordia
Ophthalmologic Emergencies Toronto Notes 2011
Ophthalmologic Emergencies
Ophthalmologic Foreign Body and Corneal Abrasion
• see also Ophthalmology. OP17
History
• patient may complain of pain, tearing, itching, redness, photophobia, foreign body sensation
• elicit history of potential trauma to eye
• mechanism of foreign body insertion- if high velocity injury suspected (welding, metal
grinding, metal striking metal), must obtain orbital x-rays or ultrasound to exclude presence of
intraocular metallic foreign body
• see Table 19 for important considerations of red eye in the emergency department
Table 19. Differential Diagnosis of Red Eye in tile Emergency Deparbnent
Light Sensitivity Iritis, keratitis, abrasion. ulcer
Unilateral Above + herpes simpleK, acute angle closure
Significant pain Above + scleritis
White spot an cornea Corneal ulcer
Blurred vision All Df1he above
Non-reactive pupil Acute glaucoma, iritis
Copious discharge Gonococcal
Physical Examination
• visual acuity in both eyes with best corrected vision
•
•
pupils, extraocular movement, external ocular structures
fundoscopy
• tonometry - measurement of intraocular pressure (with Tonopen)
• normal pressure: 10-20 mmHg, glaucoma associated with increased pressures
• slit lamp exam:
• start with unaffected eye, perform a systematic examination: lids, lashes, lacrimal apparatus,
conjunctiva, sclera, cornea, anterior chamber, iris, lens, vitreous
• proparacaine anaesthetic drops may ease examination
• look for rust ring with metallic foreign body; corneal edema, anterior chamber cells/flare
• may use tluoroscein dye which stains de-epithelialized cornea green when viewing with
cobalt blue filter
Management
• copious irrigation with saline for any foreign body
• remove foreign body under slit lamp exam with cotton swab or sterile needle
• antibiotic drops qid until healed
• patching may not improve healing or comfort - do not patch contact lens wearers
• limit use of topical anesthetic to examination only
• consider tetanus prophylaxis
• ophthalmology consult if globe penetration suspected
Initial Management of other Opthalmologic Emergencies
• ruptured globe - stabilize any foreign body, shield eye with no pressure, elevate head of bed to
30°, tetanus prophylaxis, IV antibiotics, NPO, analgesic, antiemetic, sedation prn
• retinal artery occlusion - globe massage, paper bag breathing, carbogen inhalation (95% oxygen,
5% carbon dioxide)
• chemical burn - immediate copious irrigation, may consider topical anaesthetic drops to
facilitate irrigation
• acute angle-closure glaucoma - IV or PO acetazolamide, topical pilocarpine and timolol
• preseptal cellulitis (2° to superficial trauma) - topical or systemic Ahx
• orbital cellulitis (2° to sinusitis) - admit, IV antibiotics, blood cultures, CT
Disposition
• most patients can be discharged with outpatient ophthalmology follow-up
• admit patients requiring emergent ophthalmologic procedures or IV antibiotics
Toronto Notes 2011 Dermatologic .Emergencies Emergency Medicine ER43

Dermatologic Emergencies
Life Threatening Dermatoses
Rash Characteristics
• DIFFUSE RASH
• stapbylococcalscalded skin syndrome (SSSS)
• caused by an exotoxin from infecting strain of coagulase-positive S. aureus
• mostly occurs in children
• prodrome: fever, irritability, malaise and skin tenderness
• sudden onset of diffuse erythema: skin is red. warm, and very tender
• flaccid bullae that are diffi.cult to see, then desquamate in large sheets
• Nikolsky's sign: gentle lateral stroking of skin causes epidermis to separate
• toxic epidermal necrolyais (TEN)
• see Dermatology, D22
• caused by drugs (e.g. phenytoin, sulfas, penicillins and NSAIDs), bone marrow
transplantation, blood product transfusions
• usually occurs in adults
• diffuse erythema followed by necrosis
• severe mucous membrane blistering
• entire epidermis desquamation
• high mortality (>50%)
• toxic &hock syndrome (TSS)
• see Infectious Diseases, ID27
• caused by superantigen from S. aureus or GAS activating T-cell and cytokines
• patient often presents with onset of shock and multi-organ failure, fever
• diffuse erythematous macular rash
• at least 3 organ systems involved: CNS, respiratory, GI, muscular, mucous membranes,
renal, liver, hematologic, skin (necrotizing fasditis, gangrene)
• VESICOBULWUS LESIONS
• erythema multiforme (EM)
• see Dermatology. D22
• immunologic reaction to herpes simplex
• viral prodrome 1-14 days before rash
• "target lesion»: central gray bulla or wheal surrounded by concentric rings of erythema
and normal skin
• Stevens-Johnson syndrome (SJS)
• see Dermatology, D22
• related to drugs such as antiepileptics and biologic agents, e.g. intliximab
• EM with constitutional symptoms and mucous membrane involvement (milder mucous
membrane involvement than TEN)
• DISCRETE LESIONS
• pyoderma gangrenosum
• often associated with immunocompromised patients (HIY,leukemia or lymphoma) with
Gram-negative sepsis
• often occurs in arms, hands, feet, or perineal region
• usually begins as painless macule/vesicle pustule/bulla on red/blue base sloughing,
leaving a gangrenous ulcer
• diaseminated. gonococcal infection (DGI)
• see Dermatology, D32
• fever, skin lesions (pustules/vesicles on erythematous base -5 mm in diameter), arthritis
Qoint swelling and tenderness), septic arthritis (in larger joints, e.g. knees, ankles and
elbows)
• most commonly in gonococcus positive women during menstruation or pregnancy
• skin lesions usually appear in extremities and resolve quickly (<7 days)
• meningococcemia
• flu-like symptoms of headache, myalgia, nausea and vomiting
• petechial, macular or maculopapular lesions with gray vesicular centres
• usually a few millimeters in size but may become confluent and hemorrhagic
• usually appear in extremities but may appear anywhere
• look for signs ofmeningeal irritation: Brodzinski, Kernig, nuchal rigidity, jolt accentuation

History and Physical Examination

• determine onset, course, location of skin lesions
• fever, joint pain
• associated symptoms: CNS, resp, GU, GI, renal, liver, mucous membranes
• medication history
• vitals
ER44 Emergency Medicine Dermatologic Emergencies/Environmental Injuries Toronto Notes 2011

..,., ,
•t----------------.
Thorough d111118tol0ilic uaminations 1111
raquirad; axaminatian of IIIYITiplomlltic
skin mav identify ma111lasionsl Ensure
adequal8 drapiniJ duriniJ dermataiOIJic
axaminlltions.
Investigations
• immediate consultation if patient unstable
• CBC, electrolytes, creatinine, AST, ALT, ALP, blood culture, skin biopsy, serum immunoglobulin
levels (serum IgE)
Management
• general: judidous IV fluids and electrolyte control, consider vasopressors if hypotensive,
prevention of infection
• determine if admission and consult needed: dermatology or infectious diseases
• specific management is determined by etiology
• SSSS, TSS, DGI and meningococcemia
• IV antibiotics
• EM, SJS, and TEN
• stop predpitating medication
• fluids
• symptomatic treatment: antihistamines, antacids, topical corticosteroids, systemic
corticosteroids (controversial), prophylactic oral acyclovir, consider IVIG
• TEN: debride necrotic tissue

Disposition
• most cases will require urgent care and hospitalization
• TEN: early transfer to bum centre improves outcome

Environmental Injuries
Heat Exhaustion and Heat Stroke
• predisposing factors: young persons who overexert themselves, older adults who cannot
dissipate heat at rest (e.g. using anticholinergic drugs such as antihistamines or TCAs), and
patients with schizophrenia who are using anticholinergic or neuroleptic medications

..,., ,
.
.----------------.
Heat exhaustion IHEI mav claselv
heat stroka. HE mav IMII1tulllly
PIOIJress to heat stroke. Therefore
diagnosis is uncerl:lin trlllt as halt
strub.
Heat Exhaustion (HE)
• clinical features relate to loss of circulating volume caused by exposure to heat stress
• "water depletion": HE occurs if lost fluid not adequately replaced
• "salt depletion·: HE occurs when losses replaced with hypotonic fluid
Heat Stroke
• life-threatening emergency resulting from failure of normal compensatory heat-shedding
mechanisms
• divided into classical and exertional subtypes (see Table 20)
• if patient does not respond relatively quickly to cooling treatments, consider other possible
etiologies ofhyperpyrexia (e.g. meningitis, thyroid storm, anticholinergic poisoning. delirium
tremens, other infections)

Teble 20. Halt Exheustion vs. Halt Stroke

Clnicll • Non-specific malaise, headache, fatigue • Occurs in salting Ill hi!#!
Features • Body temp <40.50C (usually IIOITTI81) ambiant l8111!1118tui"BII (e.g.
• No coma or seilii"8S heat wave. poor ventilation)
• Dehythtion {1' HR, orthostatic • Often patients n okjer, pear,
hypotension) and sedentary or immobile
• Dry, hot liki1
• Temp uSUBIIy >4c.s•c
• Altered mental status, seizures,
deliiurn, coma
• May have elevated AST, ALT
Eullio1111 Hilt Stroa
• Occurs with high endogenous
heat production (e.g. exercise)
illd owrwhelmed homeostatic
meclllllisms
• Patients ellen younger, more aclive
• Skin often diaphoretic
• Olh111 fecrtum a& far clas&ical HS,
but mav also have DIC, BCUte ranll
failure, rhabdomyolysis, marked
lactic acidosis

Tlllllmllll: • Rast in acool anvironment
• Normal salile IV if orthostatic
hypotension; otherwise replace
losses slowly PO
• Cool dawn body temperature with water mist (e.g. spray bottle) and
standing fans
• Ice Wllll!r irnnersion also effective; monilar body temp closely to avoid
hypothermic oversholll
• airway because of risk of seizures and aspiration
• Gin ftuid IBIIU&eililtion if &till hypotensin after above 1herapy
• Avoid a-egonists (e.g. epinephrile) peripheral VBSOConstriction and
antipyretics (e.g. ASA)
Toronto Notes 2011 Environmental Injuries Emergency Medicine ER45

Hypothermia and Cold Injuries

• predisposing factors: extremes of age, lack ofhousing, drug overdose, EtOH ingestion, trauma
(incapacitating), cold water immersion, outdoor sports
• treatment based on: (a) re-warming and (b) supporting cardiorespiratory function
• complications: coagulopathy, acidosis, ventricular arrhytluni.as (VFib), asystole, volume and
electrolyte depletion
• labs: CBC, electrolytes, ABG, serum glucose, creatinine/BUN, Mg, Ca. amylase, coagulation
profile
• imaging: CXR (aspiration pneumonia, pulmonary edema are common)
• monitors: ECG, rectal thermistor, Foley catheter, NG tube, monitor metabolic status frequently

Tabla Zl. Classification of Hypothermia

Mild 32-34.9"C Tachypnea, tachycardia, ataxia, dysar111ia, shivering

Moderate 28-31.9°C Loss of slivering. arrytimias, Osborne (J) waves on ECG, decreesed LOC, combative behBViour,
musde rigidity, dilated !XJpils
s_. <Z8°C Coma, hypot1111ion. acidemia. ventricular fibrillation, asystole, flaccidity, a111aa

Re-warming Options
• gentle fluid and electrolyte replacement in all (due to cold diuresis)
• Passive External Re-warming (PER)
• suitable for most stable patients with core temperature >32.2°C
• involves covering patient with insulating blanket; body generates heat and re-warms through
metabolic process, shivering
• Active External Re-warming (AER)
• involves use of warming blankets
• beware "afterdrop" phenomenon (warming of extremities causes vasodilation and movement
of cool pooled blood from extremities to core, resulting in a drop in core temperature -+
cardiac arrest)
• safer when done in conjunction with active core re-warming
• Active Core Re-warming (ACR)
• generally for patients with core temperature <32.20C, and/or with cardiovascular instability
• avoids "afterdrop" seen with AER alone
• re-warm core by using
• warmed humidified oxygen, IV fluids
• peritoneal dialysis with warm fluids
• gastric/colonic/pleural irrigation with warm fluids
• external circulation (cardiopulmonary bypass machine) is most effective, fastest

Cardiac Arrest in the Hypothermic Patient

• do all procedures gently or may precipitate VFib
• check pulse and rhythm for at least 1 minute; may have profound
• if any pulse at all (even very slow) do NOT do CPR
• if in VFib try to defibrillate up to max 3 shocks if core temperature <300C
• intubate gently if required, ventilate with warmed, humidified 0 2
• medications (vasopressors, antiarrhythmic&) may not be effective at low temperatures
• controversial; may try one dose
• focus oftreatment is re-warming

FROSTBITE

Classification
• ice crystals form between cells
• classified according to depth - similar to burns (1st to 3rd degree)
• 1st degree
• symptoms: initial paresthesia. pruritus
• signs: erythema. edema. hyperemia. no blisters
• lnddegree
• symptoms: numbness
• signs: blistering (clear), erythema, edema
• 3rddegree
• symptoms: pain, burning, throbbing (on thawing); may be painless if severe
• signs: hemorrhagic blisters, skin necrosis, edema. no movement

Management
• treat for hypothermia: fluids, maintenance of body warmth
• remove wet and constrictive clothing
ER46 Emergency Meclidne Emironmeatal.lnjuries 1'oroDio 2011

,, , • immerse in 40·42"C agitated water for 10·30 mlmrtes (very painful; administer adequate analgesia)
• dean injured area, leave injured region open to air
a..n ....: • consider aspiration/debridement of blisters (controversial)
lhllllllll (flamll, 8elld) • debride skin gently
a.ma1 • tetanus prophylaxis
Rldillion (UV. mlldiciUitunparticJ • consider penicillin G as frost bite injury Bl: high risk of infection
Bactrical

,,•., • surgical intervention may be required to release restrictive eschars

• never allow a thawed area to re-dilll/freeze

High llilll Fubln1 far lliwctilln

• Puncbn wol.ftds
Burns
• Crush ll)riM
• 1Naunda .,..ta" th., 12 l'llu111 Did • see PL15
• HIIWl orfootwwwls, WMds rajDi11s

•Pili••
• lmmunocampromised patient
.....,than 50 years
• Prasthalic jairts Dl' - - bilk "'
Physical Examination
• bum size
andoclnlitis) • rule of nines (see Figure 15); does not include 1• degree burns
• bumdepth
..._,, • superfu:ial: epidermis ocly (e.g. sunburn)
.. • partial thickness: into superficial dermis deep or hair follicles, sweBI: glands
• full thiclcness: all layers ofthe skin
U• palm of the patient'a hand Ill
wti111111111" of BSA lllflletlld. • deep: to fat, muscle, even bone

Management
• remove noxious agent/stop burning process
• establish airway ifneeded (indicated with bums >4096 BSA or smoke inhalation injury)
• resuscitation for 2nd and 3rd degree bums (after initiation of2large bore IVs)
• Parkland Formula: Ringer's lactate 4 cc/kgi%BSA burned; give half in first 8 hours, halfin
next 16 hours; mamtenance fluids are also required ifpatient cannot tolerate PO hydration
• urine output ls best measure of resusdtation, should be 40-50 cc/br or 0.5 cc/kgfbr; avoid
diuretic&
• pain relief- continuous morphine infusion with breakthrough bolus
• investigations: CBC, electrolytes, urinalysis. CXR. ECG, ABG, carboxyhemoglobin
• bum wowul care- prevent infection, dean/debride with mild soap and water. sterile dressings
• escharotomy or fasdotomy for circumfi:rential burna (chest, extremities)
• topical antlbiotle&, systemic antibiotics Infrequently indicated
• tetanus prophyluls ifbum is deeper than superfidal dermis

Disposition
• admit
• 2nd degree burns to >1096 BSA; any slgnificant 3rd degree burns
• 2nc1 degree on face, hands, feet, perineum or across major joints
• electrical. chemical burns and inhalation injury
• burn victims with underlying medical problems or immunosuppressed patients

Inhalation Injury
Etiology
• carbon monoxide (CO) poisoning
• direct thermal inJury - limited to upper airway
• smoke causes bronchospasm and edema from particulate matter and toxic inhalants (tissue
asphyxiates, pulmonary irritants, systemic tmins)

History and Physical

• risk factors: closed space fires, period of WlCODScioumess, nonoua chemicals involved
• cherry red skin (unreliable, usually post-mortem finding)
• singed nasal haira, soot on oral/nasal membranes, sooty sputum
• hoarseness, stridor, dyspnea
• dec.reased we, confusion
• P02 normal but sat low suggests CO poisoning

Investigations
R•l• all's far Tobll • measure carboxyhemoglobin levels
lady S•rfaGa Ani liSA) • ABG
..._,, • CXR ±bronchoscopy

Management
lniiJbllb a.ly if you 1111pld inhallllian • CO poisoning: 10096 0 2 ± hyperbaric Oa (controversial)
q..y, as aiwly Din bacama Dllslructad • direct thermal inJury: humidifted oxygen, early intubation, pulmonary toilet, bronchodllators
dletDidllme.
Toronto Notes 2011 Environmental Injuries Emergency Medicine ER47

Bites
Mammalian Bites
• see Plastic PL6
·history
• time and circumstances of bite, symptoms, allergies, tetanus immunization status, comorbid
conditions, rabies risks, HIV/hepatitis risk (human bite)
• high morbidity associated with clenched fist injuries (CFI), "fight bites"
• physical enmination
• assess type of wound: abrasion, laceration, puncture, crush injury
• assess for direct tissue damage: skin, bone, tendon, neurovascular status
• investigations
.... ,,
• ifbony injury or infection suspected check for fracture and gas in tissue with x-rays
• get skull films in children with scalp bite wounds, ± CT to rule out cranial perforation High lllsk Criteria for lnfecti•
• initial management WDUmlhc:bml
• wound cleansing and copious irrigation as soon as possible • Puncture wounds
• Cru511 injuries
• irrigate/debride puncture wounds if feasible, but not if sealed or very small openings; avoid • Wounds >12m old
hydrodissection along tissue planes • Hand or foot wounds
• debridement is important in crush injuries to reduce infection and optimize cosmetic and • Wounds near joints
functional repair htient hc:bml
• culture wound if signs of infection (erythema, necrosis or pus); obtain anaerobic cultures if • lmmunacarnpramised
wound foul smelling, necrotizing, or abscess; notify lab that sample is from bite wound • Age >50 Vear1
• prophylacti.c antibiotiC8 • Prosthllic joints or wives
• types of infections resulting from bites: cellulitis, lymphangitis, abscesses, tenosynovitis,
osteomyelitis, septic arthritis, sepsis, endocarditis, meningitis
• a 3-5 day course of antibiotics is recommended for all bite wounds to the hand and should be .... ,,}-----------------,
,
considered in other bites if any high-risk factors present (efficacy not proven)
• dog and cat bites (pathogens: Pasteurella multocida, S. aureus, S. viridans) ConUd• AdmiaiDn if:
• 80% of cat bites, 5% of dog bites become infected • Maclnta to severe inflctians
• 1st line: amoxicillin + clavulinic acid • Infections in inmunocampramised
• human bites (pathogens: Eikenella corrodens, S. aureus, S. viridans, oral anaerobes) paliants
• Nat responding to oral Rx
• 1st line: amoxicillin + clavulinic acid • Penetnlting injuries to tendons, joints,
• rabies (see Infectious Diseases, IDS) CNS
• reservoirs: warm-blooded animals except rodents, lagomorphs (e.g. rabbits) • 0plll1 fm:lures
• post-exposure vaccine is effective; treatment depends on local prevalence
• suturing
• vascular structures (i.e. face and scalp) are less likely to become infected, therefore
consider suturing
• allow avascular structures (i.e. pretibial regions, hands and feet) to heal by secondary
intention
• tetanus immunization if> 10 yrs or incomplete primary series

Snake Bites
• history, physical exam, investigations and initial management similar to mammalian bites
• additional management issues
• snake bites are rarely fatal but proper precautions must be taken
• supportive management, observe for compartment syndrome, analgesia, tetanus prophylaxis
• contact regional Poison Control Centre for consultation
• constriction band should be placed proximal to bite
• observe for signs and symptoms of envenomation 15min-2hrs after bite (pain, sweating,
edema, chills, weakness, numbness, tingling, HR changes, faintness, ecchymosis, NN); if no
envenomation then remove band and monitor closely for 24 hrs
• if envenomation present, administer antivenom

Insect Bites
• BeeStiop
• 5 types of reactions to stings (local, large local, systemic, toxic, unusual)
• history and physical exam key to diagnosis; no lab test will confirm
• investigations: CBC, electrolytes, BUN, creatinine, glucose, ABGs, ECG
• ABC management, epinephrine 0.1 mg IV over 5 minutes if shock. antihistamines,
cimetidine 300mg IV/IM/PO, steroids, for SOB/wheezing 3 mg in 5 mL NS via
nebulizer, local site management
• West NUe VlrWI (see Infectious Diseases, ID28)
• severity: asymptomatic 80%, flu-like symptoms 20%, encephalitis <1%
• clues: aseptic meningitis/encephalitis in late summer in prevalent area
• incubation 3-14 days, symptoms last 3-6 days
• general symptoms: fever, malaise, anorexia, headache, altered mental status, motor weakness,
ataxia, extrapyramidal signs, GI signs, myalgias, lymphadenopathy, rash, myocarditis, optic
neuritis
• investigations: CBC, electrolytes, CSF, Cf/MRI
• diagnosis: CSF and serum for serology
• management: ABCs, IV fluids for dehydration, antibiotics if meningitis (based on CSF
analysis), analgesia, antipyretics, interferon-a 2b, ribavirin
ER48 Emergency Medicine Environmentallnjurlesi'I'micology Toronto Notes 2011

Near Drowning
• most common in children <4 yrs and teenagers
• causes lung damage, hypoxemia and may lead to hypoxic encephalopathy
• must also assess for shock, C-spine injuries, hypothermia, scuba-related injuries
(barotrauma, air emboli, lung re-expansion injury)
• complications: volume shifts, electrolyte abnormalities, hemolysis, rhabdomyolysis, A1N, DIC

Physical Examination
• ABCs, vitals: watch closely for hypotension
• lungs: rales (ARDS, pulmonary edema), decreased breath sounds (pneumothorax)
• CVS: murmurs, arrhythmias, JVP (CHF, pneumothorax)
• H&N: assess for C-spine injuries
• neuro: GCS or AVPU, pupils, focal deficits

Investigations
• labs: CBC, electrolytes, ABGs, Cr, BUN, urinalysis
• imaging: CXR (pulmonary edema, pneumothorax)
• ECG

Management
• ABCs, treat for trauma. shock, hypothermia
• cardiac and 0 2 sat monitors, IV access
• intensive respiratory care
• ventilator assistance if decreased respirations, pC02 >50 mmHg, or p02 <60 mmHg on max 0 2
• may require intubation for airway protection, ventilation, pulmonary toilet
• high flow 0 2/CPAP/BiPAP may be adequate but some may need mechanical ventilation with
PEEP
• arrhythmias: usually respond to corrections of hypoxemia, hypothermia, acidosis
• vomiting: very common, NG suction to avoid aspiration
• convulsions: usually respond to 0 2; if not, diazepam 5-10 mg IV slowly
• bronchospasm: bronchodilators
• bacterial pneumonia: not necessary to prophylax with antibiotics unless contaminated water or
hot-tub (Pseudomonas)
• must observe for at least 24 hours as non-cardiogenic pulmonary edema may develop late

Disposition
• non-significant submersion - discharge after short observation
• significant submersion (even if asymptomatic) -long period of observation (24 hrs) as
pulmonary edema may appear late
• CNS symptoms or hypoxemia - admit
• severe hypoxemia, decreased LOC - ICU

Toxicology
Alcohol Related Emergencies
• see Psychiatcy. PS20

Acute Intoxication
• slurred speech, CNS depression, disinhibition, lack of coordination
• nystagmus, diplopia, dysarthria, ataxia -+ may progress to coma

..... ',.}-----------------, • frank hypotension (peripheral vasodilation)

• if obtunded rule out
• head trauma/intracranial hemorrhage
Alc:ohol intwtication 11111y inVIIIidatll • associated depressant/street drugs, toxic alcohols
inlonned consent • may also contribute to respiratory/cardiac depression
• hypoglycemia (screen with bedside glucometer)
• hepatic encephalopathy: confusion, altered LOC, coma
• precipitating factors: GI bleed, infection, sedation, electrolyte abnormalities, protein meal
• Wernicke's encephalopathy (ataxia, ophthalmoplegia, delirium)
• post-ictal state, basilar stroke
Toronto Notes 2011 Toxicology Emergency Medicine ER49

Withdrawal
• beware withdrawal signs (see Table 22)
• treatment
• diazepam 10-20 mg IV or PO OR lorazepam 2-4 mg IV or PO q 1hr until calm
• may use CIWA protocol and give benzodiazepines as above until CIWA <10
• thiamine 100 mg 1M then 50-100 mglday
• magnesium sulfate 4 g IV over 1-2 h (ifhypomagnesemic)
• admit patients with delirium tremens (DT), arrhythmias, or multiple seizures

Table 22. Alcohol Wlllldrawal Signs

.... ,,
Time Since Last Drink Syndrome Description
CIWA Wdhdr-llymptams
&-1 hr Mild withchwal Generalized 1nmar, anxiety, agillltian, but no delirium N1U181 and vomiting
Aut!lnornic hyperactivity (silus tachycardial. insomnia, nausea. vomiting Tremor
Pnxysmal SW181s
1-2 dByl Alcoholic hallucinations Visual (most common), audi!Dry 111d tactile hallucinations Anxiety
Vrtals often normal Agitation
I hr-2 dByl WrthdlliWIII seizures Typically brief generalized tonic-clonic seizures Visual distubances
Tactile disbriJances
May have several within afew hours Auditory disturbances
J.5 dByl Delirium ln!mens (Dl) 5% af urrtn!ated withdrawal patients Headache
Severely confused state, fluctuating levels af consciousness Disarienlatian
Agitation, insomnia, hallucination&idelusions. 1nmar 10 rymptomallllch scored out of 7
Tachycardia, hyperpyraxia. diaphoresis except orientation is out of 4.
High morlillity rate

Seizures
• associated with ingestion and withdrawal
• withdrawal seizures
• occur 8-48 hrs after last drink (typically brief generalized tonic-clonic seizures)
• if >48 hrs, think of DT (see Table 22)
• prophylaxis: diazepam 20 mg PO q lh x 3 minimum, regardless of CIWA score
• CT head if focal seizures have occurred

Cardiovascular Complications
• lfi'N
• cardiomyopathy: SOB, edema
• arrhythmias ("holiday heart'")
• atrial fibrillation (most common), atrial flutter, SVT, VT (especially Torsades if
hypomagnesemic/hypokalemic)

Metabolic Abnonnalities
• alcoholic ketoacidosis
• history of chronic alcohol intake with abrupt decrease/cessation
• malnourished, abdominal pain with nausea and vomiting
• anion gap (AG) metabolic acidosis, urine ketones, low glucose and normal osmolality
.... ,,._, ________________
• treatment: dextrose, thiamine (50-100 mg prior to dextrose), volume repletion (with NS) eo..man Ddciencilla
• generally resolves in 12-24 hr • Thiamine
• other alcohols • Niacin
• ethylene glycol -+ CNS, CVS, renal findings • Falalll
• Glycopn
• methanol
• early: lethargy, confusion • Potassium
•late: headache. visual changes, N/V, abdominal pain, tachypnea
• both produce severe metabolic acidosis with AG and osmolar gap
• EtOH co-ingestion is protective
• treatment
• fomepizole 15 mg/kg IV bolus OR EtOH 10% IV bolus and drip to achieve blood level of
20mmoi/L
- EtOH loading may be done PO
• consider folic acid for methanol and pyridoxime for ethylene glycol- both help reduce
conversion to active metabolites
• urgent hemodialysis required
• other abnormalities associated with alcohol: hypomagnesemia, hypophosphatemia,
hypocalcemia, hypoglycemia, hypokalemia

Gastrointestinal Abnonnalities
• gastritis
• common cause of abdominal pain and GI bleed in chronic alcohol users
• pancreatitis
• serum amylase very unreliable in patients with chronic pancreatitis, may need serum lipase
• hemorrhagic form (15%) associated with increased mortality
• fluid resuscitation very important
• hepatitis
• AST/ALT ratio >2 suggests alcohol as the cause as well as elevated GGT with acute ingestion
ER50 Emergency Medicine Toxicology Toronto Notes 2011

• peritonitis/spontaneous bacterial peritonitis

• occasionally accompanies cirrhosis
• leukocytosis, fever, generalized abdominal pain/tenderness
• paracentesis for diagnosis (common pathogens: E. coli, KlebsieUa, Strep)
• GI bleeds
• most commonly gastritis or ulcers, even if patient known to have varices
• consider Mallory-Weiss tear secondary to retching
• often complicated by underlying coagulopathies
• minor - treat with antacids
• severe or recurrent - endoscopy

Miscellaneous Problems
• rhabdomyolysis
• presents as acute weakness associated with muscle tenderness
• usually occurs after prolonged immobilization
• increased creatinine kinase (CK), hyperkalemia
• myoglobinuria - may lead to acute renal failure
• treatment: IV fluids, forced diuresis (mannitol20% 15 mglkg IV over 30 min)
• increased infections - due to impaired host defenses, immunocompromise, poor living
conditions

Disposition
• before patient leaves ED ensure
• stable vital signs
• can walk unassisted
• fully oriented
• offer social services to find shelter or detox program
• ensure patient can obtain any medications prescribed and can complete any necessary follow-up

Approach to the Overdose Patient -----------------

History
,, , • who? age, weight, underlying medical problems, medications
• what? substance and how much
• when? time since exposure determines prognosis and need for decontamination, symptoms
Suspect OVIIniDH when:
• Altered level of consciousnessfcoma
since
• Young patient with ln-1hrntaning • how? route
arrhythmia • why? intention, suicidality
• Trauma patient
• Bizarre or pUlZiing clinical
prasantlllion
Physical Examination
• focus on: ABCs, LOC/GCS, vitals, pupils

Principles of Toxicology
• 4 principles to consider with all ingestions
I. resuscitation (ABCs)
II. screening (toxidrome? clinical clues?)
III. decrease absorption of drug
IV. increase elimination of drug

ABCs of Toxicology
• basic axiom of care is symptomatic and supportive treatment
• address underlying problem only once patient is stable
A Airway (consider stabilizing the C-spine)
B Breathing
C Circulation
Dl Drugs
• ACLS as necessary to resuscitate the patient
• universal antidotes
D2 Draw bloods
D3 Decontamination (decrease absorption)
E Expose Oook for specific toxidromes)/Examine the Patient
F Full vitals, ECG monitor, Foley, x-rays, etc.
G Give specific antidotes, treatments
Go back and reassess
Call poison information centre
Obtain corroborative history from family. bystanders
Toronto Notes 2011 Toxicology Emergency Medicine ER51

01 - Universal Antidotes
• treatments that will not harm patients and may be essential

Oxygen
• do not deprive a hypoxic patient of oxygen no matter what the antecedent medical history
(ie. even COPD with COz retention)
• if depression of hypoxic drive, intubate and ventilate
• exception: paraquat or diquat (herbicides) inhalation or ingestion (oxygen radicals increase
morbidity)

Glucose
• we
give to any patient presenting with altered
• measure blood glucose prior to glucose administration if possible
• adults: 0.5-1.0 glkg (1-2 mL/kg) IV ofD50W
• children: 0.25 glkg (2-4 mUkg) IV of D25W
..... ,,
Thiamine {Vitamin 81)
• 100 mg IVliM to all patients with IV/PO glucose Po!MHtio111 at Iiiii fllr Thilllline
• a necessary cofactor for glucose metabolism, but do not delay glucose if thiamine unavailable D.W.ncy
• Alcoholics
• to prevent Wernicke-Korsakotf syndrome • AnoriiXicl
• must assume all undifferentiated comatose patients are at risk • H'1J)81'81118Sis of pregnancy
• Malnutrition lllatn
Naloxone (central Jl·receptor competitive antagonist, shorter t 112 than naltrexone)
• antidote fur opioids: administration is both diagnostic and therapeutic (1 min onset of action)
• used fur the undifferentiated comatose patient
• loading dose
• adults
• 2 mg initial bolus IV/IM/SUSC or via ETT (ETT dose= 2-2.5x IV dose) I

• if no response after 2-3 minutes, increase dose by 2 mg increments until a response or to Admilistnllion of naloxone can cause
max10mg opillle wilhdniWIII in chronic usm.
Minor withd111Wl11 may present as
• known chronic user, suspicious history, or evidence of track marks, give 0.01 mglkg
lacrimation, lhinonilH, dilphomil,
•child yawning, piloerection, ffrn, and
• 0.01 mglkg initial bolus IV/IO/ETT lllchyl;llrdill. SevenJ withcnwal may
• 0.1 mg/kg if no response and narcotic still suspected to max of 10 mg pmant as hat and cold fllllhn,
arthnllgial, myalgiu, N/V, and
• maintenance dose
abdominal CRIIIPI.
• may be required because half-life of naloxone (30-80 mins) is much shorter than many
narcotics
• hourly infusion rate at 2/3 of initial dose that produced patient arousal

02 - Draw Bloods
• essential tests (see Table 24)
• CBC, electrolytes, BUN/creatinine, glucose, INRJPTT, osmolality
• ABGs, measure 0 2 sat
• acetylsalicylic acid (ASA), acetaminophen, EtOH levels
• potentially useful tests
• drug levels - this is NOT a serum drug screen
• Ca,Mg,P04
• protein, albumin, lactate, ketones, liver enzymes, CK - depending on drug and clinical
presentation

Serum Drug Levels

• treat the patient, not the drug level
• negative tox screen does not rule out a toxic ingestion - signifies only that the specific drugs
tested were not detectable in the specimen
• specific drugs available on general screen vary by institution; check before ordering
• urine screens also available (qualitative only)
ER52 Emergency Medicine Toxicology Toronto Notes 2011

Table 23. Toxic Gaps (see also Neohrologv)

.... '.. , METABOUC ACIDOSIS

lncrtllllld AG: "MUDPILES CAT'(* toxic)
Melhlllol*
Increased POG: "MAE DIE" (if it ends in ·.or, it will likely
1' the POGI
P1111111 Clsmollr Bap(POG) Uremia Methi11ol
- (2 Na + glucose + urea)- pl8SIIIl Diabetic kl!toacidosis/Starvalion kl!toacidosis Acetone
o.molllrity Phanftrmin*/Pareldahyda* Ethanol
Normal POG < 10 m0sm/11ci Isoniazid. Iron, Ibuprofen Diuretics (glycerol, mamitol, sorbitol)
Lacliltll (anything that caU&85 seizurv& or shock) Isopropanol

'..,
.... .-----------------,
Ethylene glycol*
Salicylat&s*
Cyanide, carbon monoxide*
Ethylene glycol
Nota: nonnal osmolll' gap does not rule out toxic
only an elevated gap is helpful
Ani1111 Gap (AG) Alcoholic Ketoacidosis
Na- Cl - bicarb Toluene, theophyllile*
Normal AG S12 mEqll
DecreuedAG lncreaad Oz saullion gap
Elaclrolyla ii'Ttalanca (increasad N..x/Mg) Carboxyhemoglobin
H-,poalbuminernia (50% fall in albumin -5.5 mmoll
d8Cillasa in the AG)
U. Br elevation
Pareproteins myeloma)
NormaiAG
High K: pyelonephritis, obstructive nephropathy, renal tubular
acidosis (RTA), IV, TPN
Low K: small bowel losses, acetazolamide, RTA I, II

Table 24. Use of the Clinical Laboratory in the Initial Diagnosis of Paisoning
Test Finding Selected C111111
ABG Hypovenlilation ('I' pCOzl CNS depressanls (opioids, sedaliv&-hypnotic agenls, phencrthiazines, EtOH)
Hypervanlilation (II; pCCJ21 Salicylat&S, CO. other asphyxianiS
Bacttolytes 1' metabolic acidosis "MUDPILES CAT': see "Melabolic Acidosis" above
Hyperkalemia Digilllli& glycosides, fluoride, pDtassium
Hypokalemia Theophylline, caffeine, beta-edrenergic agents, soluble barium salts,
diuretics, insulin
GIIICOie Oral hypoglycemia agenls, insulin, EtOH, ASA
Osmolality and Bevatad osmolll' gap "MAE DIE": sea "Toxic Gaps" above
O•muGIP
ECG Wide ORS con-Pax TCAs, quinidine, crthar clil$5 Ia il'ld lc il'ltiarrhythmic agents
Pllllonged QT interval and related antiarrlrythmics, terfenadine, astemizale,
antipsychotics
Abiovenbicular black Ca anlagonists, digitalis glycosides, phenylpropanolamile
Abd0111i111l X-«ay Radiopaque pills or objects "CHII•ES": Calcium, Chloral hytele, CCI. Heavy metals, nn, Potassium,
Enleric COBII!d Salicylates, and some fnn!ign bodies
Serum Bevated level (> 140 mWL or May be only sign of acebmilophen poisonilg
.Acllllminaph1111 1DOD !lii1Dil4 hours afler ingestion)

D3 - Decontamination and Enhanced Elimination

Ocular Decontamination
• saline irrigation to neutralize pH; alkali exposure requires ophthalmology consult
Dermal Decontamination (wear protective gear)
• remove clothing, brush off toxic agents, irrigate all c::xternal surfaces
,,..-----------------,
, Gastrointestinal Decontamination
• single dose activated charcoal (SDAC) (see Table 27 for drug toxidromes that are treated with
charcoal)
Sullltl- NOT AdlorbMI by
Actlvatad CIIIICOII
• adsorption of drug/toxin to AC prevents availability
• Lilllium • contraindications: caustics, SBO, perforation
• Iran • dose: lOglgdrugingested or lglkg body weight
• Alcohols • odourless, tasteless, prepared as slurry with H 2 0
• Lelld • whole bowel irrigation
• Caustics • 500 mL (child) to 2000 mL (adult) of polyethylene glycol solution/hour by mouth until clear
effluent per rectum
• start slow (500 mL in an adult) and aim to increase rate hourly as tolerated
• indications
• awake, alert, can be nursed upright
• delayed release product
• drug/toxin not bound to charcoal
• drug packages (if any evidence of breakage -+ emergency surgery)
• recent toxin ingestion
Toronto Notes 2011 Toxicology Emergency Medicine ER53

• contraindication&
• evidence of ileus, perforation, or obstruction
• surgical removal in extreme cases
• indicated for drugs that are toxic, form concretions, or cannot be removed by conventional
means
• no evidence for the use of cathartics (or ipecac)

EXTRA-CORPOREAL DRUG REMOVAL (ECDRJ

Urine Alkalinization
• may be used for: ASA, methotrexate, phenobarbital, chlorpropamide
• weakly acidic substances can be trapped in alkali urine (pH >7.5) to increase elimination
Multidose Activated Charcoal (MDAC)
• may be used for: carbamazepine, phenobarbital, quinine, theophylline
• for toxins which undergo enterohepatic recirculation
• removes drug that has already been absorbed by drawing it back into GI tract
• various regimens: 12.5 g (1/4 bottle) PO q1h or 25 g (1/2 bottle) PO q2h until non-toxic
Hemodialysis
• indications/criteria for hemodialysis
• toxins that have high water solubility, low protein binding, low molecular weight, adequate
concentration gradient, small volume of distribution (Vd) or rapid plasma equilibration
• removal oftoxin will cause clinical improvement
• advantage is shown over other modes of therapy
• predicted that drug or metabolite will have toxic effects
• impairment of normal routes of elimination (cardiac, renal, or hepatic)
• clinical deterioration despite maximal medical support
• useful for the following blood toxins:
• methanol
• ethylene glycol
• salicylates
•lithium
• phenobarbital: 430-650 mmoUL
• chloral hydrate (-+ trichloroethanol): >200 rnglkg
• others include theophylline, carbamazepine, valproate, methotrexate

E - Examine the Patient

• vital signs (including temperature), skin (needle tracks, colour), mucous membranes, pupils,
odours and CNS
• head-to-toe survey including
• C-spine
• signs oftrauma. seizures (incontinence, "tongue bitint(. etc.), infection (meningismus),
chronic alcohol/drug abuse (track marks, nasal septum erosion)
• mental status
Tabla 25. Specific TOllidromes
Tllllidrama Ovanla• Sip IIIII SVnJpiDIII Examples ul Drup
Antichalinergics Hyperthermia "Hot as a hare" Antidepressants (e.g. TCAs)
Dlated pupils "Blind as a bat" Cyclobenzalfine (FiexeriPI
Dry skin "llry asa bona· Cll'oamazepina
Vasodlation "Red as abeat" Antihistaminas {a.g. diphenhydramine)
Agitationlhalucinations "Mad as a hatter" Antiparkinsonians
Ileus lhe bowel and bladder lose Antipsychotics
Urinary ratantion thllir tone and 111& ha.t Antispasmolics
Taclryardia goss on alone" Beladonna alkllloids (e.g. atropinal
Chalnqics "OUMBELS" Natural plants: rooshrooms. tru111l81 Hower
OiaphDI8Sis, Oianhaa. Decreased blood prvssure Anticholinasteresas: physostigmina,
Urination Insecticides {organophosphates, carballlllles)
Miosis Nerve gases
Bronchospasm, Bronchonhea, Bradyt:ll'dia
Emesis, Excitation of skeletal muscle
Lacrimation
Salivlltion, Seizures
Extrapyr1111idll Dysphonia, dysphagia Major tllllquilizers
Rigidity and tremor Antipsychotics
Motor restlessness, crawling sensation (llkathisial
Constant mavamants (dyskinesia)
Dysmnia (muscle spasms,llryrcjospasm. trismus,
oculogyric crisis, torticallisl
ER54 Emergency Medicine Toxicology Toronto Notes 2011

Table 25. Specific Toxidromes (continued)

TIIJiid1011111 Owenlllse Signs and Symptoms
Hemaalabin Increased respiratory nrte Carbon monoxide poisoning
Dnnaements Decreased level of consciousness Drug ingestion (methemoglobin,
Sei211111S sulfmethemoglobin)
Cyanosis unresponsive to
Lactic acidosis
Hypothermia EtDH
Hypotension Benmdiazepiles
Respiratory depression Opiates (morphine, heroin, etc.)
Dilated or constricted pupils (pinpoint in opiate OD) Barbiturates
CNS depnMion GHB
lncr&ISed Amphetamines, caffeine, cocaile, LSD, PCP
CNS &KCitation (including seizures) Ephedrine and other decongestlrltl
Tachyclldia, hypertension Thyroid hormone
Nausea and vomiting Sedatives, EIOH withdrawal
Diaphoresis
Dilated pupils
Serotonin Syndl'llllle Mental stlltus changes, autonomic hyperactivity, MAOI, TCA. SSRI, opiate analgesics
neuromuscular abnormalities. hyperthermia. Cough medicine, weijrt reduction medications
diarrhea, HTN
Nlllt: JSA lnl hypoglycamia mimic syn'llllhamil1111ic: lllxidroma

G- Give Specific Antidotes and Treatments

---
Urine Alkalinization Treatment for ASA Overdose
• urine pH >7.5
• fluid resuscitate first, then 3 amps NaHC03/litre ofD5W@ 1.5 x maintenance
• add 20-40 mEq KCIJlitre if patient is able to urinate

Table 26. Protocol for Warfarin Overdose

INR Mlnlglllllnt
<5.0 Cessation of warfarin adminirlrlllion, observation. seriaiiNRIPT
5.1-9.0 If no risk factoli for bleeding, hold Wilfarin x 1-2 days and reduce maintenance dose
OR
Vltlrnil K1-2 mg PO Wpatient at increased risk of bleeding or fresh frozen plesma (FPP) active bleed
9.1-20.0 Hold warfarin. Vitamin K2--4 mg PO. seriaiiNRIPT, additional Vrtamin Kif neces511Y or FFP if active bleed
>20.0 FFP 1G-15 miJkg, Vitamin K10 mg rl over 10 min, increase VItamin Kdosing (q4h) if needed

Table 27. Specific Antidotes and Treatments -

call local poison information centre for specific doses and treatment recommendations
Toxin Tl'llllnlnt Canlillll'lli111111
Acalllmilop'- Decontsninate (activated chcucoal) OftEn clilically silent; evidence of liverfrenal damage delayed >241n
N-acetylcysteine Toxic dose > 200 rngtlg (>7.5 g achJt)
Monitor drug level immediately and 41n post-ingestion; also liver
enzymes, INR, PIT. BUN, Cr
Hypoglycemia. metabolic acidosis. encephalopathy -+ poor prognosis
ASA Decontaminelll (activated chcucoal) Monitor serum pH and drug levals dosaly
Ablinize urine; want urine pH >7.5 Monitor Klevet mav IIIJiire supplement lor urine alkalinization
Hemodialysis may be needed Wintraclllble metabolic acidosis, very
high IMis, or end-organ damage (i.e. unable to diul'86e)
Antic:holilarvics Decontsninate (activated chcucoal) Special antidotes available. ConsuH Poison lnlormation Centre (PIC)
Supportive ca111
Blnzudiutpiles Decontsninelll (activated chcucoal)
Supportive ca111
jl-llloc:bn Decontsninelll (activated chcucoal)
CorJSider or high dose insulin
(HDIE)
Calcium Channel 1-4 gof 10'1o sol'n rl if hypotensive ()der ECG. electrdytes (especially Ca. Mg.. Na. IQ, gb:agon mav help
Blcx:bn Atropine or isopruterenol if severe (2-5 mg)
Other: HIJE inotropes or aggressive
supportive lhe111py
Cyanide Cyanide antidota kit or hydroxycoballlmin
Toronto Notes 2011 Toxicology Emergency Medicine ER55

Table 27. Specific Antidotes and Treatments-

call local poison information centra far specific doses and treatment recommendations (continued)
TDJdn Tnlltment Censidendions
Digllllil DecontaminaiB (activlt&d Use for lile-1hrsat&ning anhythmias unresponsive Ill
Digoxin-specific Ab fragments conventiona11herapy, 6hr serum digoxin >19 nmol/1., initial K
16-20 vials IV Wacute; 3-6 Wchronic >5 mM, ingestion > 10 mg >4 mg (child)
1 vial (40 mg) neutralizes 0.5 mg oftoxil Common llllhythmiu include VFib, VTach, and conduction
blocks
Aclllll Dystanic Rxn BenziJOpina: 1-2 mg IMIIV then 2 mg PO x3 days Benztropine (Cogantin111) has euphoric alfact and potantial
OR Diphanhylhmina 1-211¢11111. for libuse
then 25 mg PO qid x 3days
Heparin Pro1amine sulfate mg IV For unfrllctionated heparin overdose only
Insulin/ Glucose IVJPWNG lllbe Glylnride carries hips! risk of among oral
Oralllypaglyl:emic: Glucagon: 1-2 mg IM Iff noacce&1illl
Consider octreotide lor oral (5!HOO 1111 SC
q&h) in these cues; consun local PIC

Thiamine 100 mg IM/IV Hypoltftemia vefY common in childlal

Manage airway and circulltoly suppot Mouthwash =70% EtOH; perfumes and colops =
4!).Wl(, EtOH
Order serum EtOH level and glucose level; treat glucose level
appropriately
E111anol (1 0%)1 0mlotg over 30 min, then 1.5 mlo'll CBC, elec:lnllytes, gU:ose, ethanol level
orlomepizole (4.fllelhylpyrazole) 15 rr¢111V load Consider hemodialysis
owr 30 min, 1han 10 IJIIVkg q12h
CO Poi10ning See ER46
Opiaidl See ER51
TCAI Aggressive supportive care Fluiii8ZI!nil antidote contraindiCided in combined TCA and
boii.IS for wide DRS/seinlrss benzodimpine overdose
Also consider cardiac and hypotension support, gastric
dacon1llmination, ii8inllll control
lntmlipid 1henvf (consun loclll PIC)
MDMA Decontaminl1e (activlt&d CK; tllllt rhllbdornyolysis wi1h high flow fluids
supportive care
Decontaminate (activated if orsl P-blockers me contraindicated in acute cocaine taxicily
Aggressive supportive care

Disposition from the Emergency Department

• methanol, ethylene glycol
• delayed onset, admit and watch clinical and biochemical markers
• TCAs
• prolonged/delayed cardioto:xicitywarrants admission to monitored (ICU) bed
• if asymptomatic and no clinical signs of intoxication: 6 hour ED observation adequate with
proper decontamination and no ECG abnonnalities
• sinus tachycardia alone (most common finding) with history of OD warrants observation in
ED
• hydrocarbons/smoke inhalation
• pnewnonitis may lag 6-8 hours
• consider observation for repeated clinical and radiographic examination
• ASA, acetaminophen
• ifborderline level, get second level2-4 hours after first
• for ASA must have at least 2levels going down before discharge (3 levels minimum)
• oral hypoglycernics
• admit all patients for minimum 24 hours if hypoglycemic
• observe asymptomatic patient for at least 8 hours

Psychiatric Consultation
• once patient medically cleared, arrange psychiatric intervention if required
• beware - suicidal ideation may not be expressed
ER56 Emergency Medicine Psychiatric Emergencies Toronto Notes 2011

Psychiatric Emergencies
Approach to Common Psychiatric Presentations
• see Psychiatry
• before seeing patient, ensure your own safety; have security/police available if necessary

History
.... ," • safety
• assess suicidality: suicidal ideation, intent, plan, lethal means, past attempts
• assess homicidality: access to weapons, intended victim, history of violence
ICily FanctiDM af Elllllrgency • command hallucinations
ITtohilltrlc ARIIHIIIIIIIt • identify current stressors and coping strategies
1. Is !he patient medicelly stable?
2. Rule out medical cause • mood symptoms: manic, depressive
3. Is P"(Chialric needed? • anxiety: panic attacks, generalized anxiety, phobias, OCD, PTSD
4. Are !here safely issues !SI, HI)? • psychotic symptoms: delusions, hallucinations, disorganized speech, disorganized or catatonic
5. Is patient certifilble? (must
demanstral8 risk list)
behaviour, negative symptoms (affective flattening, alogia, avolition)
and apparent mental illness [future • substance use history: most recent use, amount, previous withdrawal reactions
list)) • past psychiatric history, medications, adherence with medications
• medical history: obtain collateral if available

Physical
• complete physical exam focusing on: vitals, neurological exam, signs of head trauma, signs of
drug toxicity, signs ofmetabolic disorder
• mental status exam: general appearance, behavior, cooperation, speech, mood and affect,
thought content and form, perceptual disturbances, cognition (including MMSE if indicated),
judgment, insight. reliability

Investigations
• investigations vary with: age, established psychiatric diagnosis vs. first presentation, history and
physical suggestive of organic cause
• as indicated: blood glucose, urine and serum toxicology screen, pregnancy test, electrolytes,
TSH, AST/ALT, bilirubin, serum creatinine, BUN, osmolality
• blood levels of psychiatric medications
• CT head if suspect neurological etiology
• LP if indicated

Acute Psychosis
Differential Diagnosis
It' • primary psychotic disorder (e.g. schizophrenia)
Fl8tures 1hat OI'QIIIic • secondary to medical condition (e.g. delirium)
Etiology • drugs: substance intoxication or withdrawal, medications (e.g. steroids, anticholinergics)
Age >40 yellr$ old • infectious (CNS)
Babbling {incaherenl speech or speech
difficulties)
• metabolic (hypoglycemic, hepatic, renal, thyroid)
Concerning vital signs • structural (hemorrhage, neoplasm)
Disorientation
Emotional lability Management
FluctUBiing course
Global impainnent of cognitive function
• violence prevention
Headaches • remain calm, empathic and reassuring
Immodesty • ensure safety of staff and patients, have extra staff and/or security on hand
Just sbrted (sudden onset) • patients demonstrating escalating agitation or overt violent behavior may require physical
K
Lass of consciousness
restraint and/or chemical tranquilization (see Violent Patient, ER57)
Movanant abnormalities (tremor, • treat agitation: whenever possible, offer medication to patients as opposed to administering with
atllxia. psychomotor rwlanlation) force (helps calm and engage patient)
Neurological findings (fol:al) • benzodiazepines -lorazepam 2 mg PO, IM or SL
01her lbnarmalitin an physicaiiXIm
Perceptions (visual hallucinations)
• antipsychotics - olanzapine 5 mg PO, haloperidolS mg PO/IM
• treat underlying medical condition
• psychiatry or Crisis Intervention Team consult
Toronto Notes 2011 Psychiatric .EmergendesJCommon Pediatric ER PresentatiOlUI Emergency Medicine ER57

Suicidal Patient
, ________________,
......_._
Epidemiology
• attempted suicide F>M, completed suicide M> F PS24 for certiliclllian
• second leading cause of death in people <24 years cansidendiana

Management
• ensure patient safety: close observation, remove potentially dangerous objects from person and
room
High m.lc l'ltilnt.
• assess thoughts (ideation), means, action (preparatory, practice attempts), previous attempts
• admit if there is evidence of intent and organized plan, access to lethal means, psychiatric SADPEISDNS
Sex= male
disorder, intoxication (suicidal ideation may resolve with few days of abstinence) Aa• >45 yi8I'S old
• patient may require certification if unwilling to stay voluntarily Depression
• do not start long-term medications in the emergency department Previo\IS attempts
• psychiatry or crisis team consult Ethanol use
lllionallhinki1g lo"
Suicide in hmily
Organized plan
Violent Patient No spousa, no suppan systJm
Sarious illna"
Differential Diagnosis
• rule out lethal organic cause (e.g. EtOH, drugs, and head injuries)

Prevention
• be aware and look for prodromal signs ofviolence: anxiety, restlessness, defensiveness, verbal
attacks
• try to de-escalate the situation: address the patient's anger, empathize

Restraints
• pharmacological
• often necessary- may mask clinical findings and impair exam
• haloperidol5-10 mg IM (be prepared for dystonic reactions, especially with multiple doses
of neuroleptics over a short period) + lorazepam 2 mg IMJIV
• look for signs of anticholinergic overdose first (see Table 25)
• benzodiazepines best option if suspected substance-induced violence
• physical
• present option to patient in firm but non-hostile manner
• sufficient people to carry it out safely
• restrain supine or on side; preferably 4-point restraints, never less than 2-points (opposite
armand leg)
• suction and airway support available in case ofvomiting
• once restrained, search person/clothing for drugs and weapons

Common Pediatric ER Presentations

Modified Coma Score
Table ZB. Modified GCS
Modified GCS lor llfants
f.yl Op•ing Vlrbllllllspanse MDIDr Response I
4 - spontaneously 5- COOS, babbles 6 - nonnal, spontaneous movement Any infant < 1,_ of age witll 1 llfV&,
3-tospeech 4- inilllble ay 5 - witlmws to 111uch baggy IICI!IIp hematoma requires CI
2-topain 3 - cries to pain 4- WillmWll to pail
1- no response 2- moans to pain 3 - decorticate flexion
1 - no response 2 - decerebrate axtension
1- no 1111ponse
Modified GCS lor Clildn1n <4 years
f.yl Op•ing Vlrbllllllspanse Mlllllr Response
4- spontaneously 5- oriented, speaks, interacts 6 - nonnal, spontaneous movement
3-tospeech 4- confused speech, disoriented, cnolable 5 -localizes pain
2-topain 3 - inappropriate words, not consolable/aware 4 - witlmws to pain
1- no response 2- incomprehensible, agitated, restless, not aware 3 - decorticate flexion
1 - no response 2 - decerebrate extension
1- no rasponse
ER58 Emergency Medicine Common PedJatric ER Preaentationa Toronto Notes 2011

Respiratory Distress
..... , • see also Pediatrics
...-----------------, History and Physical Examination
In Pllfilllric reapir.tory dim.-. mpt
aiiOru.. olll:
• infants not able to feed, older children not able to speak in full sentences
• AnaphyiiiXis • anxious, irritable, lethargic - may indicate hypoxia
• Foreign body • tachypnea >60 (>40 if preschool age, >30 if school age), retractions, tracheal tug
• Pneumonia • see Pediatrics Table 1 for age specific vital signs
• Bronchiolitis
• pulsus paradoxus
• wheezing, grunting, vomiting

Tabla 29. Stridorous Upper Airway Disaasas: Diagnosis

fllluN Croup Bacterial Tracheitis
Aa•lll•u•lvnl D.5-4 5-1 D 2-8
Pradrome Days Hrsto days Minutes to In
T.,..el'ltll'e Low grade High Hijl
llldiogl'lplly Exudates in trlchea
Etiology Parainlluenm s_ illlreus/GAS H. lit type b
BerkyCaugh Yes Yes No
Drooling Yes No Ya6
Appear Toxic No Yes Yes
lntulmion? ICU? No Yes Yes
Antililllics No Yes Ya6
NDTE: No oral exam
1Now rare with Hib vaccine in common use

..... , • management of croup (laryngotracheitis caused by parainfluenza m-uses)

...-----------------,
Admlsllon Crflllrlll far C1'011p
• Stridor at rast or lignilicent
respiramry distress
• Relapse after 2 doses Df epinephrine
or incampl111 mpons1
• Co-morbid respinrtory or underlying
condition
..... ,
Admi11ion Critlrlll far Adln111
• Re1piratory diltn!H &In after
ltaroidl
• Ventalin required > q3h
• Naod for supplamantal DX'(ilan
• Consider I pnrvio1111 ICU ldminion
• humidified 0 2 should not be given (no evidence for efficacy)
• racemic epinephrine q1h x 3 doses, observe for 'rebound effects'
• dexamethasone x 1 dose
• consider bacterial tracheitis/epiglottitis if unresponsive to croup therapy
• management of bacterial tracheitis
• start croup therapy, but may have poor response
• usually require intubation, ENT consult, ICU
• start antibiotics (e.g. cloxacillin), pending C&S
• management of epiglottitis
• 4 D's: drooling. dyspnea, dysphagia, dysphonia + tripod sitting
• do not examine oropharynx or agitate patient
• immediate anaesthesia, ENT call- intubate
• then IV fluids, Abx, blood cultures
• management of asthma
• supplemental 0 2 if sats <90% or Pa02 <60%
• bronchodilator therapy: salbutamol (Ventolin•) 0.15 mg!kg by masks q20 minx 3
• add 250-500 1!8 ipratropium to first 3 doses salbutamol
• give corticosteroid therapy as soon as possible after arrival (prednisolone 2 mg!kg,
dexamethasone 0.3 mg/kg)
• MgS04 if critically ill, not responding to inhaled bronchodilators, steroids; give IV bolus,
then infusion
• IV if critically ill and not responding to above

Febrile Infant and Febrile Seizures

..... ,
..}-----------------,
Rochlltar Critllril far Fellrile Infants
Age 2WO Dap Old
• Non-toxic looking
• Prsvio1111ly wall (>37 weeu
GA, horne willl mother, no
hyparbilirubinamia, no prior antibiotics
or hospitalizations, no chronic/
Lnllrlying illnanl
• No skin, soft tissue, bona, joint, or &ar
infection on physical exam
• wac sooo-1s,ooo, bands < 1soo;
ll'ine <10 WBC/HPF, stool < 5 WBC/
HPF
FEBRILE INFANT
• see also Pediatrics
• for fever >38•C without obvious focus
• <28days
•admit
• full septic work up (CBC & blood C&S, urine C&S, CSF, CXR if indicated)
• treat empirically with broad spectrwn IV antibiotics
• 28-90days
• as above unless infant meets Rochester criteria (see sidebar)
• >90days
• toxic: admit, treat, full septic workup
• non-toxic and no focus: investigate as indicated by history and physical
Toronto Notes 2011 Common Pediatric ER Presentations Emergency Medicine ER59

FEBRILE SEIZURES
• see Pediatrics. P52

Etiology
• children aged 6 months to 5 years with fever or history of recent fever
• simple vs. complex febrile seizures
• normal neurological exam afterward
• no evidence of intracranial infection or history of previous non-febrile seizures
• often positive family history of febrile seizures
• relatively well looking after seizure

Investigations and Management

• if it is a febrile seizure: treat fever and look for source of fever
• if not a febrile seizure: treat seizure and look for source of seizure
• note: may also have fever but may not meet criteria for febrile seizure

Tabla 30. Simpla vs. Complex Fabrila Saizuras

Charsc:tarillic: Sinple C.....IIX
Durillion <15min >15min
Tp al Seizure Generalized Focal features
frllquncy 1 in 24 hours >1 in 24 hours

Abdominal Pain
• see also Pediatrics. P41

History
• nature of pain, associated fever
• assodated GI, GU symptoms
• anorexia, decreased fluid intake

Physical Examination
• HEENT, respiratory, abdominal exam including DRE, testicular/genital exam

Tabla 31. Differential Diagnosis uf Abdominal Pain in lnfants,/Childrao/Adolascents

Medical Surgical
Colic Malrotatim with volwus
UTI
Constipation Necrotizing enterocolitis
Gastroenteritis lncan:ntlld hernia
Sepsis Intussusception
HSP (Henoch Schonlein purpura) atresia
Inflammatory Bowel Disease Appendidis
HUS (Hemolytic Uremic Syndrome) Cholecystitis
Pneumonia Pancrartitis
Strep Throat Testiculil"tol8iDn
SCD crisis Ectopic pregna1cy
DICA Trauma
F111ctional Pyloric stsnosis
'llamlll'llar tD lalap an indlx rlupil:iln for chid lhU18
ER60 Emergency Medicine Common PedJatric ER Preaentationa Toronto Notes 2011

Common Infections
• see also Pediatrics

Tabla 32. Antibiotic Traabnant of Pediatric Bacterial Infections

lnr.:tion
MENINGinS
SEPSIS
Neonalal GBS, E. coli, listeria, S. auretl$, Gram-negative bacilli • ampicilin + aminoglycoside {gentamicin
or
• ampicilin + cefotaxime ± cloxacili1 arisk of S. aureus
1-3 months Same pathogens as above and below a
• ampicilin + cefotaxime ± cloxacili1 risk of S. aureus
>3 months S. pneumoctJCCUS, H. inlfuenzae type b • cefumxime
{>5 yrs), meningococcus • ceftriaxone or celotaxime, risk of meningitis
• vancomycin. penicillin'cephalospom188istant
pneumococci
aTTnSMEDIA
1st line S. pneumonia8. H. inffu8nzJJe type b. M. Catlnhalis • amoxicili180-90 mQI1cg per day
2nd line • amoxiciln.davutanata {Ciawlin•)
Treatment failure • high dose Clawlinat or ceflroxime or ceflriaxone
STREP PIIARYNGmS
Group A beta-hemolytic StreptrJcoccu$ • penicilirv'amoxicillin or aythromycin {pencilli1 allergy)
un
f. coli. Pn1teus, H. itrffuenzae, Pseudomonas. • amoxiciliVampicillin or
S. S6(JfiJIJhyticu fntenx:occus, GBS • bimethoprim-sulfamelhaxazole
PNEUMONIA
1-3 months S. pneumonia&, C. trat:honlllis, B. p8llussis, • cefumxime ± macrolide {erythromycin) or ampicillin ±
S. H. inffuenzle macrolide
3 months- S. pneumoniae, S. inlfuenzae. • ampicilirv'amoxicillin or cefuroxime
M;cop/8sm& pneumoniee
As above • ampicilirv'amoxicillin + macrolide or celuroxime +
macrolide

Child Abuse and Neglect

• see also Pediatrics
• obligation to report any suspected/known case of child abuse or neglect to CAS yourself
.... ,
...-----------------,
(do not delegate)
• document injuries
I'Nqntation uf Neglect
• consider skeletal survey x-rays, ophtho consult, CT head
• Failu111 ta thrive, diiValopmanllll dilley • injury patterns associated with child abuse
• lnadequaiB or dirty clothing. poor • head injuries: tom frenulum, dental injuries, bilateral black eyes, traumatic hair loss, diffuse
hygi- severe CNS injury, retinal hemorrhage
• Child axhibits poor attachment to
paran11, no st111ngar lriXillty
• Shaken Baby Syndrome: diffuse brain injury, subdural/subarachnoid hemorrhage, retinal
hemorrhage, minimal/no evidence of external trauma, associated bony fractures
• skin injuries: bites, bruises/bums in shape of an object, glove/stocking distribution ofbums,
bruises of various ages, bruises in protected areas
• bone injuries: rib fractures without major trauma, femur fractures age <1 year of age, spiral
fractures oflong bones in non-ambulatory children, metaphyseal fractures in infants,
multiple fractures of various ages, complex/multiple skull fractures
• genitourinary/gastrointestinal injuries: chronic abdominal/perineal pain, injury to genitals/
rectum, STI!pregnancy, recurrent vomiting or diarrhea
Toronto Notes 2011 Procedural Sedation/Common Medications Emergency Medicine ER61

Procedural Sedation
• procedural sedation: the technique of sedative or dissociative agent administration with or
without analgesics to induce a state that allows a patient to tolerate an unpleasant or painful
procedure while maintaining all protective cardiorespiratory functions (Le. a depressed level of
consciousness without loss of a patient's protective airway reflexes)
• must weigh degree ofpain and expected relief versus risk/complications of sedation and
procedure
• examples of procedures that may require sedation in the emergency department:
• setting fractures, reducing dislocations, draining abscesses, exploring wounds/ulcers/
superficial infections, endoscopic examination
• may also be required to reduce patient agitation if imaging is acutely required

Requirements for Safe Procedural Sedation in the Emergency Department

• airway suitable for safe intubation and ventilation
• appropriate equipment/personnel available
• intact and functioning cardiorespiratory and neurological system
• ideally, NPO for minimum 4-6 hours
• anesthetic history and drug allergies, including manifestations
• appropriate IV access, monitoring (oxygen saturation, BP, HR, etc.)
• informed consent obtained

Common Procedural Sedation Medications (titrate to effect)

• see Common Medications, below

Common Medications
Table 33. Commonly Used Medications
Drug D11ing Schedule lnllc:atiOII
fantllnyl 0.5·1.0 Procedural sedation Very short acting narcotic
midazolam 50 Procedural sedation Short acting benzodiazapine
when used with narcotic)
Fentanyl and midamlam often used together fur procldlral
sedation
1J11palol 0.25.{).5111Q11qj IV Procedural sedation Short acting
Anestheticisedative (complication=apnea, decreased BP)
0.3 mg IV bolus q5min x 3doses Revetsal a! procedual sedation Benzodimpine antagonist
NB don't usa in chronic biiiZOdiazapine user
lidocaine with api max7 mg./kg SC Locelanesthlllic Not to be used in fingers, nose, toes, penis. ears
lidocaine w/o api max 5 mg/kg SC Local anesthetic
l'olysporin8 to aff&ctad araa bid-tid infections
morphine 15-30 mg PO qll-12h Mild to modaralll acute/chronic pain Gl and constipation side ellects
0.1.n.2111Q11qj max 15 mg IV q4h Prescribed in combinlllion with NSAIDs DO NOT CRUSH, CUT or CHEW
or acetaminophen
Percocet 10,1'3258 1·2 tabs PO q6h pm Moderate pain colllrDI Oxycodane + acetaminophen
Max 4 gacetaminophen daily
acetaminophen 325-650 mg PO q4-6h pm Pain control Max 4 g daily
Tylenol #38 1-2 tabs PO q4-6h pm Pain control Max 4 gacetaminophen daily
Ibuprofen ZOO.BDO mg PO tid pm max 1200 mgld Mild to modaralll acuta pain
AnalgBSia and anti-ilfllrnmatory prupertiBS
1hiamine Wernicke's encephalopathy: To treat/prevent Wemicke's Caution use in pregnancy
100 mg IV/1M encephalopa1hy
then 5G-1 00 mg IM/IV ODJl'O x3d
diazepam anxiety: 2-1 0 mg PO tid/qid Anxiety
alcohol withdrawal: 10-20 mg POJ1V Alcohol withdrawal
q1h tibated to sig!Wsymptoms
lorazepam anxiety: 0.5-2 mg POIIIINIV q6.ah Anxiety
status epilepticus; 4 mg IV Status epiepticus
rapaat up to q5min
phanyt!lin status epilepticus: see Table 13 Status apiepticus Begin maint..ance dose 12hr liter loading dose
Continuous ECG. BP moritoring mandatory
epinephine anaphylaxis: 0.1.{).5 mg IM; Anaphylaxis Max 1mg/dose
can repeat q1 G-15min
ER62 Emergency Medicine Common MedicationsJR.eferenc:es Toronto Notes 2011

Table 33. Commonly Used Medications (continued)

Drug Dosing Schedulll lndicllians Ca11menls
salbllllmol 2 IXIIf1 inhaled q4-6h (4yrs) Asthma Caution with cardiac abnormalities
max 12 pull!/day
ipratropium bromide 2-3 pulls inhaled tid-qid, max 12 pufk/day Asthma Contraindicated with peallll/soy allergy
Caution with narrow-angle glaucoma
acute angina: 0.3-0.6 mg SL q5min. An gila Nllt to be used with lither illtt-hypertensives
OR 5 IV inCilNISilg Al:uteMI
by 5-20 q3-!imin
ASA 325-650 mg PO q4h max 4W'day Pain control
stroka.IMI risk: 81-325 mg PO OD Cardiac pravanlion
(metoprclol) 5 mg slow IV q5rnin x 3 AculeMI
if no contraildications
enoxaparin 1mglkg SC BID AculeMI
insulin bolus 5-10 U(0.2 UAcg) Hyperglycemia Monitor blood glucose levels
then 5-1 0 U (0.1 IJAcg) per hour Consider Kreplacement. also measure blood glucose
lavals bal0111 administration
glucose 0.5-1.0 glkg IV of D50W Hypoglycamill"DKA
furosemide CHF: 40--80 mg IV CHF Monitor 1or electrolyta imbalances
HTN: 10--40 mg PO BID HTN
haloperidol 2.5-5.0 mg POIIM initial eflective dose Psychosis Monitor with Parkilson's; results in CNS depression
6·20 mw'day
naloxone 0.5-2 mg or 0.01·0.02 mwq initial bolus Comatose patient
IVJIMISI/SC or via ETT (2-2.5x IV dose), Opioid overdose
increase dose by 2 mg until Reversal in procedural sedation
responsl!/max 10 mg
activated charcoal 3G-100 gPO in 250 ml H20 Poisoninw'overdose

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