1956   SECTION 24: Psychosocial Disorders
The central theme of the somatic type, and a potential trigger for an ED with anorexia nervosa.8 MRI studies detect differences in brain behavior and
visit, is a preoccupation with health and organ function. For example,
individuals may be convinced that they have an infestation of insects on
their skin or that a part of their body is not functioning.2
Schizoaffective disorder is about one third as prevalent as
schizophrenia.36 It is characterized by Criterion A of schizophrenia
(see Table 290-5) occurring concurrently with a major mood episode
(major depressive or manic). Patients with schizophrenia and schizoaf-
fective disorder have a 5% lifetime risk of suicide, with higher risk in
patients with depressive symptoms.37
Catatonia may occur in the context of various conditions. Medical
conditions associated with catatonia include encephalitis, head trauma,
hepatic encephalopathy, and neoplasms. The acute presentation of cata-
tonia often includes stupor, and therefore, patients often have their first
clinical contact in the ED. It is therefore important to recognize that
catatonia is frequently associated with an organic cause.38
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER Eating Disorders
291 Gemma C.L. Bornick
INTRODUCTION AND EPIDEMIOLOGY
Eating disorders, such as anorexia nervosa, bulimia nervosa, and
binge eating disorder, are psychological conditions characterized by a
pathologic relationship with food that adversely affects psychosocial
functioning. Eating disorders can be challenging in the ED because
physical manifestations may be subtle and historical features may not be
elicited unless a disorder is suspected from medical complications. The
fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
refines the diagnostic criteria of eating disorders from the previous edi-
tion (Table 291-1).1
There are two subtypes of anorexia nervosa: restrictive and binge/
purge, with crossover between the two.2 Restrictive patients minimize
their food intake, whereas those with bingeing/purging make up for unac-
ceptable food intake with diuretics, laxatives, enemas, or vomiting. There
are also two subtypes of bulimia: purging and nonpurging. Those who
purge do so by the above methods; those classified as nonpurging use
other compensatory methods such as fasting or excessive exercise. Up to
50% of anorexia patients develop bulimia.3 Binge eating disorder is char-
acterized by habitual, recurrent binge consumption episodes that cause
significant distress. This is distinct from simple episodic overeating and
must be both independent of anorexia or bulimia and free of compensatory
mechanisms. The Diagnostic and Statistical Manual of Mental Disorders,
fifth edition, also defines avoidant/restrictive food intake disorder, pica,
and rumination disorder, which are not addressed here.
Anorexia nervosa has an estimated lifetime prevalence of 0.9% in
women and 0.3% in men, and median age of onset is 18 years old.4,5
Bulimia nervosa has an estimated lifetime prevalence of 1.5% in women
and 0.5% in men, and median age at onset is also 18 years old.5 Binge
eating disorder is more common in older individuals and males than
both anorexia and bulimia, with a lifetime prevalence of 3.5% in women
and 2.0% in men.4,5
PATHOPHYSIOLOGY
There is evidence that eating disorders run in families, possibly due to both
genetic influences and similar underlying temperaments and behaviors.6,7
For example, genetic locus (rs4622308) on chromosome 12 is associated
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structure, and some implicate brain regions involved in reward processing.9-12
CLINICAL FEATURES
 HISTORY
Patients with eating disorders often present to the ED with vague signs
and symptoms such as weakness, fatigue, pallor, dizziness, syncope,
confusion, bloating, edema, or persistent nausea.13 Complaints may
otherwise be due to medical complications, such as chest pain and
hematemesis caused by a Mallory-Weiss tear from purging; palpitations
from dysrhythmias; dysmenorrhea from disruption of the hypothalamic-
pituitary axis; or fractures from osteoporosis. Depression, anxiety,
substance abuse, self-injurious behavior, or suicidality may coexist.14,15
Therefore, if an eating disorder is suspected, consider screening for
depression and suicidality.
If clinical suspicion is raised for an eating disorder based on com-
plaint cluster, physical examination, or family report, explore a more
focused history. Important data points to elicit include eating and diet-
ing behavior; desire for weight loss; typical daily dietary intake; presence
of calorie counting; compensatory exercise behavior; guilt patterns fol-
lowing eating; menstruation pattern; and use of over-the-counter dietary
supplements or laxative agents. Certain sensitive history points may be
difficult to elicit in the ED, such as early childhood GI issues or picky
eating or obesity, self-esteem issues, societal thinness pressures, teas-
ing, propensity toward perfectionism, or sexual abuse. Certain physi-
cal activities raise risk for eating disorders, such as gymnastics, ballet
and other dance, wrestling, swimming, and cross-country running.16-18
Because eating disorders are characterized by denial of symptoms and
behaviors, take a nonjudgmental approach to encourage trust and truth-
ful disclosure.14
 PHYSICAL EXAMINATION
Patients with anorexia are typically easily identifiable based on a very
thin body habitus. Other signs include hypotension (resting or ortho-
static), bradycardia or tachydysrhythmia, heart murmur and S2 “click”
of mitral valve prolapse, or hypothermia. Patients may also exhibit signs
of vitamin deficiencies such as brittle, flaking, or ridged nails (nonspe-
cific malnutrition); stomatitis or cheilitis (B vitamin deficiency); or
perifollicular petechiae (scurvy). They may also develop fine, long
hair on the arms and face, acral cyanosis (impaired thermoregula-
tion), and/or pretibial edema secondary to malnutrition.14 Nonsuicidal
self-injury is also common, and stigmata of cutting, picking, burning, or
bruising may be present.19
Patients with bulimia or binge eating disorder can be difficult
to detect in the ED because they tend to be normal weight or over-
weight. Consider eating disorder diagnoses in the presence of other
physical indicators, even in normal weight or overweight patients.
Self-induced vomiting can cause painless hypertrophy of the parotid
glands (sialadenosis), dental erosion, and trauma or callus formation to
the dorsal hands (Russell’s sign),20 as well as pharyngeal erythema or
abrasions, gingivitis, facial petechiae or subconjunctival hemorrhage,
and halitosis. Laxative abuse may cause peripheral edema, anal fissures,
hemorrhoids, perianal dermatitis, and rectal bleeding. Patients with
binge eating disorder will likely have no abnormalities apparent on
physical examination.
 DISEASE COMPLICATIONS
Eating disorders can be life threatening. Death by suicide is six
and four times more common in patients with anorexia and bulimia,
respectively, than in the general population.21 Medical complications are
typically more severe in anorexia than in bulimia or binge eating. Com-
plications of anorexia are generally directly due to malnutrition22 and
can account for a large proportion of deaths.23 Bulimia medical com-
plications are usually related to method and frequency of purging and
are often the result of chemical derangements or structural damage to
the GI tract.24 Patients with binge eating disorder describe significantly
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 CHAPTER 291: Eating Disorders   1957

TABLE 291-1 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Criteria for Eating Disorders
Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder
Restriction of caloric intake relative to Recurrent episodes of binge eating characterized by both: Recurrent episodes of binge eating characterized by both:
requirements, leading to a lower than • Eating in a discrete time period an amount of food that is larger • Eating in a discrete time period an amount of food that is
expected body weight in the context of than most people would eat in the same period under the same larger than most people would eat in the same period of
age, sex, development, and physical health circumstance time under the same circumstance
(<85% predicted) • A feeling of lack of control over eating during an episode • A feeling of lack of control over eating during an episode
Fear of weight gain or becoming fat, Recurrent, inappropriate compensatory behaviors to prevent weight The episodes are associated with three of the following:
despite lower than predicted body weight gain including self-induced emesis; abuse of laxatives, diuretics, or • Eating much more quickly than normal
other medications; caloric restriction; or excessive exercise • Eating until feeling uncomfortably full or overfull
• Eating large amounts of food even when not feeling hungry
• Eating alone because of embarrassment about how much
one is eating
• Feeling disgusted, depressed, or guilty afterward
Derangement in the way the patient’s body Bingeing and purging at least 1 time a week for 3 weeks The patient exhibits marked distress regarding binge eating.
weight or appearance is experienced, undue Self-evaluation is unduly influenced by body weight and appearance The binge eating occurs at least 1 time a week for 3 months.
effects of body weight on self-evaluation, or
The disturbance does not occur exclusively during episodes of anorexia The binge eating is not associated with inappropriate
denial of the dangerousness of the current
compensatory behavior and does not occur exclusively during
low body weight
the course of anorexia, bulimia, or avoidant/restrictive food
intake disorder.
Source: Data from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. Washington, DC: American Psychiatric Association; 2013.

more somatic symptoms than the general population, but true medical
complications are rare.25
Cardiopulmonary Complications Among the most deadly of the
eating disorder complications in anorexia are structural and functional
changes to the cardiovascular system.26 Malnutrition causes decreased
cardiac muscle mass and increased vagal tone. This leads to decreased
contractility and cardiac output and, therefore, results in hypotension,
bradycardia, and orthostasis. Relative decreases in cardiac muscle mass
can lead to the development of mitral valve prolapse.27 Rarely, patients
with anorexia nervosa can develop myocardial fibrosis28 or pericardial
effusion, which in a few cases has led to cardiac tamponade requiring
pericardiocentesis.29 Syrup of ipecac, used as an emetogenic, is directly
cardiotoxic and can cause an irreversible cardiomyopathy. Prolonga-
tion of the QT interval on ECG has been described, but this is rare in
the absence of electrolyte disturbance or congenital long QT syndrome
and should prompt evaluation for these conditions.22 Increased QT
dispersion (difference between maximum and minimum QT intervals
seen in each lead of a single ECG) indicates heterogeneous ventricular
depolarization and is a marker for increased arrhythmic risk.30 QT
derangements as a result of eating disorders are reversed by adequate
refeeding. QT resolution is associated with normalization of heart rate,
heart rate variability, and exercise tolerance31 and, therefore, has been
used as a marker to guide rehabilitation.32 Most other cardiac sequelae
are also reversible with appropriate weight gain, but there is increased
risk of cardiac complications during the first week of refeeding after
severe nutrient depletion.31,33 Cardiac complications are only rarely seen
in patients with bulimia nervosa or binge eating disorder.24,34
Pulmonary Complications Anorexia can lead to weakness of respi-
ratory muscles, decreased pulmonary and aerobic capacity,35,36 and
aspiration due to pharyngeal muscle weakness. Aspiration pneumonitis
and subsequent pneumonia can occur as a result of pharyngeal muscle
weakness and from chronic purging.37 There are case reports of pneu-
mothorax and pneumomediastinum.38 Patients with bulimia and binge
eating disorder are often smokers and may have pulmonary complica-
tions related to smoking.39
GI Complications Patients with anorexia are at increased risk of con-
stipation, gastroparesis, acute gastric dilatation, gastroesophageal reflux,
and acute pancreatitis.14,40,41 Gastroesophageal reflux and laryngopha-
ryngeal reflux commonly occur in patients with bulimia or purging-type
anorexia and may result in hoarseness or dysphagia.14,42 Forceful vomit-
ing can result in Mallory-Weiss tears or, rarely, Boerhaave syndrome.34
Chronic stimulant laxative abuse can lead to development of ileus, rectal
prolapse, melanosis coli, or the cathartic colon syndrome.43-45
Nutritional Complications The proportion of eating disorder patients
with vitamin deficiencies is difficult to determine because many take
supplements. Decreased bone mineral density and skeletal fragility
are common but are not associated with decreased vitamin D levels.46
Iron and vitamin B12 deficiencies can lead to anemia in severely food-
restrictive patients but are uncommon. Skin erythema and pruritus with
sun exposure, glossitis, epidermal desquamation, and diarrhea should
raise suspicion of pellagra.47 Confusion, confabulation, ataxia, ophthal-
moplegia, and/or nystagmus suggest Wernicke-Korsakoff encephalopathy.
Other vitamin deficiencies reported in association with eating disorders
include wet beriberi and scurvy, although these are extremely rare.48,49
Poor nutritional state can result in hypoplastic or aplastic bone marrow50
and resultant cytopenias.51
Renal and Electrolyte Complications Electrolyte derangements and
other lab abnormalities are more common in purging-type eating dis-
orders. Patients with restrictive-type anorexia may not demonstrate any
laboratory abnormalities. Frequent vomiting can result in metabolic
alkalosis, hyponatremia, and hypochloremia. Laxative and diuretic
abuse and vomiting can lead to potassium and magnesium deple-
tion. Hyponatremia may also develop in patients who abuse diuretics.
Signs of starvation ketosis may be evident. In patients with very severe
anorexia, hypoglycemia and hypophosphatemia can develop.14,22,52,53
Refeeding following prolonged nutrient depletion can also cause
electrolyte abnormalities, most commonly hypokalemia, hypophospha-
temia, and hypomagnesemia, due to redistribution of electrolytes from
the extracellular to the intracellular space triggered by insulin release
and from depletion of phosphorus during protein synthesis. This can
lead to arrhythmias, congestive heart failure, pericardial effusions, and
cardiac arrest.33
Endocrine Complications Profound food restriction affects the
hypothalamic-pituitary axis. Low levels of gonadotropins, loss of the
normal pulsatile waves of luteinizing hormone, and estrogen deficiency
lead to hypothalamic amenorrhea.54 Anorexia is also associated with
the “euthyroid sick syndrome” in which thyroid-stimulating hormone
is normal or slightly low, T3 is low, and sometimes T4 levels are also
decreased. Thyroid deficiencies likely contribute to the bradycardia,
orthostasis, and hypothermia in anorexia. High cortisol levels and low
levels of insulin-like growth factor 1 (somatomedin C), T3, estradiol, and
testosterone contribute to loss of bone mass.55 Refeeding and recovery
from illness do not fully return bone mass to normal levels, and patients
with anorexia remain at an increased risk of fracture for many years
following initial diagnosis.56 The endocrine effects of bulimia and binge
eating disorder are less well studied. Bulimia is associated with both

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 1958   SECTION 24: Psychosocial Disorders

TABLE 291-2 SCOFF Questionnaire TABLE 291-4 Society of Adolescent Medicine Criteria for Hospital Admission
•• Do you make yourself sick because you feel uncomfortably full? Anorexia Nervosa Bulimia Nervosa
•• Do you worry you have lost control over how much you eat? Body weight <75% of ideal for age, sex, Potassium <3.2 mmol/L
•• Have you recently lost more than 1 stone (14 lb) in a 3-month period? and height
•• Do you believe yourself to be fat when others say you are too thin? Daytime heart rate <50 beats/min or Chloride <88 mmol/L
•• Would you say that food dominates your life? nighttime heart rate <45 beats/min
Note: A score of 2 or more indicates a probable eating disorder with a sensitivity of 84.6% and a specificity Body fat <10% of body weight Esophageal trauma and hematemesis
of 89.6%. Dehydration Vomiting unresponsive to antiemetics
Source: Reproduced with permission from Morgan JF, Reid F, Lacey JH: The SCOFF questionnaire: a new Cardiac arrhythmia including QT Dehydration
screening tool for eating disorders. West J Med 2000;172(3):164-165. prolongation
Temperature <96°F Cardiac arrhythmia including QT
prolongation
type 1 and type 2 diabetes mellitus. There is some evidence to support
an increased risk of dyslipidemia, glucose dysregulation, and diabetes Orthostasis and syncope Temperature <96°F
in binge eating disorder.25,57 Repeated vomiting can lead to metabolic Acute psychiatric emergencies such as Orthostasis and syncope
alkalosis, hypokalemia, and increased aldosterone secretion—a cluster hallucinations or suicidality
described as pseudo-Bartter syndrome.58 Systolic blood pressure <90 mm Hg Acute psychiatric emergencies such as
hallucinations or suicidality
DIAGNOSIS Ongoing weight loss despite outpatient Ongoing purging despite outpatient
treatment treatment
Diagnostic criteria are outlined in the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders, but screening tools are more
practical for presumptive diagnosis in the ED. The SCOFF Question-
test; hepatic function panel; serum albumin; lipase and amylase; and
naire (Table 291-2) is useful for screening for anorexia and bulimia in
thyroid-stimulating hormone.63
a brief encounter and can be remembered by its acronym: Sick, Control,
One stone, Fat, Food.59 Other screening tools, such as the Eating Disor-
der Diagnostic Scale or the Eating Attitudes Test, are more extensive and  IMAGING
are more useful in a primary care setting.60,61 The Questionnaire on Eat- Obtain imaging only to rule out an underlying organic cause of present-
ing and Weight Patterns–Revised is specific for binge eating disorder.62 ing symptoms or to exclude medical complications. Nonspecific radio-
It is very important to search for, diagnose, and treat organic pathol- graphic findings in patients with anorexia may include decreased muscle
ogy as part of the assessment of a patient with a potential eating disorder mass, paucity of subcutaneous fat, mild small bowel dilatation,63 and
(Table 291-3). osteoporosis.65 There are no specific radiographic findings diagnostic of
binge eating disorder or bulimia, but a swallowed toothbrush or similar
 LABORATORY TESTING item suggests purging by induced vomiting.66
Initial testing should include an ECG and a full chemistry panel includ-
ing magnesium, calcium, and phosphorus; CBC; urinalysis; pregnancy TREATMENT AND DISPOSITION
The ED treatment of eating disorders is limited to stabilization of
urgent medical complications, followed by hospital admission or out-
TABLE 291-3 Differential Diagnosis of New-Onset Eating Disorders patient referral to a mental health specialist. Tables 291-4 and 291-5
Endocrine Adrenal insufficiency list guidelines for hospital admission.63,67 Most medical complications of
anorexia nervosa can be treated in an outpatient setting if the patient’s
Hyperthyroidism weight is >70% of ideal body weight or body mass index is >15 kg/m2.52
Diabetes
GI Hepatitis
TABLE 291-5 American Psychiatric Association Criteria for Hospital Admission
Pancreatitis
Medical status Adults: heart rate <40 beats/min, blood pressure
Celiac disease <90/60 mm Hg, glucose <60 milligrams/dL (<3.3 mmol/L),
Inflammatory bowel disease potassium <3 mEq/L, temperature <97.0°F, end-organ
Superior mesenteric artery syndrome compromise requiring acute treatment, poorly controlled
diabetes
Infectious disease Mononucleosis
Children: heart rate near 40 beats/min, orthostasis, blood
Human immunodeficiency virus pressure <80/50 mm Hg, hypokalemia, hypophosphatemia,
Tuberculosis hypomagnesemia
Cancer Nervous system malignancy Suicidality Specific plan with high lethality or intent
Ovarian malignancy Weight Generally <85% of ideal body weight or acute weight
Intra-abdominal malignancy change with food refusal
Pregnancy Hyperemesis gravidarum Motivation to recover Very poor motivation; patient preoccupied with intrusive
repetitive thoughts and/or uncooperative with treatment
Psychiatric Substance abuse
Comorbid disorders Any existing psychiatric disorder requiring hospitalization
Major depressive disorder
Structure required Needs supervision to ensure caloric intake, prevention of
Bipolar disorder
exercise, or prevention of purging behaviors
Schizophrenia
Environmental Severe family conflict or absence of family, absence of
Inborn error of metabolism Mitochondrial disorders appropriate outpatient resources in patient’s geographic
Enzyme deficiency region

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Long-term treatment of all eating disorders requires a multidisciplinary
approach, including psychotherapy, dietary interventions, and pharma-
cotherapy in certain cases.63 If pharmacotherapy is indicated, it should
be initiated by a psychiatrist or primary care provider.
SPECIAL POPULATIONS
 PREGNANT WOMEN
Pregnancy can be a stressful time for a woman with an eating disorder,
particularly with respect to maintaining adequate weight gain. There are
conflicting data on whether the presence of eating disorders increases
the risk of complications. The broadest study of its kind revealed that the
majority of patients with anorexia and bulimia have normal pregnancies
and healthy babies with, however, an increased risk of birth by cesarean
section and an increased risk of postpartum depression. These differences
remained between groups who had active symptoms and those with his-
tory of an eating disorder who were asymptomatic during pregnancy.68
 MEN
Do not neglect the possibility of eating disorders in men. Men may
account for between 10% and 25% of cases of anorexia and bulimia,69
and binge eating is more prevalent in men than both anorexia and
bulimia. The exact proportion of men with eating disorders is unknown
because men are less likely to be diagnosed. Eating disorders in males
are typically characterized by the drive to add muscle bulk and lean mass
and are often associated with antecedent obesity, athletic performance
concerns, bullying, and occasionally (but not always) sexual abuse. Men
with eating disorders are more likely to abuse steroids and growth hor-
mones, particularly when muscle dysmorphia is present.70
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER Substance Use Disorders
292 Kathryn Hawk
Elizabeth A. Samuels
Scott G. Weiner
Gail D’Onofrio
Edward Bernstein
INTRODUCTION AND EPIDEMIOLOGY
In EDs around the world, on every shift, patients present for medical
conditions related to the consequences of unhealthy drinking or drug
use. The World Health Organization reported in 2012 that 5.9% of all
global deaths (3.3 million people) were attributed to the consumption of
alcohol.1 From 2006 to 2014, ED alcohol-related visits increased in the
United States from 827,100 to 1.46 million.2,3 In 2015, an estimated
29.5 million people, or 0.6% of the global adult population, qualified for
a drug use disorder, yet fewer than 16% were afforded treatment. The
majority of worldwide illicit drug–related deaths (190,000) were attrib-
uted to opioids. In 2016, the United States accounted for more than 25%
of these deaths.4 U.S. ED drug-related visits doubled from 2005 to 2014,5
fueled by increased supply and misuse of prescription opioids; social and
economic determinants; and the low cost and easy availability of heroin,
synthetic fentanyl, and analogs.6 Between July 2016 and September 2017,
U.S. opioid overdose ED visits among those aged 11 years old and older
increased 29.7% overall, with significant increases across all demograph-
ics examined.7 It is noteworthy that “available data suggest that non-
medical prescription-opioid use is neither necessary nor sufficient for
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CHAPTER 292: Substance Use Disorders   1959
TABLE 292-1 Nonstigmatizing Substance Use Disorder Language
Avoid These Terms Use These Instead
Addict, user, drug abuser, junkie Person with opioid use disorder or
person with opioid addiction, patient
Addicted baby Baby born with neonatal abstinence
syndrome
Opioid abuse or opioid dependence Opioid use disorder
Problem Disease
Habit Drug addiction
Clean or dirty urine test Negative or positive urine drug test
Opioid substitution or replacement therapy Opioid agonist treatment
Relapse Return to use
Treatment failure Treatment attempt
Being clean Being in remission or recovery
Source: Data adapted from www.thenationalcouncil.org/consulting-best-practices/national-council-shareables.
Accessed June 27, 2018.
the initiation of heroin use and that other factors are contributing to the
increase in the rate of heroin use and related mortality.”8
The scope of substance use disorders (SUDs) includes unhealthy
use of alcohol, use of illicit drugs, and nonmedical use of prescription
drugs. Severe SUDs resemble asthma, diabetes, hypertension, and other
chronic diseases in that they have genetic components and patients have
problems with adherence to medication, loss to follow-up, exacerbations,
repeat visits to the ED, and hospital admissions.9 Nevertheless, only a
small fraction of those needing alcohol or drug treatment actually receive
indicated therapy, compared with a much higher fraction of patients
with chronic medical conditions.10 This understanding of addiction as
a chronic, relapsing medical condition requires us to shift our focus
toward providing linkage to ongoing integrated treatment and com-
munity support services as an addition to acute care.11 The gap in SUD
treatment also reflects the impact of social stigma on disparities in avail-
ability, accessibility, and affordability of services. Language is powerful,
especially when talking about substance use because stigma perpetuates
negative perceptions, discourages use of treatment services, and contrib-
utes to further substance use. Words do matter and the language used
to discuss addiction is important to decrease stigma (Table 292-1).12-14
UNHEALTHY ALCOHOL USE
The term unhealthy alcohol use describes a spectrum of alcohol con-
sumption ranging from “risky” or hazardous use (no consequences
experienced), to harmful use (experience of consequences), to what was
previously called alcohol dependence but is now termed mild, moderate,
or severe alcohol use disorders in the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition classification.15 The National Institute on
Alcohol Abuse and Alcoholism defines low-risk drinking as follows: for
men, no more than 14 drinks per week and no more than four drinks over
a 2-hour occasion. Women of all ages and men >65 years old are advised to
drink no more than seven drinks per week and no more than three drinks
over a 2-hour occasion, because of gender and age differences in volume
distribution and concentrations of alcohol dehydrogenase in the liver.
Binge drinking (drinking too much too fast) is alcohol consumption that
results in a blood alcohol level over the U.S. legal limit of 0.08 gram/dL,
which for the average male is the result of more than four drinks in
2 hours and for the average female is more than three drinks in 2 hours.
Nearly 32 million adults engage in extreme binge drinking, described as
consuming two or more times these thresholds.16 Abstinence is advised
for pregnant women and underage drinkers, and a lower limit or absti-
nence is advised for patients with chronic conditions exacerbated by
alcohol or who are taking medications with an alcohol interaction.17
Those who begin drinking before age 15 have a fourfold increased
risk of developing dependence than those who begin drinking later.18
Early onset also predicts adverse health status.1 Underage drinking and
drug use have a profound impact on the developing nervous system,
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 1960   SECTION 24: Psychosocial Disorders
Alcohol Screening in the ED (Revised and approved by the American College of Emergency
Physicians [ACEP] Board of Directors April 2011. Reaffirmed January 2017.)
“ACEP believes alcohol abuse is a significant public health problem. Further, ACEP believes
emergency medical professionals are positioned and qualified to mitigate the consequences of alcohol
abuse through screening programs, brief intervention, and referral to treatment. ACEP encourages wide
availability of resources necessary to address the needs of patients with alcohol-related problems and
those at risk for them.”
FIGURE 292-1. American College of Emergency Physicians policy on alcohol screening in the ED.
so early intervention is needed to mitigate life-altering consequences.19
Gaps between women and men are narrowing for prevalence, frequency,
and intensity of drinking; early-onset drinking; and driving under the
influence.16,20 Women who drink are more likely to experience medical
complications of alcohol use including liver injury and cirrhosis, some
cancers, cognitive dysfunction, and cardiovascular complications such
as stroke, hypertension, and cardiomyopathy.21-24 National survey data
demonstrate an upward trend in drinking among U.S. adults aged 60
and older, particularly among women who were found to have increased
rates of binge drinking.25 The ED is an important site for alcohol screen-
ing (Figure 292-1).
SUBSTANCE USE DISORDERS
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition,
groups substance abuse and dependence into categories from mild to
severe SUD.26 The diagnosis of SUD requires two or more of the follow-
ing 11 criteria: (1) tolerance; (2) withdrawal; (3) recurrent use in greater
quantities or for a greater duration than intended; (4) failed attempts to
cut back or quit substance use; (5) spending a great deal of time obtain-
ing, using, or recovering from the substance; (6) persistent or recurrent
use despite physical and or psychological consequences; (7) giving up
important activities in order to use; (8) failure to fulfill responsibilities
in work, school, and/or home because of recurrent use; (9) recurrent use
resulting in physically hazardous behavior, such as driving under the
influence; (10) persistent use despite social or interpersonal problems;
and (11) craving alcohol or other drugs. Severity is based on the number
of criteria met: two or three of the criteria constitute mild SUD, four to
five constitute moderate SUD, and six or more constitute severe SUD.26
More than 20 million Americans aged 12 and older27 and 110 million
people worldwide28 meet criteria for an SUD.
SCREENING, BRIEF INTERVENTION, AND
REFERRAL TO TREATMENT
Screening, brief intervention, and referral to treatment techniques were
established in 2003 by the U.S. Substance Abuse and Mental Health
Services Administration to address the gap in preventive services for
unhealthy alcohol and drug use, to stem the progression to addiction
by early intervention, and to address the treatment gap by promoting
help seeking and facilitating access to addiction treatment and recovery
support services. Screening, brief intervention, and referral to treatment
have been associated with short-term benefits and reduction in cost and
ED utilization.29-43
 SCREENING FOR UNHEALTHY DRINKING AND DRUG USE
Brief standardized screening questions have a higher sensitivity for
identifying heavy and dependent drinkers and illicit drug–using patients
than noting the smell of alcohol on breath, patient self-report, or profil-
ing based on demographics or presenting complaint. Brief screening
instruments are easy to administer and may help match an individual
to the most appropriate treatment resource. Validated brief screen-
ing questions useful for ED providers include the National Institute
on Alcohol Abuse and Alcoholism Quantity/Frequency Questions17
and the Single Screening Questions for Alcohol44 and Drug Use
(Table 292-2).45 Questions can be integrated into the triage electronic
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medical record.46 Screening for heavy smoking is also important since there
is an association between heavy smoking and multiple drug use.15 An alter-
native approach is to implement the National Institute on Drug Abuse–
Modified Alcohol, Smoking and Substance Involvement Screening
Test instrument into ED practice if additional ED support personnel are
available (e.g., health promotion advocate, alcohol and drug counselors,
recovery coaches, trained medical workers, behavioral health or social
workers).33,47-49 The National Institute on Drug Abuse–Modified Alcohol,
Smoking and Substance Involvement Screening Test instrument was
developed to guide clinicians through a series of questions to identify
risky substance use in their adult patients. Final scores of 4 to 26 on the
instrument stratify risk and encourage clinicians to advise, assess, and
assist patients with follow-up to primary care; a score of greater than
26 indicates the need for referrals to SUD specialty treatment.
As part of the social history, emergency care providers can integrate
questions that reflect their concern for the patient’s overall health and
safety. SUD screening questions could be embedded among other
preventive health issues to reduce stigma and patient resistance and
encourage veracity and trust. Questions asked in a nonjudgmental,
matter-of-fact fashion are well accepted by patients.50
Patients who are above the “low-risk” drinking guidelines could
benefit from a brief intervention and primary care referral to motivate
reducing consumption. For moderate to severe alcohol use, provide
referral to a specialized treatment center.
 THE BRIEF NEGOTIATED INTERVIEW FOR SUBSTANCE USE
INTERVENTION
The brief negotiated interview29,30,36,37,51,52 has four key elements: establish
rapport, provide feedback, enhance motivation, and negotiate a plan of
action. The first principle of promoting health behavior change is that the
argument for change needs to come from the patient, not the healthcare
provider. Begin a respectful, nonjudgmental conversation by recognizing
the patient as the decision maker and asking the patient’s permission
to talk about alcohol or drug use and health concerns. An important
opportunity for early intervention may occur during an ED visit for acute
medical care or a social or criminal justice crisis.53 The entire interaction
often can be accomplished in 5 to 7 minutes,51 and the conversation can
take place at any point in care, such as at discharge or while suturing or
casting or performing an incision and drainage of an abscess.
The brief negotiated interview algorithm incorporates key elements
of motivational interviewing: open-ended questions, affirmations,
reflective listening, and summaries (Figure 292-2). (See Videos: Brief
Negotiated Interview and Active Referral to Treatment.)
TABLE 292-2 Single Screening Questions
“Would it be okay with you if I ask you some very personal questions that I ask all
my patients to improve the care I give? You do not have to answer them if you are
uncomfortable.”
• Single Screening Question for Alcohol: “Do you drink beer, wine, liquor, or distilled
spirits? How many times in the past year have you had 5 or more (for men)/4 or more
(for women) drinks in a day?”6,44 Clarify that a standard drink is 1.5 oz of spirits, 6 oz of
wine, and 12 oz of beer.6
• Single Screening Question for Drug Use: “How many times in the past year have you
used an illegal drug or used a prescription medication for nonmedical reasons?” You
can add something like “. . . for instance, for the experience or feeling it gives you?”45
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 CHAPTER 292: Substance Use Disorders   1961

BNI Steps Dialogue/Procedures

1. Raise subject Hello, I am _______. Would you mind taking a few minutes to talk with me
about your alcohol use? <<PAUSE and LISTEN>>
2. Provide feedback
• Review screen From what I understand you are drinking [insert screening data]…
We know that drinking above certain levels can cause problems, such as
[insert facts]…I am concerned about your drinking.
• Make connection What connection (if any) do you see between your drinking and this
ED visit?
If pt sees connection: reiterate what pt has said
If pt does not see connection: make one using facts

• Show NIAAA guidelines
and norms
3. Enhance motivation
• Readiness to change
• Develop discrepancy
• Explore pros and cons
• Use reflective listening
4. Negotiate and advise
• Negotiate goal
• Give advice
• Summarize
• Provide handouts and
suggest PC f/u
• Thank patient
These are what we consider the upper limits of low risk drinking for your
age and sex. By low risk we mean that you would be less likely to experi-
ence illness or injury if you stayed within these guidelines.
[Show readiness ruler] On a scale from 1–10, how ready are you to change
any aspect of your drinking?
If patient says:
≥2 ask Why did you choose that number and not a lower one?
<2 or resistance ask pros and cons
Help me to understand what you enjoy about drinking?
<<PAUSE AND LISTEN>>
Now tell me what you enjoy less about drinking.
<<PAUSE AND LISTEN>>
On the one hand you said, <<RESTATE PROS>>
On the other hand you said, <<RESTATE CONS>>
So tell me, where does this leave you?
What’s the next step?
What do you think you can do to stay within the safe drinking guidelines?
If you can stay within these limits you will be less likely to experience
[further] illness or injury related to alcohol use.
This is what I’ve heard you say…Here is a drinking agreement I would
like you to fill out, reinforcing your new drinking goals. This is really an
agreement between you and yourself.
Provide drinking agreement [pt keeps 1 copy]
Suggest Primary Care f/u to discuss drinking level/pattern
Thank patient for his/her time

FIGURE 292-2. Screening, brief intervention, and referral to treatment algorithm as taught in the standardized ED curriculum. BNI = brief negotiated interview; f/u = follow-up; NIAAA =
National Institute on Alcohol Abuse and Alcoholism; PC = primary care; pt = patient. [Reproduced with permission from D’Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O’connor PG:
Development and implementation of an emergency practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency department. Acad Emerg Med 12: 249, 2005.
Copyright John Wiley & Sons.]

Establish Rapport Establish rapport and ask the patient’s permission
to discuss his or her use of alcohol and drugs. Establish an atmosphere
of trust through respect. The patient is not the problem (a stigmatizing
approach) but is a person who has a problem. Instead of “What’s wrong
with our patient?”, an alternative approach based on compassionate
curiosity would lead the clinician to inquire, “What’s happening with
our patient?”
Provide Feedback Elicit the patient’s thoughts on low-risk or safe
alcohol and drug use. Provide information by reviewing current drink-
ing and drug use and guidelines. Express concern that by drinking in
excess of safe limits, the patient is at risk for injury or illness. Elicit/
solicit the reaction to the guidelines. Ask patients to make a connection
between alcohol and/or drug use and quality of life; possible negative
consequences related to health, family, legal system, and employment;
and, if applicable, the current ED visit or injury. If appropriate, discuss
physical dependence, withdrawal, and the cycle of behaviors to obtain
more alcohol and/or drugs.
Enhance Motivation Assess readiness to change on a readiness ruler. Ask
patients to mark on a drawing of a ruler, with a scale of 1 to 10, how ready
they are to change, cut back, or quit their alcohol and/or drug use. If they
say 5, give affirmation and say that “You are 50% on the way,” and ask,
“Tell me why you didn’t mark a 2 or 3 or a lesser number?” Here is when
we try to elicit change talk or reasons and motivation for change. Repeat
what the patient has shared with you and follow up with, “It sounds like
you have some important reasons to change, so what small steps can
you take to stay healthy and safe?” If the patient shows resistance to the
readiness ruler or the score is <2, then explore the pros and cons of cur-
rent use. A discussion of the pros and cons promotes self-questioning and
draws attention to the patient’s own reasons for tipping the scale toward
change. Use open-ended questions such as, “Help me to understand (or
see it through your eyes) what you like and dislike about your use of
alcohol?” Explore the importance to the patient of the issues that emerge.
Use reflective listening to summarize what you think the patient said to
verify your interpretation, for example: “On the one hand, you like the
taste and how it helps you to loosen up and forget your problems, and it

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 1962   SECTION 24: Psychosocial Disorders
is something to do when you’re bored. On the other hand, you said you
don’t like how you feel the next day and that wrecking your car in a crash
and ending up in the ED is no fun. You also told me you are spending
a lot of money on drinking and are concerned about not meeting some
responsibilities. So then, in the balance, where does that leave you?”
Negotiate and Advise Negotiate an action plan. Explore with patients
what life might be like if they made these changes. What would be the
benefits of change, and what would be the challenges? Add the steps they
would need to take to address challenges and explore and support confi-
dence in ability to make a change. Offer a menu of options and resources to
assist with the change plan, including, if appropriate, referrals to primary
care providers and SUD treatment. Document the plan. Ask the patient
to state in her or his own words the agreed-on steps and document them
on a piece of paper or discharge instructions as a reminder of goals
(a prescription for change). Reflect back to the patient and reinforce rea-
sons for, and steps toward, change. End the conversation by thanking the
patient for being honest and spending time talking with you.
Afterward, take a minute for self-assessment using the FLOAT mne-
monic: To what degree did you provide feedback? Did you listen care-
fully? Did you ask open-ended questions? Did you offer affirmations
and alternatives? Did the patient have enough time to talk, or did you
do the majority of talking? Did you negotiate a concrete action plan?
 REFERRAL TO TREATMENT
Factors that often accompany unhealthy alcohol and drug use, such as
psychiatric illness, trauma, homelessness, low level of health literacy,
lack of insurance coverage or ability to pay for medications, criminal
justice involvement, absence of family support, and limited availability
of treatment and recovery support services, make patient management
and disposition challenging.
Effective linkage to SUD treatment can be facilitated by training ED
staff in screening, brief intervention, and referral to treatment. Develop
an ED collaborative team with staff such as behavioral health and social
workers, care managers, psychologists, nurse specialists, peer alcohol
and drug counselors, volunteers from Alcoholics Anonymous or
Narcotics Anonymous, health promotion advocates, or recovery coaches
to enhance the efforts of existing staff and motivate and assist patients
with identifying and accessing treatment options.33,47-49,52
Build and maintain a referral and resource service network.33,47,52 Cur-
rent practice in most EDs is to provide patients and family members
with a list of detoxification or treatment resources in the community.
The Center for Substance Abuse Treatment at the U.S. Department
of Health and Human Services has an online resource locator (http://
dasis3.samhsa.gov). The resource list and referral networks ideally would
include a continuum of specialized treatment facilities for patients with
co-occurring medical, traumatic, and psychiatric illnesses; inpatient and
outpatient detoxification, acupuncture, and medication for addiction
treatment such as methadone maintenance programs, buprenorphine,
and oral and IM naltrexone for opioid and alcohol addiction; outpa-
tient individual and group counseling; intensive outpatient or partial
hospitalization; sober housing and residential treatment communities;
Alcoholics Anonymous and Narcotics Anonymous meetings; and pro-
grams focused on the needs of women, culture-specific programs, and
programs designed for gay, lesbian, and transgender clients.
If patients are not ready to enter specialized treatment or attend
Alcoholics Anonymous or Narcotics Anonymous, then try to provide
information and negotiate a safety plan such as the identification of a
designated driver or use of a taxicab when drinking heavily or avoiding
drinking while taking medications. The injection drug user who is not
ready to accept a treatment referral may accept testing for human immu-
nodeficiency virus or hepatitis C virus, condoms, a referral to a syringe
exchange program, or other harm reduction strategies. The patient with
opioid use disorder, heroin or fentanyl use, or a recent opioid overdose
would benefit from overdose education, provision of naloxone through
direct distribution or prescription, and a safe discharge plan that
includes engaging the patient’s social support network and linkage to
addiction treatment. Opioid agonist therapy, also known as medication-
assisted treatment, with buprenorphine or methadone is vital to reduce
mortality among patients with opioid use disorder.54
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 THE MEDICAL EVALUATION
EDs often function as sources for the medical evaluation before patient
transfer to a substance or psychiatric treatment facility. There is consid-
erable variability in the levels of medical care provided in such facilities,
ranging from facilities that manage an array of chronic health problems
to those with minimal nursing support only for very stable patients.
Medical evaluation means that the patient does not have a medical
emergency or acute medical condition requiring hospitalization or pre-
venting addiction treatment. Patients with mild or moderate uncompli-
cated alcohol withdrawal that responds well to initial ED treatment (i.e.,
those with no trauma or major medical comorbidities, with no suicidal
or homicidal ideation or a seizure disorder) can be managed successfully
in a detoxification unit.
The criteria for placement in a detoxification unit are very similar to
those for safe discharge and include the following: patients are stable
(in the short term rather than long term) and ambulatory, can take oral
medications, and are not suicidal or likely to seize. Patients on medica-
tions (including buprenorphine) should bring them to the treatment
facility or be given prescriptions or provided with several doses. Stable
patients with dual diagnoses who are not suicidal or acutely psychotic
can be medically cleared for transfer, as long as they have a supply of
current psychiatric and nonpsychiatric medications and can be expected
to take their medications correctly and reliably. Because detoxification
from opioids can place patients at high risk for opioid overdose once
discharged because of loss of tolerance, opioid overdose education and
provision of take-home naloxone are critically important.
PHARMACOLOGIC MANAGEMENT FOR ALCOHOL,
OPIOID, AND SEDATIVE USE DISORDERS
A large body of evidence supports the efficacy of pharmacologic inter-
ventions for the treatment of alcohol, opioid, and sedative use disorders.
Management of alcohol, opioid, and sedative intoxication; overdose;
and withdrawal syndromes is covered in chapters dedicated to each
substance. Pharmacologic management of individuals with moderate
to severe alcohol, opioid, and sedative use disorders is discussed here.
Many of these treatments will not be typically initiated in the ED, but
knowledge of their existence and effectiveness is important for the ED
provider to understand both when caring for patients who are pre-
scribed these medications and in providing referrals for medical man-
agement to patients with SUDs.
 ALCOHOL USE DISORDER MANAGEMENT
Medications for the treatment of alcohol use disorder include alco-
hol antagonist agents, such as disulfiram (Antabuse®), and medica-
tions that directly reduce alcohol consumption, including acamprosate
(Campral®), oral naltrexone, and long-acting injectable naltrexone
(Vivitrol®). Disulfiram is an oral medication that irreversibly binds to
and inhibits alcohol dehydrogenase, causing the unpleasant disulfiram-
ethanol reaction, which can include nausea, vomiting, diaphoresis,
flushing, and tachycardia, the avoidance of which serves as a deterrent
for the consumption of alcohol.54,55 Acamprosate, an amino acid derivative
that increases γ-aminobutyric acid transmission, was previously found
to be effective in reducing return to alcohol use in a number of U.S. and
European studies, but did not show efficacy in a large multicenter trial.56
In the Combined Pharmacotherapies and Behavioral Interventions
study, a large prospective multisite study investigating the effect of
combinations of medications and behavioral therapies on alcohol use
disorder, acamprosate showed no significant effect on drinking versus
placebo, either by itself or with any combination of naltrexone, cognitive
behavior therapy, or both.57
Naltrexone, an opioid receptor antagonist with no intrinsic agonist
activity, is hypothesized to lead to reduce alcohol consumption by indi-
rectly affecting the dopaminergic reward pathway through effects on
the µ opioid receptor.55 Early studies reported that oral naltrexone, in
conjunction with behavioral intervention, led to lower reports of crav-
ing, fewer drinks and drinking days, and fewer relapses; more recent
systematic reviews report that naltrexone is effective at reducing return
8/2/19 5:19 PM

to heavy drinking and the amount of alcohol consumed.56,58 A long-
acting IM naltrexone injection was approved by the U.S. Food and Drug
Administration in 2006 and can decrease heavy drinking days while
avoiding the challenges of taking a daily medication.59 Importantly, these
medications are not mutually exclusive to each other, as multiple stud-
ies have shown improved outcomes in patients taking a combination of
medications for alcohol use disorder, as well as medications augmented
with behavioral or psychosocial interventions.56,57
 OPIOID USE DISORDER MANAGEMENT
A substantial body of literature supports medications for addiction
treatment or medication-assisted treatment for moderate or severe
opioid use disorders, and such treatment is recognized by the
Centers for Disease Control and Prevention, National Institute of Drug
Abuse, and World Health Organization.60-63 Collectively, methadone and
buprenorphine are referred to as opioid agonist treatments and have
been associated with a variety of improved outcomes including reduced
craving, decreased opioid use, decreased crime, decreased nonfatal
overdose, decreased mortality, cost-effectiveness, and improved social
functioning.61,62,64-66
Methadone Methadone is a long-acting oral medication with full opi-
oid agonist properties at the µ receptor. Methadone can be prescribed by
physicians for the treatment of pain, but the prescription of methadone
for treatment of addiction is limited by the Federal Narcotics Act to inpa-
tient units or outpatient facilities licensed by the U.S. Drug Enforcement
Administration. Several large-scale studies have shown a relationship
between outcomes and methadone dose, with improved outcomes
including less opioid and cocaine use at doses above 60 milligrams.61,67
Methadone has been associated with QT prolongation on the ECG.68
Buprenorphine Buprenorphine is a partial opioid agonist and a weak
antagonist. It has a high affinity for µ receptors, displacing other opioids
from the receptor and causing acute withdrawal in patients who have
recently used opioids. The antagonist effects of buprenorphine block
respiratory depression and provide a good margin of safety to treat
withdrawal or to provide opioid substitution therapy. The U.S. Food
and Drug Administration approved two sublingual formulations of
buprenorphine in 2002 for the treatment of opioid dependence. The
preferred preparation is a combination of buprenorphine combined with
naloxone in a ratio of 4:1, as a sublingual tablet or film (brand name
Suboxone® or Zubsolv®) to prevent diversion and overdoses.56,69 The
naloxone component is rapidly bioavailable if the medication is tam-
pered with and will precipitate withdrawal symptoms in opioid users.
Non–naloxone-containing films are traditionally reserved for pregnant
patients or settings with directly observed medication ingestion. Over-
doses can be managed with naloxone. Advise patients about the risks of
concurrent benzodiazepine use, including respiratory depression and
overdose of prescribed and illicit sedatives with all opioids, including
methadone and buprenorphine.
The Drug Addiction Treatment Act of 2000 established office-based
opioid treatment in an effort to integrate treatment options into compre-
hensive clinical care practice and reduce stigmatization of medication-
assisted treatment. The prescription of methadone for treatment of
addiction is limited by the Federal Narcotics Act to inpatient units or out-
patient facilities licensed by the U.S. Drug Enforcement Administration,
and buprenorphine is limited to certified clinicians in office- or clinic-
based practices. However, there is a “3-day rule” (Title 21, Code
of Federal Regulations, Part 1306.07b) that allows a practitioner who
is not separately registered as a narcotic treatment program or certi-
fied as a “waivered Drug Addiction Treatment Act of 2000” physician
to administer (but not prescribe) narcotic drugs to a patient to relieve
acute withdrawal symptoms while arranging for referral to treatment
(http://www.buprenorphine.samhsa.gov/faq.html). Only 1 day’s supply
may be administered or given to a patient, and this may be done for
72 hours only, which cannot be extended. The intent of Title 21, Code of
Federal Regulations, Part 1306.07b is to provide flexibility in emergency
situations and is especially relevant to emergency physicians. This offers
patients options for relief of withdrawal symptoms to bridge the patient
for follow-up to either a specialized treatment program or an office-
based physician program in the community.
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CHAPTER 292: Substance Use Disorders   1963
A study of 329 ED patients found that patients with moderate or severe
opioid use disorder randomized to receive a brief intervention with ini-
tiation of buprenorphine in the ED with primary care follow-up were
significantly more likely to be engaged in formal treatment for opioid use
disorder at 30 days (78%; 95% confidence interval [CI], 70% to 85%), com-
pared with referral alone (37%; 95% CI, 28% to 47%) and brief intervention
with a facilitated, direct referral (45%; 95% CI, 36% to 54%; P < .001).70
The buprenorphine group reduced the number of days of illicit opioid use
per week from 5.4 days (95% CI, 5.1 to 5.7) to 0.9 days (95% CI, 0.5 to 1.3)
versus a reduction from 5.4 days (95% CI, 5.1 to 5.7) to 2.3 days (95% CI,
1.7 to 3.0) in the referral group and from 5.6 days (95% CI, 5.3 to 5.9) to
2.4 days (95% CI, 1.8 to 3.0) in the brief intervention group (P < .001 for
both time and intervention effects; P = .02 for the interaction effect).70
This important study from 2015, combined with the rapid increase in
opioid-associated fatalities, laid the foundation for EDs to help bridge the
treatment gap for patients with opioid use disorder by collaborating with
local treatment providers to develop pathways for rapid linkage to care.
The starting dose for treatment of opioid withdrawal is sublingual
buprenorphine/naloxone, 4 to 8 milligrams of buprenorphine/2 milligrams
of naloxone, given to patients who meet criteria for moderate or severe
opioid use disorder and show signs of opioid withdrawal according to
the Clinical Opiate Withdrawal Scale (Figure 292-3).56,71 If the patient
does not yet exhibit symptoms of at least a score of 7 on the Clinical
Opiate Withdrawal Scale, a physician with a Drug Addiction Treatment
Act of 2000 waiver can prescribe a short course of buprenorphine
and discharge with instructions and with close follow-up in place
(Figure 292-4). In the case of naloxone administration after an over-
dose, patients will likely not meet criteria for opioid withdrawal during
the length of an ED stay after the naloxone wears off. Thus, if they wish
to start buprenorphine, they will be discharged with a prescription for
unobserved induction with close follow-up.
Naltrexone Naltrexone is a long-acting µ receptor antagonist that
reduces relapse or return to opioid use in patients by blockading any
positive reinforcement from taking opioids.71 Naltrexone is best suited
to patients with opioid use disorder who are highly motivated to avoid
opioids, as it provides modest relief from craving, or who were recently
released from a controlled environment such as incarceration or an
abstinence program. Naltrexone requires at least a 7-day period with-
out opioid exposure to avoid the complication of precipitated with-
drawal. Recent studies comparing it with opioid agonist treatment such
as buprenorphine highlight the fact that patients may refuse treatment,
and evaluation of effectiveness has been complicated by poor study and
treatment retention.55,56
Benzodiazepines The chronic use of sedatives, particularly benzo-
diazepines, is a common comorbidity with other substance use dis-
orders. The emergency provider often encounters patients with signs
and symptoms of withdrawal, when prescriptions are not filled after
hospitalizations or surgeries. Symptoms of withdrawal may develop up
to 7 to 10 days after stopping chronic benzodiazepine use, and patients
may develop withdrawal seizures. The clinical picture resembles alcohol
withdrawal with symptoms of hypertension, tachycardia and tachypnea,
tremulousness, anxiety, agoraphobia, insomnia, altered mental status,
delirium, and hallucinations. Medical management for the treatment
of benzodiazepine withdrawal is complicated by risk of withdrawal sei-
zures. Most evidence supports a prolonged benzodiazepine taper over
4 to 12 weeks.57 A 2006 Cochrane review found support for a gradual
benzodiazepines taper, although it did not find significant differences
between patients being tapered on long- versus short-acting benzodiaz-
epines, and no additional benefit was found to support the adjunct use
of additional medications such as propranolol or hydroxyzine.58 A meta-
analysis of 29 studies evaluating strategies for the discontinuation of
benzodiazepines found that both minimal interventions and systematic
discontinuation of benzodiazepines were more effective than treatment
as usual and concluded that there is adequate support of the stepped care
model, in which minimal intervention is followed by systematic discon-
tinuation.57 Preliminary evidence for the use of carbamazepine exists,
but large, controlled trials have not been reported.59 Benzodiazepines
should be continued in collaboration with the primary care provider
or mental health provider, and the patient should be referred to an
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 1964   SECTION 24: Psychosocial Disorders

APPENDIX 1
Clinical Opiate Withdrawal Scale (COWS)

For each item, circle the number that best describes the patient’s signs or symptom. Rate on just the apparent
relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just
prior to assessment, the increase pulse rate would not add to the score.

Patient’s Name:_____________________ Date and Time ____/____/____:_________

Reason for this assessment:___________________________________________________________________

Resting Pulse Rate: ________beats/minute GI Upset: Over last 1/2 hour

Measured after patient is sitting or lying for one minute 0 no GI symptoms
0 pulse rate 80 or below 1 stomach cramps
1 pulse rate 81-100 2 nausea or loose stool
2 pulse rate 101-120 3 vomiting or diarrhea
by [HSRL - Health Science Research Library] at 14:04 02 September

4 pulse rate greater than 120 5 multiple episodes of diarrhea or vomiting

Sweating: Over past 1/2 hour not accounted for by Tremor Observation of outstreched hands
room temperature or patient activity. 0 no tremor
0 no report of chills or flushing 1 tremor can be felt, but not observed
1 subjective report of chills or flushing 2 slight tremor observable
2 flushed or observable moistness on face 4 gross tremor or muscle twitching
3 beads of sweat on brow or face
4 sweat streaming off face
Restlessness Observation during assessment Yawning Observation during assessment
0 able to sit still 0 no yawning
1 reports difficulty sitting still, but is able to do so 1 yawning once or twice during assessment
3 frequent shifting or extraneous movements of legs/arms 2 yawning three or more times during assessment
5 unable to sit still for more than a few seconds 4 yawning several times/minute
Pupil size Anxiety or Irritability
0 pupils pinned or normal size for room light 0 none
1 pupils possibly larger than normal for room light 1 patient reports increasing irritability or anxiousness
2 pupils moderately dilated 2 patient obviously irritable or anxious
5 pupils so dilated that only the rim of the iris is visible 4 patient so irritable or anxious that participation in
the assessment is difficult
Bone or Joint aches If patient was having pain Gooseflesh skin
previously, only the additional component attributed 0 skin is smooth
to opiates withdrawal is scored 3 piloerrection of skin can be felt or hairs standing up
0 not present on arms
1 mild diffuse discomfort 5 prominent piloerrection
2 patient reports severe diffuse aching of joints/muscles
4 patient is rubbing joints or muscles and is unable to sit
still because of discomfort
Runny nose or tearing Not accounted for by cold
symptoms or allergies
Total Score ________
0 not present
The total score is the sum of all 11 items
1 nasal stuffiness or unusually moist eyes
2 nose running or tearing Initials of person
4 nose constantly running or tears streaming down cheeks completing assessment: ______________

5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal
This version may be copied and used clinically.
Journal of Psychoactive Drugs Volume 35 (2), April - June 2003

FIGURE 292-3. Clinical Opiate Withdrawal Scale. [Reproduced with permission from Wesson DR, Ling W: The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs 35: 253, 2003.
Copyright Taylor & Francis Ltd.]

addiction medicine specialist as needed. If benzodiazepines are neces- hepatitis C virus transmission rates, fewer injection drug risk behav-
sary for continued treatment of debilitating psychiatric illness, patients iors, decreased overdose incidents, and more rapid entry into detox
should have a psychiatry consult or evaluation as these medications are programs.74-76 Naloxone, a competitive opioid receptor antagonist, has
frequently inappropriately prescribed or overprescribed. been distributed for bystander opioid overdose reversal since 1996 at
community naloxone distribution programs.77 Community naloxone
distribution programs have demonstrated that lay people and injection
REDUCTION OF HARM FROM OPIOID USE drug users can reliably administer naloxone.78-82 Population studies have
DISORDER noted that naloxone distribution is associated with decreased commu-
nity overdose deaths83 and decreased deaths among people released from
Many ED patients with opioid use disorder will not be ready to enter prison,84 is cost-effective when provided to heroin users,85 and reduces
treatment at the time of the ED visit, but we still have an opportunity opioid-related ED visits when co-prescribed with opioids for chronic
to help them progress in their readiness to seek treatment, prevent pain by a primary care provider.86 Given the increasing incidence of
individual and societal harms associated with drug use, and prevent opioid overdose, some cities and states have started storing publicly
future overdose deaths. Syringe access72,73 and supervised consumption accessible naloxone with automated external defibrillator devices, in
facilities have demonstrated lower human immunodeficiency virus and designated NaloxBoxes, and at public schools.87

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 CHAPTER 292: Substance Use Disorders   1965

ED-Initiated Buprenorphine
Diagnosis of Moderate to Severe Opioid Use Disorder
Assess for opioid type and last use
Patients taking methadone may have withdrawal reactions to buprenorphine up to 72 hours after last use
Consider consultation before starting buprenorphine in these patients

(0–7) none - mild (≥8) mild - severe

COWS
withdrawal withdrawal

Dosing: Dosing:
None in ED 4–8 milligrams SL*

Waivered provider able to Observe for 45–60 min

prescribe buprenorphine? No adverse reaction

YES NO
If initial dose 4 milligram SL repeat
All Patients Receive: 4 milligram SL for total 8 milligram
Unobserved
buprenorphine Referral for -Brief Intervention
induction and referral ongoing treatment -Overdose Education
for ongoing treatment -Naloxone Distribution Observe**

Notes: Waivered provider able to prescribe

*Clinical Opiate Withdrawal Scale (COWS) ≥ 13 (Moderate-Severe) consider buprenorphine?
starting with 8 milligram buprenorphine or buprenorphine/naloxone SL
**If patient remains in moderate withdrawal may consider adding additional 4 milligram
and observation for 60 minutes YES NO
***Consider high dosing in consultation with an Addiction Medicine Specialist
Warm hand-offs with specific time & date to opioid treatment providers/
programs within 24–72 hours whenever possible Prescription Consider return to the ED for
All patients should be educated regarding dangers of benzodiazepine and 16-milligram dosing for 2 days of 16-milligram dosing
alcohol co-use each day until appointment (72-hour rule)***
Ancillary medication treatments with buprenorphine induction are not needed for ongoing treatment Referral for ongoing treatment

FIGURE 292-4. ED-initiated buprenorphine. SL = sublingual. [Adapted from study protocol D’Onofrio G, O’Connor PG, Pantalon MV, et al: Emergency department-initiated
buprenorphine/naloxone treatment for opioid dependence. JAMA 313: 1636, 2015. The study was supported by grant 5RO1DA025991 from National Institute on Drug Abuse. https/www
.drugabuse.gov/ed-buprenorphine]

In addition to referring patients to addiction treatment, community
syringe access, and naloxone distribution programs, in 2009 EDs started
providing take-home naloxone to patients at high risk of opioid over-
dose to prevent opioid overdose death.88-91 Naloxone can be either pre-
scribed for pickup at a pharmacy or given to patients in a preassembled
“kit” that includes administration instructions, a mouth barrier for CPR,
and two doses of naloxone. Provision of naloxone at the time of the ED
visit decreases access barriers and ensures that the patient and/or their
family member has received the medication.
Naloxone can be given IM or intranasally. IM naloxone can
be prescribed as two single-dose vials, 0.4 milligram/mL with a 3-mL
syringe and 1-inch 23-guage needle (Table 292-3). This is the cheapest
formulation, but it requires drawing up the medication into a syringe prior
to administration. Another IM formulation, Evzio, is a U.S. Food and
Drug Administration–approved prefilled autoinjector. It has a single dose
of naloxone 2 milligrams/0.4 mL (prior formulation had 0.4-milligram
dose) and comes in packs of two. It is easy to use but more expensive and
requires prior insurance authorization, limiting its utility in the ED setting.
Narcan® is a U.S. Food and Drug Administration–approved intranasal
form of naloxone that contains 4 milligrams of naloxone and requires no
assembly. It is very easy to use but more expensive than generic formula-
tions. Generic intranasal naloxone is prescribed as two prefilled Luer-Lock
needless syringes containing 2 milligrams/2 mL to be dispensed with a
mucosal atomizing device. This formulation requires assembly before use.

TABLE 292-3 Naloxone Formulations Characteristics and Prescriptions

Generic Intramuscular Evzioø Auto-Injector Generic Intranasal Narcan® Nasal Spray
Dose 0.4 milligram/mL 2 milligrams/0.4 mL 1 milligram/mL 4 milligrams/0.1 mL
Titratable dose X X
Assembly required X X
Cost $ $$$ $$ $$
Prescription and quantity Two single-use 1-mL vials PLUS two One two-pack of two 2 mil- Two 2-mL Luer-Jet Luer-Lock needle- One two-pack of two 4 mg/0.1 mL
3-mL syringes with 23- to 25-gauge ligram/0.4 mL prefilled auto- less syringes plus two mucosal atomizer intranasal devices; two refills
1- to 1.5-inch IM needles; two refills injector devices; two refills devices (MAD-300); two refills

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 1966   SECTION 24: Psychosocial Disorders
Primary considerations when considering distributing naloxone
include state regulatory barriers, which can limit direct to patient
naloxone distribution and third-party prescribing; cost; and patient
education. Naloxone is covered by most insurance plans. Any trained
staff member can provide overdose prevention, response, and naloxone
administration education. Patient education is best done in person in
combination with facilitation of treatment referral; however, it can also
be done with video.88
SAFE PRESCRIBING OF OPIOID PAIN RELIEVERS
Emergency providers commonly treat painful conditions.92 Opioids are
frequently prescribed for patients with pain, with a multicenter study
showing that 17% of discharged patients received an opioid prescription.93
With heightened awareness of the risks associated with opioids, that per-
centage is decreasing, but it is likely that opioids will always continue to
have a role for certain ED patients with pain. ED prescribing is not a sig-
nificant contributor to the overall number of opioid prescriptions writ-
ten annually in the United States, providing only about 4% to 5% of the
total number of opioid prescriptions and about 2% when converted to
morphine equivalents.94,95 However, providers must be aware that short-
term ED prescriptions can have long-term consequences: One study
showed that 12% of opioid-naive patients given an ED opioid prescrip-
tion had recurrent use,96 and another concluded that about one third
of patients with opioid use disorder who were first exposed to opioids
by a legitimate prescription obtained that prescription from the ED.97
Standardization of treatment is key: There is currently wide variation in
rates of opioid prescribing among physicians practicing within the same
ED, and higher-intensity opioid prescribers within an individual depart-
ment are more likely to have patients who are on opioids long term.98
Furthermore, the longer the duration of an initial opioid prescription,
the more likely it is the patient will develop long-term use,99 leading to
the following recommendation by the Centers for Disease Control and
Prevention: “When opioids are used for acute pain, clinicians should
prescribe the lowest effective dose of immediate-release opioids and
should prescribe no greater quantity than needed for the expected
duration of pain severe enough to require opioids. Three days or less
will often be sufficient; more than seven days will rarely be needed.”100
Therefore, a framework for safe prescribing of opioids from the ED
is essential to incorporate into practice and consists of the following
four pillars.
1. Determine if an opioid is indicated. There is mounting evidence that
outcomes for acutely painful conditions are the same whether or not
an opioid is used. For example, for patients with acute arm or leg
sprain pain, the combination of ibuprofen and acetaminophen results
in the same level of pain reduction at 2 hours as do combinations of
acetaminophen with oxycodone, hydrocodone, or codeine.101 Like-
wise, patients with nonradicular back pain who were given naproxen
had similar functional outcomes at 1 week whether or not they also
took oxycodone/acetaminophen or cyclobenzaprine.102 Given these
similar outcomes, it would be prudent to use nonopioid pain reliev-
ers (e.g., acetaminophen, ibuprofen, topical lidocaine) and avoid the
exposure altogether. A formal “alternatives to opioids” program can
be created, which encourages use of nonopioid pain medications,
triggerpoint injections, nitrous oxide, and ultrasound-guided nerve
blocks to avoid opioids when possible.
2. Screen patients for opioid misuse risk factors. If the decision is made to
prescribe an opioid, determine whether the patient is at higher risk
for future opioid misuse. Several screening tools have been produced
for this purpose, including the Screener and Opioid Assessment for
Patients with Pain–Revised and the Opioid Risk Tool.103,104 It is impor-
tant to note that these tools were derived and validated in non-ED
settings, and recently, the Centers for Disease Control and Prevention
declared that the tools have insufficient accuracy for classification of
patients as at low or high risk for abuse or misuse.105 It is therefore pru-
dent to use caution for all patients when prescribing opioids, although
be particularly careful when patients have high-risk features that are
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TABLE 292-4 Identifying Substance Abuse Risk
When assessing a prescription drug monitoring program (PDMP) profile, it is important to
look at the following factors:
• From how many providers did the patient receive prescriptions?
— Patients who used 4 or more prescribers or 4 or more pharmacies in 6 months may
have risk of death from overdose.59,60
• Is the patient taking both opioids and benzodiazepines?
— Patients who use combinations of medications may be at increased risk for
overdose.61
• How many morphine milligram equivalents of opioids is the patient taking per day?
— Patients who take 50 to 100 morphine milligram equivalents per day are at greater
risk of overdose death.62-64
• Is the patient taking long-acting/extended-release (LA/ER) opioids?
— Patients taking LA/ER may be at increased risk for overdose.65
• How often did the patient fill another prescription before the previous one
was scheduled to finish?
— Early refills indicate nonmedical use or noncompliance with treatment plan.65
• Is the patient taking buprenorphine?
— Patients taking buprenorphine are likely under the care of a pain specialist who
should be contacted prior to prescribing a scheduled medication.
• Is the patient taking psychiatric medications, such as methylphenidate?
— Psychiatric comorbidities are associated with increased risk of overdose.
• If reported by the PDMP, how often did the patient self-pay?
— Patients may pay out of pocket for a prescription without involving an insurer to
avoid detection of nonmedical use.
detected by these tools, such as concomitant psychiatric illness and/or
previous personal or family history of drug or alcohol abuse.
3. Utilize a prescription drug monitoring program. Nearly all states
have implemented prescription drug monitoring programs that
track the prescribing and dispensing of controlled substances at the
pharmacy level.106 When first implemented, states with prescription
drug monitoring programs appeared to have lower rates of substance
abuse treatment admission and lower rates of increase in abuse/mis-
use compared to states that did not have them.107 Prescription drug
monitoring program data can change prescribing behavior because
providers do not have adequate sensitivity or positive predictive
value in detecting certain aberrant drug-related behaviors (e.g.,
“doctor shopping”) without the aid of this tool.108 Although they
should be used prior to every opioid prescription, there are limitations
to these databases, particularly that they do not detect medications
that are diverted or purchased illegally, which are the main sources of
non–medically used opioid pain relievers.109,110 Use prescription drug
monitoring program data along with history, physical examination,
and clinical impression. Do not use prescription drug monitoring pro-
gram data as a reason to withhold adequate and necessary analgesia.
Several factors from prescription drug monitoring program data may
suggest concerning substance abuse risk (Table 292-4).
4. Educate about safe opioid use. Every patient who receives an opioid pre-
scription should be provided with specific education about safe use and
the risks of the medication. This education should include the following:
(1) use recommended nonopioid pain relievers (e.g., acetaminophen
and ibuprofen, if not contraindicated) first and understand that the
opioid is an adjunct that should be used only to make the pain tolerable
but not remove the pain entirely; (2) immediately stop use of the opi-
oid medication once the pain is tolerable with nonopioid medications;
(3) safely store the medication away from others in the household who
may be at increased risk of nonmedical use, such as adolescents; and
(4) dispose of any unused medication promptly and properly, which can
now be done at most pharmacies and police stations.111
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
8/2/19 5:19 PM

Abuse and Assault
CHAPTER Female and Male Sexual
Assault
293 Lisa A. Moreno-Walton
INTRODUCTION AND EPIDEMIOLOGY
Sexual assault is a crime of violence, intended to dominate and humiliate
the victim through the use of intimidation and fear.1 In many parts of the
world, sexual assault is a tool for oppression, a weapon of war, and an act
of genocide. Psychological trauma is a universal consequence of rape
and sexual assault, but the absence of physical injury does not indicate
that an assault did not take place. Sexual assault remains a major public
health problem throughout the world, with case rates of police-recorded
incidents as high as 92.9 per 100,000 in Botswana to a first-time record
of 0.0 in Liechtenstein in 2010.2 In the United States, the incidence of
rape decreased from 1.6 cases per 1000 people in 2015 to 1.1 cases per
1000 in 20163; however, nearly one in five American women (18.3%)
report being raped at some time during their lives.4
Although males are less commonly victimized, studies estimate that
between 0.6% and 22.2% of males have experienced sexual assaults.5-7
According to the National Electronic Injury Surveillance System, sexual
assaults accounted for >150,000 ED visits in 2001 in the United States.8
However, many sexual assault survivors do not report the assault to
police or seek medical care.9 The Department of Justice estimates that
only 34.8% of sexual assaults are ever reported.10 Women are likely to seek
treatment earlier for more severe assaults and injuries, and they are more
likely to delay seeking assistance if assaulted by a known perpetrator.9
In most cases of rape in the United States, a single assailant is
involved, and most often, the perpetrator is known to the victim.11
Twenty-six percent of assailants are current or former partners, 38% are
friends or acquaintances, and only 26% are strangers.10 Force or coercion
is used in most assaults, but a weapon is reported in only 11% of cases.4
About half of female12 and male13 assault survivors have genital or rectal
trauma on examination, and about two thirds have some evidence of bruis-
ing elsewhere.12 Injuries are more often found in female patients <20 years
old or >49 years old, those who have experienced anal assault, and those
who present within 24 hours of assault. Survivors age 12 to 17 years are more
likely to have anogenital injuries than those age 18 to 49 years.14
HEALTHCARE RESPONSIBILITIES
Care of the sexual assault victim is complex and can be time consuming.
Responsibilities include obtaining the medical and forensic history; per-
forming and documenting results of the medical examination; collecting
forensic evidence and ensuring that material follows the proper chain of
custody; treating potential sexually transmitted infections; treating other
acute medical problems and injuries; assessing pregnancy risk and pro-
viding treatment options; providing referral for crisis intervention and
medical follow-up; coordinating care with sexual assault advocates; and
testifying in court if needed.15 Although some hospitals provide sexual
assault nurse examiners (see next paragraph) to aid in medical and
forensic evaluation, in many institutions, emergency physicians will be
expected to provide most of the care for sexual assault victims.
Sexual assault nurse examiners (SANEs) provide expert assistance
for sexual assault evaluation. SANEs are certified by examination
through the Commission for Forensic Nursing Certification. Require-
ments before examination include an unrestricted registered nurse
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SECTION
25
license, 2 years of nursing experience, 40 hours of coursework, and
competency in supervised sexual assault examination.16 Physicians,
physician assistants, and nurses can also complete a separate course of
training and receive certification as sexual assault forensic examin-
ers (SAFEs). The Department of Justice established national training
standards for SAFEs in 2006.17 Individuals, most often physicians and
physician assistants, who complete the proscribed training and pass a
standardized exam receive certification as a SAFE. There is little differ-
ence between SANE and SAFE training, but only registered nurses are
eligible to train as SANEs, and the Commission for Forensic Nursing
maintains authority over the certification of SANEs.
Because SAFEs and SANEs are specially trained to perform the
precise and sensitive history, physical and forensic examination, and
to preserve evidence in a chain of custody, many U.S. hospitals have
designated these individuals as part of sexual assault response teams
(SARTs). Local EMS personnel can transport survivors of sexual assault
to SARTs as a matter of protocol.
 CULTURAL DIFFERENCES AND MINORITIES
Appropriate cultural competency skills often set the tone for the first
steps toward healing. Some cultures consider rape a punishment or a
consequence of aberrant sexual behavior.18 Societies characterized by
gender-based power disparities are often less likely to define sexual
coercion and threats of violence as rape. Women from such cultures
often present for care with other chief complaints or will give inconsis-
tent histories if they feel they are culpable or could have offered more
resistance.19 In countries with a history of slavery, indentured servitude,
human property laws, and rigid caste or class systems, policies, tradi-
tions, and biases affect the treatment and adjudication of sexual assault.
Survivors may be reluctant to report victimization if they fear a biased
criminal justice system, do not think police will help, or anticipate being
blamed by their family or community.11,20,21
Fear of deportation may impact the decision of illegal aliens regard-
ing evidence collection, police reporting, and testifying in court. Before
encouraging patients to make a police report, learn your state’s laws
about illegal aliens who are crime victims.
Women of color face more challenges than white women in obtain-
ing assistance after rape. Services for victims of diverse backgrounds are
limited, and minority victims are often reluctant to contact rape crisis
centers.11 For black women survivors of sexual assault, poverty is a posi-
tive predictor of increased lifelong risk of depression and posttraumatic
stress disorder.11,22,23 Sexual minorities also suffer disproportionately.
In September 2018, the Centers for Disease Control and Prevention
published its National Intimate Partner and Sexual Violence Survey,24
documenting that 46% of bisexual women have been raped, in contrast
to 17% of heterosexual women and 13% of lesbians. Although most large
cities have good referral services and resources for providers, smaller
communities may not have support services for minority and ethni-
cally diverse patients. The Substance Abuse and Mental Health Ser-
vices Administration National Council for Trauma-Informed Care
provides excellent resources for institutions, providers, and patients,25
especially for referrals for continuing care.
THE SEXUAL ASSAULT EVALUATION
 TRIAGE
Triage sexual assault patients as a high priority, in accordance with
Department of Justice recommendations.15 Notify the SAFE or SANE
on call, and place the patient in a private room, ideally one reserved for
1967
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 1968   SECTION 25: Abuse and Assault
the care of sexual assault victims. If a SAFE or SANE examiner is not
in-house or if the hospital does not have a SART program, the triage
nurse should notify the emergency physician of the patient’s presence in
the department. Make sure the patient does not undress or change into
a hospital gown, as all clothing must be properly removed and stored
for forensic evaluation. Tell the patient not to wash, drink, or rinse
the mouth. Provide appropriate medical care whether or not patients
agree to evidence collection, police reporting, or assisting with criminal
prosecution.
 HISTORY
Begin the interview with introductions, express regret about the assault,
and provide reassurance that medical and psychological needs will be
addressed. Maintain a professional, caring attitude. A patient’s response
is affected by the physician’s attitude. A physician’s shock or outrage may
increase the patient’s concern about physical injuries or cause the patient
to feel marginalized. Questions perceived as critical or judgmental result
in feelings of guilt and shame and interfere with the survivor’s ability to
provide a thorough history. Calm reassurance will facilitate the history,
examination, and collection of evidence.
Ask open-ended questions about sexual history. For some women,
sexual assault is the first sexual encounter, and for some lesbian patients,
it may be the first sexual encounter with a male.
Obtain a thorough past medical history and general assault descrip-
tion, and ask the patient about injuries. In some instances, the triage
nurse will have obtained the past medical history. In EDs with SANE
services, a detailed assault history, to help guide the evidentiary exami-
nation, will be obtained by the SANE. If there are no SANE services,
but a sexual assault advocate, police representative, or social worker is
available, have those individuals in the room during the history taking
so that the patient does not have to repeat information.
Details to gather about the assault and medical history are listed
in Tables 293-1 and 293-2. Most authorities caution that the chances
of finding forensic evidence >72 hours after the assault are slim, so a
forensic examination is not necessary if >72 hours have elapsed since
the assault, unless the specific state allows evidence collection up to
96 hours after the assault. Verify the policy in your state well in advance
of the need to know.
 CONSENT FOR FORENSIC EXAMINATION
Have the patient sign the consent form for the forensic examination,
collection of evidence, photography, and transfer of evidence to law
enforcement authorities. Most hospitals have a prepackaged rape kit
with equipment and directions. However, check with the police if you
are unsure about the utility of your hospital’s kit, because some police
departments may require use of a specific kit for their precincts. Hos-
pitals will usually allow the storage of a rape kit for a specified period
of time while the patient decides whether or not she wishes to make a
police report. In such a case, encourage the patient to consent to the
forensic exam. Not every part of the forensic evidence kit needs to be
used every time. Tailor the collection of evidence to the specifics of
the assault.
If >72 hours (or 96 hours, according to your hospital’s policy) have
elapsed or the patient does not want an evidentiary examination, still
perform a full history and physical examination, provide pregnancy and
sexually transmitted disease prophylaxis, and refer for follow-up medi-
cal care and rape crisis counseling.
 PHYSICAL EXAMINATION
General Examination Record general information such as vital signs
and mental status. After clothing is properly removed and stored, per-
form a head-to-toe inspection, and look for injuries. Focus on defensive
injury areas such as the extremities, and carefully check potential areas
of injury such as the oral cavity, the neck (for strangulation signs), and
the breasts, thighs, and buttocks. Describe all injuries, and record all
areas of tenderness, even if there is no outward sign of injury. Injuries,
predominantly bruises, are often located on limbs (32%), face (23%),
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TABLE 293-1 Assault History
Who?
• Did the assault survivor know the assailant?
• Was it a single assailant or multiple assailants?
• Can the survivor recall any identifying features of the assailant (height, build, age, race,
tattoos, scars, birthmarks, etc.)? (Document in the medical records.)
What happened?
• Was the patient physically assaulted?
• With what (e.g., gun, bat, or fist) and to what part of the body?
• Was there actual or attempted vaginal, anal, or oral penetration?
• Did ejaculation occur? If so, where?
• Was a foreign object used?
• Was a condom used?
• Has alcohol been recently ingested? (Alcohol affects ED treatment with metronidazole
or tinidazole.)
• Has the victim been sexually assaulted before?
• Does the victim have suicidal or homicidal ideation?
When?
• When did the assault occur?
• (Emergency contraception is most effective when started within 72 h of the assault.)
Where?
• Where did the assault occur?
• (Corroborating evidence may be found based on the location of the assault.)
Suspicion of drug-facilitated rape?
• Was there a period of amnesia?
• Is there a history of being out drinking and then suddenly feeling very intoxicated?
• Is there a history of waking up naked or with genital soreness?
Douche, shower, or change of clothing?
• Did the patient douche, shower, or change clothing after the assault? (Performing any
of these activities prior to seeking medical attention may decrease the probability of
sperm or acid phosphatase recovery, as well as recovery of other bits of trace evidence.)
and torso (7%), with most assault survivors sustaining light (44%) or
moderate (18%) injuries.26 Other nongenital injuries include abrasions
(40%), lacerations (4%), and bites and burns (1%).12
 FORENSIC EXAMINATION
The forensic examination includes collection of head and pubic hair and
buccal swabs for DNA comparison, photographs of injuries, and vaginal
and perineal examination, often with colposcopy. Tell the patient what
the examiner is doing at each stage of the process. Tell the patient she
can take a break at any point during the examination. (See Video: Sexual
Assault.)
Assemble all of the needed equipment for forensic examination.
Throughout the examination, keep the patient’s body covered as much
as possible. Have several pairs of gloves available for different parts of
the examination—change gloves between the physical and the genital
exam, and again between the genital and the anal exam. A detailed list
of equipment and a demonstration of the examination and evidence col-
lection are available. Take photographs of abrasions, bruises, contusions,
TABLE 293-2 Medical History
• Last menstrual period? Birth control method?
• Last consensual intercourse?
• If the patient has had consensual intercourse within the past 3 to 4 days, it may
confuse laboratory analysis for sperm and acid phosphatase and genetic typing.
• Allergies, medication history, and possible pregnancy?
• Medical comorbidities
• Mental health issues or substance use disorder history
8/2/19 1:50 PM

lacerations, bite marks, burns, areas of erythema, hematomas, incisions,
petechiae, and swelling. Document location, position of patient, and
position of injury, using a clock face reference. Traditionally, when the
patient is in lithotomy position, the pubic bone is at 12 o’clock, the left
hip is at 3 o’clock, and the right hip is at 9 o’clock. Begin the photographic
series with a photograph of the patient’s face and end with a photograph
of the patient’s hospital wrist band. If photography is not available,
describe signs of trauma and areas of tenderness in detail using a body
map.
Begin the genital exam with combing of the pubic hair and extraction
of hair samples. Patients can pluck their own hair, but make sure that
the hair root is included. Examine the genital and rectal areas for inju-
ries and signs of trauma. Note any vaginal discharge, vaginal abrasions,
cervical abrasions, and cervical lacerations. In some institutions, a topi-
cal application of toluidine blue dye is used to highlight microtrauma.
Toluidine is a dye with affinity for DNA and RNA.27 When placed on
an area where the topical nonnuclear layer has been removed (as by
abrading by injury), toluidine dye will be taken up by underlying cellular
tissue. It is typically mixed for use by the hospital pharmacy. Toluidine
is applied to the external vulva, especially the posterior fourchette, but
not onto mucous membranes. If toluidine dye is used, do not perform
a speculum examination until after the toluidine dye examination is
completed, because the speculum examination itself may induce small
abrasions that can be confused with injuries from the assault.28 After
examination, remove excess dye with a water-soluble lubricant. If the
solution is not used soon after it is mixed, cover the bottle with alumi-
num foil, store at 4°C (39.2°F), and bring to room temperature before
use.29 An alternative to bottles of toluidine blue dye is the commercially
available Forensic Blue Swabs®.
Colposcopy detects injuries not visible to the naked eye.13 In one
study, only 34% of genital lesions were seen with the naked eye, 49%
were seen with a colposcopy, and 52% were seen with toluidine blue
dye.28 If the colposcope is used to photograph injuries, document mag-
nification. If the patient reports anal penetration, examine the anus and
rectum for abrasions or lacerations.
Finally, darken the room and scan the entire body surface with a
Wood’s lamp to detect traces of semen. Swab areas where the perpetrator
made any oral contact, and swab areas that illuminate with the Wood’s
lamp. Dry and label all swabs and add to the rape kit.
After all evidence is collected, make sure to maintain chain of
custody. Do not leave the kit unattended. Each party that releases and
accepts the evidence kit must sign, date, and time the chain-of-evidence
form. If the police are not present to receive the evidence, store the kit in
a locked cabinet specifically designated for this purpose. Many rape kits
contain elements that require refrigeration. In this case, when police are
not available to accept the kit, store the entire kit in a locked refrigerator
only used to store rape kits.
 LABORATORY TESTING
Obtain ancillary tests as clinically indicated. If there is high suspicion
of drug-facilitated rape, a urine sample can be sent to a labora-
tory for toxicologic testing. Drugs that are typically thought of as
“date rape” drugs, such as ketamine, flunitrazepam (Rohypnol), and
γ-hydroxybutyric acid, are not detected on routine ED toxicology
screening tests, and special “send out” tests must be ordered. Rohypnol
can be detected in the urine for up to 72 hours, and γ-hydroxybutyric
acid can be detected for 12 hours. Results, however, are not available
for days.30 Most SANEs typically send these tests when indicated and
assume responsibility for checking the results. In some hospitals with
SART programs, consent forms give the right to the prosecuting attor-
ney in the Special Victims Unit to receive the results. If these “send
out” tests are ordered by the ED physician, develop a protocol for
checking results and documenting results in the patient’s record. Guid-
ance for appropriate ordering can be obtained from womenshealth.gov
or by calling 800-994-9662.
Obtain a urine or serum pregnancy test before giving emergency
contraception. Testing for gonorrhea, chlamydia, and bacterial vagi-
nosis is not necessary, because treatment is provided at the ED encoun-
ter. However, do test for syphilis, hepatitis B and C, and human
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CHAPTER 293: Female and Male Sexual Assault   1969
immunodeficiency virus (HIV). Obtain serum chemistry, liver func-
tion studies, and CBC for patients who will receive HIV postexposure
prophylaxis.31 Follow baseline HIV testing with repeat testing at 6 weeks
and 3 and 6 months.
TREATMENT
Follow standard care protocols and also individually assess the needs
of the survivor.32,33 Treat physical injuries and provide immediate cri-
sis intervention if needed. Offer emergency contraception, sexually
transmitted disease prophylaxis, tetanus and hepatitis B vaccination if
needed, and prophylaxis against HIV infection (Table 293-3).31
 SEXUALLY TRANSMITTED INFECTION PROPHYLAXIS
The prevalence of sexually transmitted infections in an adolescent urban
population varies as follows by causative organism: Neisseria gonor-
rhoeae, 0.0% to 26.3%; Chlamydia trachomatis, 3.9% to 17%; Treponema
pallidum, 0.0% to 5.6%; Trichomonas vaginalis, 0.0% to 19.0%; and
human papillomavirus, 0.6% to 2.3%.34 The regimens currently recom-
mended by the Centers for Disease Control and Prevention are provided
in Table 293-4.
 EMERGENCY CONTRACEPTION
Obtain a pregnancy test on all women unless there is a history of hys-
terectomy. Offer pregnancy prevention to those who are not pregnant
and of childbearing age.35-40 The probability of a single act of intercourse
within the fertile window is about 25%.41 Also prescribe an antiemetic
for nausea and vomiting.39,40 Offer meclizine 50 milligrams, metoclo-
pramide 10 milligrams, or ondansetron 4 milligrams.40 Four emergency
contraceptive regimens are listed in Table 293-5.42 A fifth method
of emergency contraception is the insertion of a copper intrauterine
device, but this method is not commonly used after sexual assault or
in the ED, there is little information on its effectiveness for emergency
use,43 and availability is limited. Provide emergency contraception as
soon as possible following exposure; best results are within 3 days, and
effectiveness is lower within 4 to 5 days.44,45 Pregnancy after emergency
contraception is 3.6 times more likely for obese women than for women
with a normal body mass index. Failure of emergency contraception
TABLE 293-3  Centers for Disease Control and Prevention Guidelines for
Postassault Prophylaxis
• If assailant status unknown and survivor not previously vaccinated, give postexposure
hepatitis B vaccination without HBIG, and inform survivor that subsequent doses must
be given at 1–2 and 4–6 mo after first dose.31
• If the assailant is known to be HBsAg positive, unvaccinated survivors should receive
hepatitis B vaccine and HBIG at the time of initial examination.
• For survivors previously vaccinated but who have not had postvaccination testing, give
a single hepatitis B vaccine booster.
• HPV vaccination is recommended for female survivors age 9–26 y and male survivors
age 9–21 y at the time of initial examination. Inform survivor that subsequent doses
must be given at 1–2 mo and 6 mo after the first dose.16
• Empiric antibiotics for chlamydia, gonorrhea, and trichomoniasis (see Table 293-4).
• Tetanus prophylaxis if needed.
• Offer emergency contraception if the assault could result in pregnancy.31
• Baseline testing for syphilis, hepatitis C, and HIV.
• Obtain serum chemistries and liver function studies if HIV postexposure prophylaxis
given.
• Provide first follow-up at 1 week.
Abbreviations: HBIG = hepatitis B immune globulin; HBsAg = hepatitis B surface antigen; HIV = human
immunodeficiency virus; HPV = human papillomavirus.
Source: https://www.cdc.gov/std/tg2015/sexual-assault.htm cdc.gov (Centers for Disease Control and
Preventions: 2015 Sexually Transmitted Diseases Treatment Guidelines.) Accessed November 18, 2018.
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 1970   SECTION 25: Abuse and Assault

TABLE 293-4  Centers for Disease Control and Prevention Recommended TABLE 293-6  Recommendations for Postexposure Assessment of Human
Regimens for Infection Prophylaxis Immunodeficiency Virus (HIV) Infection Risk for Adolescent and
• Ceftriaxone, 250 milligrams IM, single dose Adult Survivors Within 72 Hours of Sexual Assault
Plus • Assess risk for HIV infection in the assailant.
• Azithromycin, 1 gram PO, single dose • Evaluate characteristics of the assault event that might increase risk for HIV
Plus transmission.
• Metronidazole,* 2 grams PO, single dose Because recommendations vary with time and between institutions, consult with a
specialist in HIV treatment for specific postexposure prophylaxis (PEP).
Or
• If the survivor appears to be at risk for HIV transmission from the assault, discuss anti-
• Tinidazole *2 grams PO, single dose retroviral prophylaxis, including toxicity and lack of proven benefit.
*
If alcohol has been recently ingested or emergency contraception is provided, metronidazole or • If the survivor chooses to start antiretroviral PEP, provide enough medication to last
tinidazole tablets can be given to the patient in the ED to take at home. until the next return visit. Reevaluate the survivor 3–7 d after initial assessment and
Source: https://www.cdc.gov/std/tg2015/sexual-assault.htm cdc.gov (Centers for Disease Control and assess tolerance of medications.
Preventions: 2015 Sexually Transmitted Diseases Treatment Guidelines.) Accessed November 18, 2018. • If PEP is started, perform CBC and serum chemistry panel at baseline. Do not delay PEP
while awaiting laboratory results.
• Perform HIV antibody test at original assessment; repeat at 6 wk, 3 mo, and 6 mo.
is more likely to occur with levonorgestrel than with ulipristal acetate; Repeat serologic assessment for syphilis can also be repeated at these times.31
however, in all women, regardless of body mass index, the most signifi-
cant factor predicting failure is the cycle day of intercourse.46 Source: https://www.cdc.gov/std/tg2015/sexual-assault.htm cdc.gov (Centers for Disease Control and
Breastfeeding is not contraindicated following emergency contracep- Preventions: 2015 Sexually Transmitted Diseases Treatment Guidelines.) Accessed November 18, 2018.
tion. Advise women that emergency contraception does not protect
against HIV infection, other sexually transmitted infections, or subse-
quent unprotected intercourse. Recommend follow-up with a healthcare through Friday where clinicians may obtain answers to questions
provider for all women and especially those with abnormal bleeding about caring for these patients. The Centers for Disease Control and
after cessation of emergency contraception.40 Advise women who use Prevention recommendations for postexposure assessment of adoles-
emergency contraception to follow up with a regular provider to begin cents and adults are listed in Table 293-6.
use of ongoing contraception in the form of oral contraception pills or If postexposure prophylaxis is administered, follow the standard
copper intrauterine device to ensure successful prevention of pregnancy protocol recommended by your hospital’s infectious disease special-
from subsequent unprotected intercourse.45,46 ists. When prescribing HIV postexposure prophylaxis, ask about sulfa
allergy. Truvada includes tenofovir, which has a sulfa moiety.
 HIV POSTEXPOSURE PROPHYLAXIS
Viral load in the assailant is the most significant factor determining DISPOSITION AND FOLLOW-UP
infectivity.48 HIV seroconversion has occurred in persons whose only
known risk factor was sexual assault or sexual abuse.49 HIV trans- Excellent care for survivors of sexual assault requires the coordination of
mission risk increases when bleeding occurs with vaginal, anal, or clinical medicine with forensic science, law enforcement, and survivor
oral penetration; if viral load in the ejaculate is high; and if genital advocacy. Once injuries are assessed and managed, offer counseling.
lesions are present in the assailant or the survivor.31 Assistance in This can be done by a dedicated rape counselor or trained social worker.
determining the advisability for postexposure prophylaxis can be If injuries are not severe, a rape counselor may be present prior to the
obtained by calling the toll-free National HIV/AIDS Postexposure physician’s assessment. Gaps in service and patient care have largely
Hotline at 1-888-448-4911 (available 9 am to 8 pm Eastern time involved lack of treatment of sexually transmitted infections and lack of
Monday through Friday, and 11 am to 8 pm Eastern time on weekends availability of pregnancy-related services.50
and holidays) or by accessing their website at http://nccc.ucsf.edu/ For patients with underlying mental health or substance use disor-
clinician-consultation/pep-post-exposure-prophylaxis/. There is also ders, recommend or arrange follow-up with their specific providers
a Clinicians’ Warmline (1-899-933-3413) open 9 am to 8 pm Monday within a week. Sexual assault victims are more likely to have substance
use disorders and previous mental health admissions, may be at risk for
depression and even suicide, and have a strong need for mental health
support.51 However, even those without such underlying disorders
TABLE 293-5 Emergency Contraception should be encouraged to receive mental health support, because post-
Drug Dose Comments traumatic stress disorder symptoms and depression are common.43
Prior to discharge, make sure that the patient has a safe place to go, a
Levonorgestrel 1.5 milligrams once Prescribe antiemetics; less nau- safe way to get there, and a plan for addressing absence from home or
(Plan B) or 0.75 milligram at sea than combined estrogen- work. This conversation should include a discussion of if, to whom, and
1 and 12 h progestin; available without how she will reveal her assault for the present time. Cultural competency
prescription; 11–24/1000 of the caregivers is essential throughout the delivery of healthcare ser-
estimated pregnancy risk vices to survivors of sexual assault, but it is critical at this juncture. If the
Combined estrogen- 100 micrograms ethinyl Prescribe antiemetics; 29/1000 team is not familiar with the cultural attitudes and practices surrounding
progestin47 (Yuzpe) estradiol plus 0.50 milligram estimated pregnancy risk sexual assault in the survivor’s religious, ethnic, or social group, ask the
levonorgestrel, at 1 and 12 h patient how his or her family, religious community, or social network
Mifepristone 25–50 milligrams PO as a Menstrual delay most common may respond.
single dose side effect; 1–10/1000 Prior to discharge, provide the opportunity for bathing and oral care.
estimated pregnancy risk Because clothing has been sequestered as part of the evidence kit,
hospitals should provide fresh, packaged underwear and outerwear
Ulipristal acetate 30 milligrams PO as a single Prescribe antiemetics; possibly for the patient. Sweat suits are customarily provided at most SART
(Ella/Fibristal) dose fewer pregnancies than with hospitals. This is an appropriate time to raise the issue of returning to
levonorgestrel the home environment, since the patient will return in clothing that is
Source: Data adapted from Shen J, Chey Y, Showell E, et al: Interventions for emergency contraception. not customary dress. Provide a headscarf for women who customarily
Cochrane Database Syst Rev 8: CD001324, 2017. [PMID: 28766313] wear head coverings in public.

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Arrange follow-up appointments according to Centers for Disease
Control and Prevention recommendations. Patients receiving postexpo-
sure prophylaxis should be seen within 1 week following initial assess-
ment, and all patients should be seen in 1 to 2 weeks.31 This ensures
the effectiveness of pregnancy prophylaxis and sexually transmitted
infection treatment.
Male sexual assault survivors should follow up with a urologist or
proctologist. Special populations, such as children, should be referred to
a pediatrician or a pediatric abuse clinic.
SPECIAL POPULATIONS
 ADOLESCENTS AND CHILDREN
Consider sexual abuse in children if no definitive explanation for non-
sexual transmission of a sexually transmitted infection can be identified.31
For extensive discussion, see Chapter 150, “Child Abuse and Neglect.”
The most experienced examiner available should examine children to
minimize pain or further trauma.
 ELDERLY PATIENTS
Most elder assaults take place at the patient’s home, and most assaults
are by an unknown assailant.52 In the case of an elderly assault survivor,
the forensic interview and examination present unique challenges. The
patient not only may resist the pelvic examination because of injury or
pain, but the pelvic area may be difficult to visualize because of hip con-
tractures or vaginal atrophy. It is also difficult to explain the examination
to a patient with dementia or cognitive impairment. Further challenges
include obtaining an accurate and reliable history of the details of the
assault, the injuries sustained, and regions of pain or discomfort.52,53
Special adjustments may be needed for the interview and sexual assault
examination.52,53
 TRANSGENDER AND LESBIAN PATIENTS
Until recently, information about sexual assault of lesbian and trans-
gendered women has mostly relied on data from informal surveys54 and
anecdotal evidence. These data indicate that 47% of transgender women
report being raped at least once in their life.55 The Centers for Disease
Control and Prevention’s 2018 report, National Intimate Partner and
Sexual Violence Survey,24 used more rigorous research methods and
presents significant data about the lesbian, gay, bisexual, transgender,
and queer community and sexual assault. FORGE (www.forge-forward
.org) is a Wisconsin-based group for the support of the transgender pop-
ulation. The group has a website with printable handouts for lesbian and
transgendered patients who are sexual assault survivors, survivor first-
person narratives, and resource links for both patients and providers.
 MEN
Male sexual assault is less common than sexual assault of women.56
Assaults on males generally result in more severe injuries,57,58 with 40%
to 60% of males sustaining anogenital injuries,58,59 and assaults on men
are likely to involve multiple assailants.60 At least a third of males who are
sexually assaulted have a history of psychiatric or cognitive disability.59
One major factor that complicates the care of male survivors is the fact
that physiologically, the stimulation of anal penetration can lead to
involuntary erection and sometimes to ejaculation. Furthermore, many
assailants manually stimulate their victims to cause ejaculation. Numer-
ous cases of male sexual assault have been determined to be consensual
by judges and defense attorneys who fail to understand the involuntary
nature of this physiologic response.60 The survivors themselves can be
confused and distressed by this response and may hesitate to offer this
information. Use a short, simple explanation of the physiology using lay
language to assist in history taking.
Hospitals have male rape kits available, and the same guidelines
should be followed for history, physical exam, collection of forensic evi-
dence, and maintaining chain of custody as have already been described.
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CHAPTER 294: Intimate Partner Violence and Abuse   1971
SANEs and SAFEs are all trained in the sexual assault forensic examina-
tion of males. Resources for counseling may be more difficult to find for
the male survivor, especially in small communities. The Rape, Abuse
& Incest National Network does have special resources for men. Its
victim hotline can be reached at 1-800-656-HOPE, and its website can
be accessed at www.rainn.org.
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER Intimate Partner Violence
and Abuse
294 Cameron Crandall
Sylvia Gonzalez Alden
INTRODUCTION AND EPIDEMIOLOGY
Intimate partner violence includes physical violence, sexual violence,
threats of physical or sexual violence, stalking, progressive social isola-
tion, and psychological aggression perpetrated by someone who is, was,
or wishes to be involved in an intimate or dating relationship with an
adult or adolescent individual. These actions are aimed at establishing
control by one partner over the other.1-3
Intimate partner violence and abuse is the preferred alternative for
previously used terms such as spousal abuse, wife battering, and domestic
violence. This term more accurately reflects the fact that this type of abuse
occurs not only in adult heterosexual married relationships but also in
relationships between cohabiting, separated, gay and lesbian, bisexual,
and transgender individuals as well as in adolescent dating relationships.3
Intimate partner violence and abuse occurs in every racial, ethnic,
cultural, geographic, and religious group, and it affects individuals of
all socioeconomic and educational backgrounds worldwide. Men are
affected, but the overwhelming burden of victimization from intimate
partner violence is borne by women.1,4 Intimate partner violence occurs
in both opposite sex and same sex relationships.3 Risk factors for inti-
mate partner violence and abuse include female sex, age between 18 and
24 years, low income level of the household, black or multiracial race/
ethnicity, bisexual sexual orientation, and relationship status of sepa-
rated rather than divorced or married.1 Presence of weapons in the home
and threats of murder are associated with increased risk of homicide.
Effects extend to family members, friends, coworkers, other wit-
nesses, and the community at large.1 In families in which either child
maltreatment or spousal abuse is identified, it is likely that both forms of
abuse exist.5 Children exposed to violence in the home have higher rates
of behavioral difficulties; mental and health problems including depres-
sion, anxiety, abusive behaviors, and drug abuse; and eating, sleeping,
and pain problems.5 Frequent exposure to violence in the home may
normalize violence for children, resulting in higher rates of victimiza-
tion and perpetration later in life.1,5
Providers should ask about a history of intimate partner violence or
abuse during healthcare encounters. Failure to recognize and intervene
in situations of intimate partner violence may have serious conse-
quences for the survivor and family. Such consequences may include
continued violence, physical and behavioral health problems, and injury
or even death.1,6,7
CLINICAL FEATURES
Intimate partner violence is often cyclical in nature. The cycle begins
with a period of tension building, which may include arguing, blam-
ing, or controlling behaviors or jealousy. The next phase is escalation
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 1972   SECTION 25: Abuse and Assault

TABLE 294-1 Health Consequences of Intimate Partner Violence TABLE 294-2 Signs Suggestive of Intimate Partner Violence
Adults Adolescents Children Findings Comments
Injuries Same as for adults Low birth weight Injuries characteristic of Fingernail scratches, broken fingernails, bite marks,
Alcohol and substance plus Prematurity and associated violence dental injuries, black eyes, broken bones, cigarette
abuse Victimization as an adult complications burns, bruises suggesting strangulation or restraint,
Sexually transmitted Failure to thrive and rope burns or ligature marks may be seen.
Fertility problems
infections Parental neglect syndrome Injuries suggesting a defensive Forearm bruises or fractures may be sustained when
Poor school performance
Human immunodeficiency posture individuals try to fend off blows to the face or chest.
and school dropout Speech disorders
virus infection Injuries during pregnancy Up to 45% of women report abuse or assault during
Unwanted pregnancy and Bedwetting
Pelvic inflammatory pregnancy.10
associated complications Headaches
disease of pregnancy, frequent Preterm labor, placental abruption, direct fetal injury,
Cognitive functioning and stillbirth can occur.
Urinary tract infections pregnancies problems—lower verbal
Vaginal bleeding Obesity and quantitative skills Central pattern of injury Injuries to the head, neck, face, and thorax, abdominal
Unintended pregnancy Behavioral disorders and genital injuries.
Psychological and
Headaches Involvement with the legal emotional problems— Extent or type of injury Multiple injuries at different anatomic sites inconsis-
system and courts aggression, hostility, inconsistent with the patient’s tent with the described mechanism of injury.
Chronic pelvic pain
withdrawal, acting out explanation The most common explanation of injury is a “fall.”
Back pain Risky sexual behaviors
Prostitution Child abuse Embarrassment, evasiveness, or lack of concern with
Eating disorders
the injuries may be noted.
GI disorders Alcohol and drug use
Multiple injuries in various These may be reported as “accidents” or “clumsiness.”
Depression stages of healing
Anxiety disorders Delay between the time of Victims may wait several days before seeking medical
Difficulty sleeping injury and the presentation for care for injuries.
Posttraumatic stress treatment Victims may seek care for minor or resolving injuries.
disorder
Visits for vague or minor com- Frequent ED visits for a variety of injuries or illnesses,
Substance abuse plaints without evidence of including chronic pelvic pain and other chronic pain
Homelessness physiologic abnormality syndromes.
Social isolation Suicide attempts Women who attempt or commit suicide often have a
Suicide history of intimate partner violence.10
Death

Multicultural and multilingual information about intimate partner

and may include verbal threats, physical and sexual abuse, or assault.
Weapons may be used at this point. Sometimes there may be a “honey-
moon” phase in which the perpetrator may apologize or make excuses
for inappropriate behavior. Over time, the abusive behavior tends
to increase in severity, and the intervals between abusive episodes
become shorter.
There are no “usual” features to help identify a victim of intimate
partner violence. Health-related consequences of violence or abuse often
lead to an ED visit (Table 294-1).2,8,9 Signs suggestive of intimate partner
violence and abuse are summarized in Table 294-2.1,8
Signs of abuse may be suspected by behavior of the partner. The
abusive partner may be defensive, hostile, and aggressive, and might
demonstrate controlling or overly solicitous behavior toward the
patient.9 The patient may appear frightened of the partner or refuse
to answer questions and instead defer all responses to the partner. In
situations raising concern, and if the patient agrees, hospital security
can prevent the alleged perpetrator from visiting the patient in the ED
and hospital.
SCREENING AND ASSESSMENT
Many experts, including the U.S. Preventive Services Task Force and
the American College of Emergency Physicians, recommend routine
screening for intimate partner violence for all adolescent and adult
women who present to the ED and for mothers of children brought
to the ED. Futures Without Violence has published national screening
consensus guidelines.9 Because of the known adverse long-term impacts
of intimate personal violence on health, when time permits, consider
screening for lifetime exposure.
A protocol should be implemented that addresses identification of,
and screening for, intimate partner violence; training of ED personnel;
confidential interviewing; and appropriate interventions, including vali-
dation and referral.2,9,11
violence and effects on abused individuals and family members should
be made available to the public and employees. This may consist of
posters and/or brochures in areas of the hospital such as public areas,
examination rooms, and restrooms. Community resources that provide
services to victims should be a part of the shared information.
Screening should be conducted by providers educated about the
dynamics of intimate partner violence. Provide a safe and private envi-
ronment for the interview. Take into account cultural differences and
expectations. If language interpreters are required, use individuals who
have no connection to the patient. Document screening results, safety
assessment, and any interventions, including referrals and required
reporting. Screening guidelines for adolescent and adult patients are
summarized in Table 294-3.9 Sample verbal screening questions are
listed in Table 294-4.9 The U.S. Preventive Services Task Force has pub-
lished a review of a variety screening tools.2
When conducting screening and assessment, be nonjudgmental, sen-
sitive, and direct. Let the patient know that you take the situation seri-
ously. Assure victims of confidentiality. Communicate an understanding
of the complexity of the situation and the difficulties of achieving a
“quick fix.” Reassure the victim that no one deserves abuse and victims
are not at fault. It is the abuser whose behavior is unacceptable. Avoid
pressuring, respect patient decisions, and work together to determine
an appropriate course of action.12 Ask abused individuals if they have
suicidal or homicidal ideation. Such ideation, particularly if accom-
panied by a concrete plan of action, should trigger immediate consul-
tation with a mental health provider.
RISK ASSESSMENT AND DISPOSITION
Ensuring the safety of the abused individual and children is the
foremost goal. The most dangerous periods for abused individuals are
during the time of abuse disclosure and during attempts to leave the
relationship. Indicators of a high-risk and potentially lethal situation

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 CHAPTER 294: Intimate Partner Violence and Abuse   1973

TABLE 294-3 Summary of National Consensus Guidelines for Screening for Intimate Partner Violence and Abuse in the ED9
Screening Assessment
Routinely screen at every visit.
Screen for current abuse, and if
time allows, screen for history of
abuse.
Screen privately (one on one)
or with nonrelated trained
interpreter.
Ask: What happened? When did
it happen? Where did it happen?
Who did this?
Respect patient decision to dis-
close or not.
Discuss any required reporting.
Include screening questions on
intake forms.
Intervention
Assess immediate safety.
Assess health impact of abuse.
Assess pattern of abuse.
Assess for danger and potential
lethality.
If the danger assessment findings
are positive, assess potential for
suicide and homicide.
Documentation
Listen carefully and provide
support.
“I’m concerned for your health
and safety.”
“You are not alone.”
“Help is available.”
“It is not your fault.”
“You don’t deserve it.”
“What happened to you can affect
your health.”
Provide information and materials.
“What can I do for you?”
Provide a safety plan.
Offer services, including an
advocate, social worker, police,
shelter, etc.
Legible, fluent; maintain confiden-
tiality of records
Abuse history:
 Subjective information:
Patient’s own words
 Objective information: Detailed
description of patient’s appear-
ance, behavioral indicators,
injuries, and health complaints
Use of forensic evidence kits where
appropriate
Results of physical examination
Use of body maps
Photographs (with patient’s
consent)
Radiologic, laboratory findings,
collection of forensic evidence:
clothes, debris, etc.
Any materials and referrals offered
Results of health and safety
assessments
Referral and Follow-Up
Refer to primary care physician,
mental health provider, social
worker, or intimate partner abuse
advocate.
Obtain permission to notify
provider.
Know current phone numbers for:
 Abuse and assault prevention
programs
 Legal services
Children’s programs
Mental health services
Law enforcement
Substance abuse programs
Transportation
 Local clergy or other commu-
nity organizations

include escalation in the frequency or severity of violence; the threat
or actual use of weapons; obsession with the abused individuals; hos-
tage taking; stalking; strangulation; and homicide or suicide threats
or attempts and evidence of violent behavior outside the home.
Another risk factor for serious injury or death is substance abuse by the
perpetrator, which can increase violent behaviors.1,8
If lethality risk is high, consult with experts before ED discharge.9
Hospital admission of the abused individual or children is an option in
high-risk situations in which there is no other way to ensure safety. Use
of a 24-hour safe room, a location established by some hospitals and
communities to provide a safe place for the patient to stay while arrange-
ments for safe disposition of the patient and family members are made,
is another option. Use of an alias name on admission and screening of
incoming phone calls may also be of benefit.
Some individuals feel safer remaining in the violent relationship than
leaving without adequate planning for a safe departure.9 Placing the
patient in a shelter or having the attacker arrested may not be congru-
ent with the individual’s goals. Ultimately, the abused individual must
decide if it is safe to return home. By providing information about inti-
mate violence, risks, and options, the ED provider can help the patient
TABLE 294-4 Sample of Intimate Partner Violence Screening Questions*
The healthcare worker should explain the following in his or her own words:
• We are concerned about your health and safety, so we ask all patients the same
questions about violence at home and personal life.
• Violence is very common, and we want to improve our response to individuals and
families experiencing violence.
The healthcare worker may ask the following questions of ALL patients:
• Are you ever afraid of your partner?
• In the last year, has your partner hit, kicked, punched, or otherwise hurt you?
• In the last year, has your partner put you down, humiliated you, or tried to control
what you can do?
• In the last year, has your partner threatened to hurt you?
If intimate partner violence has been identified in any of the above questions, ask if the
individual would like assistance today. Be prepared to offer resources, assess for safety,
and discuss a safety plan with the individual.
*
Additional screening tools are available.2,9
decide what is best. The patient’s decision making may be very complex,
because depression, lack of self-esteem, lack of support, social isolation,
financial dependence on the perpetrator, and fear make it difficult to
leave the relationship.
Refer individuals to intimate violence experts, such as trained hos-
pital social workers or community-based advocates, who can help the
victim assess the situation, understand options, plan for safety, and
arrange safe shelter. Community advocates are typically on call or avail-
able by telephone. If the patient can be safely discharged from the ED
and personal contact with an advocate cannot be made before discharge,
give the patient up-to-date information about available services in the
community. Intimate personal violence advocates should not be asked
to call the patient directly unless the patient agrees, because calls to
the home could jeopardize the patient’s safety.
Resources for healthcare providers to assist in preparing their prac-
tices for optimal response to victims of intimate personal violence are
available from a number of organizations (Table 294-5). Table 294-6
lists hotlines for patients.
 ED RECORD DOCUMENTATION
Voluntary descriptions of intimate personal violence should be quoted
and described in the patient’s own words. Do not use the word alleged
because it implies that the person recording the incident does not believe
the complaint.9 A complaint of “sexual assault” is no more alleged than
is a complaint of “ear pain” or a “sore throat.”
Record past and current abuse, with details of date, time, location,
witnesses, and specific injury. Describe the patient’s health complaints,
injuries, appearance, and demeanor. Annotated body maps and photo-
graphs can supplement written notes.
TABLE 294-5 Resources for Healthcare Providers
Futures Without Violence (formerly Family http://www.futureswithoutviolence.org
Violence Prevention Fund)
National Domestic Violence Hotline http://www.thehotline.org/
800-799-SAFE (7233)
National Coalition Against http://www.ncadv.org
Domestic Violence

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 1974   SECTION 25: Abuse and Assault
TABLE 294-6 Hotlines for Patients
National Domestic Violence Hotline: 24 h; links caller to help 800-799-SAFE (7233)
in her (or his) area—emergency shelter, domestic violence
shelters, legal advocacy and assistance programs, social services
800-787-3224 (TTY)
Rape, Abuse, and Incest National Network: 24 h; automatically 800-656-HOPE (4673)
transfers caller to nearest rape crisis center anywhere in the http://www.rainn.org
nation
Obtain relevant forensic evidence, and follow the appropriate chain
of custody of evidence. If sexual assault has occurred, document ED
testing and treatment; arrange for a sexual assault nurse examiner exam,
if locally available. See Chapter 293, “Female and Male Sexual Assault,”
for detailed discussion.
Record safety assessment and planning. A safety assessment form or
referral notes from an expert are helpful adjuncts.
 LEGAL CONSIDERATIONS
Most states in the United States have laws that require healthcare provid-
ers to report specified injuries, wounds, or crimes. Intimate personal
violence is a crime in all 50 states.13 Four states have exceptions to manda-
tory reporting for injuries related to domestic violence. The specifics of
the reporting requirements vary from state to state, and the adequacy
of response by the police to reporting varies by jurisdiction. Inadequate or
inappropriate response to the reports (e.g., informing the perpetrator
of the report without providing for the safety of the abused individual)
can increase the risk of harm to the abused. Inform the victim if there is
an obligation to make a police report and explain possible ramifications.
SPECIAL POPULATIONS
 PREGNANCY
Prevalence of intimate partner violence during pregnancy ranges from
6% to 22%.4,8 Women who report intimate partner violence and abuse
during pregnancy are at increased risk of postnatal abuse. Women
assaulted during pregnancy are three times more likely to be admitted
to the hospital than nonpregnant women.8
 IMMIGRANT POPULATIONS
Overall, prevalence of intimate partner violence is lower in people born
outside of the United States. However, certain immigrant populations
have rates far higher than U.S. natives.1,14 Moreover, the burden of
intimate partner violence can be much higher in these populations as
victims may be socially and linguistically isolated and perpetrators can
use threats of deportation to restrain victims from seeking help.14 The
federal Violence Against Women Act establishes protection that may
protect undocumented persons from deportation if they have been a
victim of crime, including intimate partner violence.
 LGBTQ PERSONS
Intimate partner violence occurs in same sex relationships at rates gen-
erally similar to opposite sex relationships. Bisexual women and men,
however, report substantially higher rates of intimate partner physical
violence overall.1 Transgender women and gender nonconforming per-
sons also experience intimate partner violence at higher rates. Lesbian,
gay, bisexual, transgender, and queer persons may not report to police
or seek advocacy services for fear of discrimination.3
Acknowledgment: The authors gratefully acknowledge the contri-
butions of Mary Hancock, the author of this chapter in the previous
edition.
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
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Tintinalli_Sec25_p1967-1978.indd 1974
CHAPTER Abuse of the Elderly and
Impaired
295 Jonathan Glauser
Frederic M. Hustey
INTRODUCTION
Elder abuse is an act or omission resulting in harm to the health or wel-
fare of an elderly person. Three key groups have published definitions of
elder abuse.1-3 Although the incidence of elder neglect and abuse is
unknown and widely felt to be underreported, the rate of different types
of abuse among the elderly has been estimated to be in the mid-single
digits up to 10% of persons age >65 years,4 or between 500,000 and
1 million U.S. adults.5,6 One meta-analysis identified the pooled preva-
lence of elder abuse overall in geographically diverse countries to be
15.7%.7 Alternatively, a clinician seeing between 20 and 40 adults over
age 60 per day could encounter more than one victim of elder mistreat-
ment on a daily basis.8 Table 295-1 summarizes the categories of elder
abuse.
CLINICAL FEATURES
 PHYSICAL ABUSE
Physical abuse is the most easily recognized form of elder abuse. It is
defined as the use of physical force that might result in bodily injury,
physical pain, or impairment. Pushing, slapping, burning, striking with
objects, and improper use of restraint are all examples of physical abuse.
Chemical restraint (such as intentional overmedication or administra-
tion of tranquilizers) is a more subtle form. Regardless of mechanism,
physical abuse is carried out with the intention of causing suffering,
pain, or other physical impairment to the abused person.
 CAREGIVER NEGLECT
Elder neglect is the most common form of elder maltreatment, account-
ing for more than half of all elder maltreatment cases reported to adult
protective services agencies annually.9 Elder neglect is defined as the
failure of a caregiver to meet basic needs for a person or to provide
goods and services necessary to prevent physical harm or emotional
TABLE 295-1 Categories of Elder Abuse
Categories of Abuse Example
Physical abuse Pushing, slapping, burning, striking with objects, improper use
of restraint (physical or chemical)
Caregiver neglect Deprivation of food, clothing, hygiene, medical care, shelter, or
supervision
Sexual abuse Unwanted touching, indecent exposure, unwanted innuendo,
rape
Financial or material Forcible transfer of property or other assets, including changing
exploitation elderly person’s will
Emotional or Verbal threats (such as threats of violence, institutionalization,
psychological abuse or deprivation), humiliation, intimidation, harassment, social
neglect, and isolation
Abandonment Desertion of an elder in the home or a hospital, nursing facility,
shopping mall, or other public location by a caregiver or caretaker
Self-neglect Failure or unwillingness to provide adequate food, clothing,
shelter, medical care, hygiene, or social stimulation to self in
individuals with diminished capacity to perform essential
self-care tasks
Source: Reproduced from U.S. Department of Health and Human Services, Administration on Aging and
Administration for Children and Families: The National Elder Abuse Incidence Study. Washington, DC:
National Center on Elder Abuse, 1998.
8/2/19 1:50 PM

discomfort.10,11 Examples of neglect include deprivation of food, cloth-
ing, hygiene, medical care, shelter, or supervision that a prudent person
would consider essential for the well-being of another.10,11
Elder neglect is both underrecognized and potentially lethal. It likely
accounts for the majority of cases of unreported abuse.12 It is also an
independent risk factor for mortality, even taking into account that the
deaths themselves may not be immediately ascribed to injury.9 Elder
neglect may be difficult to diagnose. Although some cases may be obvi-
ous (such as in a patient with multiple deep pressure ulcers), neglect is
often more subtle and difficult to detect.
 SEXUAL ABUSE
Sexual abuse is broadly defined as nonconsensual sexual contact of any
kind with an elderly person. The spectrum of sexual abuse ranges from
unwanted touching, indecent exposure, or unwanted innuendo, to rape
itself. Although sexual abuse is underreported across all age groups, in the
elderly, sexual abuse is even less likely to be reported. Fear of retaliation
and shame on the part of patients, as well as stereotyping of older patients
as asexual or not sexually desirable by clinicians, police, and others, may
be factors in underrecognition and underreporting of sexual abuse.13
 FINANCIAL OR MATERIAL EXPLOITATION
Financial abuse is estimated to be the second most common form of
elder abuse, accounting for approximately 20% to 30% of abuse cases.14
Financial or material exploitation is the illegal or improper use of an
elder’s funds, property, or assets.15 It occurs when family members, care-
givers, or friends take control of the elder person’s resources. Coercion
or outright theft may occur, with or without the awareness of the elder
person experiencing abuse. An elderly person may unwittingly sign
over access to savings accounts and other assets when he or she is in an
incapacitated state. Social Security checks or pensions may be used by
caregivers for personal gain. Theft may be blatant or coerced, with forc-
ible transfer of property, including changing of the elder’s will. Anticon-
stitutional abuse is a term coined to describe violation of constitutionally
guaranteed human rights, such as theft of identity papers, coercion, or
false pretense resulting in the surrender of rights.16 Abuse may result in
a decrease in the standard of living and an inability to pay bills, purchase
food, or obtain medications.
 EMOTIONAL OR PSYCHOLOGICAL ABUSE
Emotional or psychological abuse is defined as the infliction of anguish,
emotional pain, or distress. Examples of psychological and emotional
abuse include verbal threats (such as threats of violence, institution-
alization, or deprivation), humiliation, intimidation, and harassment.
Social neglect and isolation are also forms of abuse. Psychological and
emotional abuse can contribute to the development and worsening of
mental health problems such as depression, which is common in many
older victims.15
 ABANDONMENT
Abandonment constitutes the desertion of an elderly person by an indi-
vidual who is that person’s custodian or who has assumed responsibility
for providing care to the elder. Desertion of an elder in the home, hos-
pital, nursing facility, shopping mall, or other public location may occur.
 SELF-NEGLECT
Self-neglect includes those behaviors of an elderly person that threaten
his or her own safety. Such behaviors include failure or unwillingness
to provide adequate food, clothing, shelter, medical care, hygiene, or
social stimulation for oneself. It is the result of an adult’s inability, due
to diminished capacity, to perform essential self-care tasks. By defini-
tion, this applies to one who understands the consequences of his or her
choices and makes a conscious decision to engage in acts that threaten
his or her own health or safety.17 Patients who have cognitive impair-
ment or who are living in poverty are at greater risk of self-neglect and
may have increased mortality.9
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CHAPTER 295: Abuse of the Elderly and Impaired   1975
TABLE 295-2 Risk Factors for the Occurrence of Elder Abuse
Risk Factors for Elders Risk Factors for Perpetrators
Cognitive impairment History of mental illness
Physical dependency History of substance abuse
Lack of social support Excessive dependence on elder for financial support
Alcohol abuse History of violence within or outside the family
History of domestic violence Unemployed
Female gender History of financial difficulties
Developmental disability
Difficult behavior (such as
aggression or verbal outbursts)
Special medical or psychiatric
needs
Limited experience managing
finances
Institutionalization
DIAGNOSIS
 RISK FACTORS
An awareness of risk factors is important for the recognition of potential
victims of elder abuse or neglect. Risk factors can be divided into two
categories: factors associated with the elders and factors associated with
the perpetrators (Table 295-2).10,17-21
Patient characteristics associated with a higher risk for elder mistreat-
ment are cognitive impairment, physical dependency, lack of social
support, alcohol abuse, female sex, and a history of domestic violence.18
In addition, developmental disabilities, special medical or psychiatric
needs, and difficult behavior (such as aggression or verbal outbursts)
also increase the risk for abuse. Individuals with limited experience in
managing finances are at increased risk for financial or material exploi-
tation. Although elder abuse is more common in residential than insti-
tutional settings, institutionalization is also recognized as a risk factor
for neglect and abuse.10,20
Three characteristics of perpetrators have been identified as risk fac-
tors: a history of mental illness and/or substance abuse, excessive depen-
dence on the elder for financial support, and a history of violence within
or outside of the family.21 Abusers are most often the primary caregiver.
Adult children tend to be more inclined to abuse than are spouses, and
males engage in abuse more often than females.17 Caregivers may be well
intentioned but simply overwhelmed by the amount of care required.
They may themselves be impaired by mental or physical problems that
serve as barriers to the provision of adequate care.
 HISTORY
The approach to the patient interview is important. Potential sufferers of
abuse should be interviewed in private. The presence of caregivers, fam-
ily, or friends may cause the patient to feel intimidated or embarrassed,
which limits the amount and accuracy of information obtained. Try to
put the patient at ease by making the assessment seem like a routine
part of the evaluation.15 Separately interview individuals accompanying
the patient. Screening tools are available to aid in the detection of elder
abuse.22-24 The use of lengthier tools is not feasible in a busy ED, but the
American Medical Association has proposed a list of nine screening
questions that may be more practical to implement (Table 295-3). An
affirmative answer to any of the questions in this screening tool raises
concern and mandates further exploration.
During the interview, be prepared to recognize behavioral signs and
symptoms that suggest elder abuse. These include depression, fear,
withdrawal, confusion, anxiety, low self-esteem, and helplessness. Other
history-related indicators that suggest abuse or neglect include a pattern
of “physician shopping,” unexplained injuries inconsistent with medical
findings, and recurrent visits for similar injuries. Additional history taking
should explore risk factors for abuse as outlined earlier in “Risk Factors.”
8/2/19 1:50 PM
 1976   SECTION 25: Abuse and Assault
TABLE 295-3 Screening Questions for Elder Abuse
• Has anyone ever touched you without your consent?
• Has anyone ever made you do things you didn’t want to do?
• Has anyone taken anything that was yours without asking?
• Has anyone ever hurt you?
• Has anyone ever scolded or threatened you?
• Have you ever signed any documents you didn’t understand?
• Are you afraid of anyone at home?
• Are you alone a lot?
• Has anyone ever failed to help you take care of yourself when you needed help?
Information can be obtained by the physician prior to conducting the
private interview or by other members of the healthcare team, such as
nurses, who are likely to have more frequent interaction with the patient
and caregivers. Observing the interaction between the accompanying
individuals can yield valuable clues (Table 295-4).
 PHYSICAL EXAMINATION
Physical examination findings range from subtle and nondiagnostic to
highly suspicious. Abuse is often detected when examination findings
prompt further history taking with results suggesting elder mistreat-
ment. Psychological abuse and financial abuse are especially hard to
diagnose in the ED setting because physical examination findings are
uncommon. Nonetheless, it is important to perform a detailed evalu-
ation, including obtaining adequate exposure of the body to evaluate
for trauma and pressure ulcers. Common physical findings in sufferers
of elder abuse are bruising or trauma, poor general appearance and
hygiene, malnutrition, and dehydration.23
Although not the most common form of elder abuse, physical abuse
is the most easily recognized. Evidence of injury to normally protected
areas of the body is highly suspicious for physical abuse.18 Examples
include contusions or lacerations on the inner arms or inner thighs and
injury to the mastoid area. It is important to expose these areas when
examining the patient to avoid missing significant findings. Contusions
on the palms, soles of the feet, and buttocks also raise concern for elder
abuse.18 Multiple injuries in various stages of healing can suggest abuse
but may also be seen in patients with recurrent falls. Taking a thorough
history is especially important in differentiating these two causes.
Although older patients may sustain burns through accidental injury
(such as coming too close to an open flame while cooking), unusual
burns or multiple burns in various stages of healing should also raise
concern. Traumatic alopecia is highly suspicious, although not necessar-
ily diagnostic (because it may be seen in patients with some psychiatric
conditions). Rope or restraint marks on wrists or ankles17 occur when
elders are inappropriately restrained. Midshaft ulnar fractures (night-
stick fractures) can occur from attempts to shield blows by raising the
forearm. Fractures of the head, spine, and trunk may be more indica-
tive of abuse, although these can occur by other mechanisms. More
recently, the radiologic literature has investigated specific findings that
may be suggestive of elder abuse, although so far these are not consid-
ered pathognomonic; examples include upper, posterior, or multiple rib
fractures; multiple subdural hematomas; small bowel hematomas; and
injuries inconsistent with reported mechanism. Spiral fractures of long
bones and fractures with rotational components also raise suspicion of
abuse.25,26
TABLE 295-4  Clues During the Medical Interview That May Suggest Elder Abuse
• The patient appears fearful of his or her companion.
• There are conflicting accounts of an injury or illness from the patient and caregiver.
• The caregiver displays an attitude of indifference or anger toward the patient.
• The caregiver is overly concerned with the costs of treatment needed by the patient.
• The caregiver denies the patient the chance to interact privately with the physician.
• The caregiver appears overly concerned and attentive.
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Tintinalli_Sec25_p1967-1978.indd 1976
Findings resulting from caregiver neglect or self-neglect are less spe-
cific. Perhaps the most identifiable finding is that of multiple or deep
pressure ulcers. Ulcers that are uncared for (such as open ulcers lacking
appropriate dressings or packing) or those not in lumbar or sacral areas
raise suspicion even further. Incapacitated patients should be turned as
part of the examination to evaluate for skin breakdown. Poor personal
hygiene, inappropriate or soiled clothing, dehydration, malnutrition,
contractures, fecal impaction, and excoriations suggest neglect.11
Sexually transmitted diseases or findings of genital trauma, especially
in an incapacitated patient, raise concern for sexual abuse. Patients may
complain of genital or anal pain, itching, bruising, or bleeding. Torn or
stained underwear, with unexplained difficulty walking or sitting, may
be present. Oral trauma can also be a manifestation of sexual abuse.
Depression, anxiety, and fear can be manifestations of psychological
abuse, although they are nondiagnostic. Observation of interactions
with caregivers and companions can provide further important clues to
this type of abuse.
Although elder abuse is widely underrecognized and underreported,
remember that underlying medical disorders are often associated with
findings that could otherwise be identified with abuse. Advanced neuro-
logic disorders such as multiple sclerosis, amyotrophic lateral sclerosis,
and Parkinson’s disease may lead to immobilization and severe disability.
Individuals with such conditions are at risk for pressure ulcers, pneumo-
nia, or venous thromboembolism, even with adequate care.17
TREATMENT, DISPOSITION, AND FOLLOW-UP
Treatment of elder abuse in the ED involves three key components:
•• Addressing associated medical and psychological needs
•• Ensuring patient safety
•• Complying with local reporting requirements (https://ncea.acl.gov/)
Medical problems, including injuries, should be stabilized and treated
and may be best managed through hospital admission. In addition to
physical injury, metabolic derangements may be present. Patients with
dehydration or malnutrition can have a variety of electrolyte abnormali-
ties and may also have coexisting renal failure. Elders left in the same
position for an extended period of time may be at risk for rhabdomy-
olysis. Additional problems may exist due to failure to administer usual
medications at home. These issues should all be addressed during the
ED visit, including the ability to conduct activities of daily living, such
as meal preparation, housework, bathing, dressing oneself, toileting, and
managing finances.
Psychological problems brought on by abuse, as well as preexisting
psychiatric conditions and substance abuse, should also be addressed.
The severity of the problem and planned disposition can affect the
extent to which treatment is completed in the ED. For patients requir-
ing hospitalization, concerns and findings should be communicated
to the admitting service and documented in the medical record. For
patients who are discharged to home, arrangements should be made
for appropriate follow-up. Follow-up must be arranged for the patient’s
medical and psychiatric needs, and arrangements must also be made for
monitoring and assessment of home safety and assessment of caregiver
stress or substance abuse. A variety of resources are available to assist
with these issues (Table 295-5). Social work consultation can be helpful
in finding local resources.
Patients in immediate danger should be hospitalized, transferred to
the care of a friend or reliable family member, or placed in an emer-
gency shelter. Suspected abuse should be reported to the appropriate
state agency (https://ncea.acl.gov/) or local adult protective services
agency in order to ensure a follow-up investigation and a thorough
long-term assessment. Adult protective services is the federal program
that receives mandatory reports of suspected abuse, typically leading
to a home visit and further investigation. Although all 50 states have
adult protective services and long-term care ombudsman programs,
reporting is not mandated by law in every state. Elderly who live in the
community are protected in all states by adult protective services agen-
cies. Elders in institutional settings are protected in all states by long-
term care ombudsman programs. Violations specific to nursing home
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 CHAPTER 295: Abuse of the Elderly and Impaired   1977

TABLE 295-5 Resources for Elder Abuse

Who to Contact
Clinical Justice Services
Public Policy Institute
American Association of Retired Persons
601 E St., NW
Washington, DC 20049
202-434-2222
National Adult Protective Services
Association (NAPSA)
PO Box 96503 PMB 74669
Washington, DC 20090
202-370-6292
http://www.napsa-now.org/
National Center on Elder Abuse
c/o University of Southern California Keck
School of Medicine
Department of Family Medicine and
Geriatrics
1000 South Fremont Avenue, Unit 22,
Building A-6
Alhambra, CA 91803
855-500-3537
http://ncea.acl.gov/
National Organization for Victim Assistance
510 King St., Suite 424
Alexandria, VA 22314
800-TRY-NOVA or 703-535-6682
http://www.trynova.org
National Coalition Against Domestic
Violence
One Broadway, Suite B210
Denver, CO 80203
303-839-1852
http://www.ncadv.org
National Domestic Violence Hotline
Toll free: 800-799-SAFE
TTY: 800-787-3224 (for hearing impaired)
http://www.thehotline.org/
National Long-Term Care Ombudsman
Resource Center
http://www.ltcombudsman.org
National Council on Aging
251 18th Street South, Suite 500
Arlington, VA 22202
571-527-3900
http://www.ncoa.org
Commission on Law and Aging
American Bar Association
321 North Clark Street
Chicago, IL 60654
312-988-5000
http://www.abanet.org/aging
Services Provided Who to Contact Services Provided
Provides self-instruction training National Center on Elder Abuse One of the main information sites for elder
program, pamphlets, and brochures on 1201 15th Street, NW, Suite 350 abuse; provides a variety of resources, both
elder abuse prevention. Washington, DC 20005 nationally and by state. Also provides link to
202-898-2586 Training Library for Adult Protective Services
and Elder Abuse.
Email: ncea@nasua.org
https://www.elderabusecenter.org/
Provides a variety of resources for elder Family Caregiver Alliance Lead agency in CareJourney, a program
abuse, both nationally and by state and 235 Montgomery Street, Suite 950 designed to provide Internet services
county. San Francisco, CA 94104 to caregivers of adults with cognitive
415-434-3388 or 800-445-8106 impairments.
http://www.caregiver.org
AARP Leading organization representing people
One of the main information sites for elder 601 E St., NW over age 50. Provides publications on care-
abuse; provides a variety of resources, both Washington, DC 20049 giving issues, financial planning, durable
nationally and by state. power of attorney, trusts, and insurance.
888-OUR-AARP
http://www.aarp.org
Other resources:
Administration on Aging
330 Independence Ave., SW
Washington, DC 29201
202-245-0641
Provides referrals, resources in every state. https://www.acl.gov/about-acl/
administration-aging
National Committee for the Prevention of
Elder Abuse
1730 Rhode Island Ave., NW, Suite 1200
Washington, DC 20036
Provides training and education on
domestic violence, publications, and 202-464-9481
programs. http://www.preventelderabuse.org
National Committee for the Prevention of
Elder Abuse
c/o Institute on Aging
Provides intervention; cannot take 119 Belmont St.
reports; confidential; available 24 h via Worcester, MA 01605
phone. Live chat service available via 508-793-6166
website 19 h/day.
Elder Care Locator Nationwide service connecting older
Provides information on support, technical U.S. Administration on Aging Americans and caregivers with local support
assistance as well as information on local 800-677-1116 resources.
long-term care ombudsman resources by
https://eldercare.acl.gov/Public/Index.aspx
state.
Addresses many aging issues through
various programs.
Provides information on laws pertinent to
elders; has contact information by state and
other law-related services for legal assistance
providers; provides mandatory reporting
requirements for each state. Makes available
Domestic Violence and Sexual Assault in
Later Life, a resource packet of information
and materials accessible online.

residents might include the following: failure to respond to calls for help, Much long-term facility abuse occurs between residents; many facilities
unattended symptoms, injury of unknown origin or falls, physical abuse, have younger psychiatric patients who are more mobile and aggressive
poor staff attitudes related to respect or dignity, inappropriate medica- than the older debilitated residents.27 Become familiar with require-
tions or dosages, stolen or lost property, or abuse by other residents. ments pertaining to your own practice area (https://ncea.acl.gov/).

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 1978   SECTION 25: Abuse and Assault
TABLE 295-6  American College of Emergency Physicians Policy on Domestic
Family Violence31
• Emergency personnel assess patients for intimate partner violence, child and elder
maltreatment, and neglect.
• Emergency physicians are familiar with signs and symptoms of intimate partner vio-
lence, child and elder maltreatment, and neglect.
• Emergency medical services, medical schools, and emergency medicine residency cur-
ricula should include education and training in recognition, assessment, and interven-
tions in intimate partner violence, child and elder maltreatment, and neglect.
• Hospitals and EDs encourage clinical and epidemiologic research regarding the inci-
dence and prevalence of family violence as well as best practice approaches to detec-
tion, assessment, and intervention for victims of family violence.
• Hospitals and EDs are encouraged to participate in collaborative interdisciplinary
approaches for the recognition, assessment, and intervention of victims of family violence.
These approaches include the development of policies, protocols, and relationships with
outside agencies that oversee the management and investigation of family violence.
• Hospitals and EDs should maintain appropriate education regarding state legal require-
ments for reporting intimate partner violence and child and elder maltreatment.
In cases of unintentional neglect, education of the caregiver may be
the only intervention necessary. Other support options include home
health aide visits, respite services, day programs, accessible transporta-
tion, support groups, adult day care, and church activities or pastoral
visitations.20,28 When mistreatment results because the caregiver is over-
burdened, interventions to decrease stress and anxiety may be welcomed
by all parties. Spouses are most likely to be primary caregivers; most of
these are women. Lack of sleep and inadequate exercise and nutrition
are commonly expressed by caregivers, perhaps leading to anger and risk
of abuse. Services for caregivers may be publicly funded or community
based with support groups. Some programs provide home-delivered
meals, respite care, counseling, and assistance with advance directives
and estate planning.29
If available, medical case management teams can provide consultation
and support by assisting in the multidisciplinary evaluation of suspected
abuse cases and developing treatment plans. Team members gener-
ally are composed of a physician, nurses, and social workers.30 Teams
may make house calls, arrange physical and occupational therapy, and
provide for nutritional improvement and management of disease states.
Legal intervention teams can also be used to address financial manage-
ment, probate and guardianships, and other legal and housing issues.
Civil courts can issue protective orders, create guardianships, and issue
emergency removal orders. Recommendations for ED management of
cases of elder abuse and neglect are provided in Table 295-6.31
SPECIAL CONSIDERATIONS
 BARRIERS TO THE DETECTION OF ELDER ABUSE
Sufferers of elder abuse often have low self-esteem and may blame them-
selves for the abuse. They may not want to admit vulnerabilities and feel
disgraced for having raised a child who would betray them.28,32
Elder abuse victims may also be unwilling to press charges against a
family member. Abused older adults are frequently unaware of available
resources.32 In addition, they may harbor a fear of being removed from the
home or placed in a long-term care facility, of implicating family mem-
bers, or of experiencing further abuse in retaliation for having divulged
information. They may worry about not being believed. Victims may be
unable to articulate their circumstances due to cognitive impairment.
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Tintinalli_Sec25_p1967-1978.indd 1978
Abusers may control access to others and prevent encounters with out-
siders to ensure that secrecy is maintained. There may also be differing
perceptions as to what constitutes abuse based on cultural background.33
Physicians may fail to report abuse for a variety of reasons. They may
not be familiar with reporting laws or adequately understand reporting
mechanisms.5 They may fear offending patients or their family members.
Time constraints in the ED can also be a barrier to recognition and
reporting. There are no published studies of physical markers of mis-
treatment to distinguish preventable injury from intentional, inflicted, or
avoidable trauma.34 In addition, some physicians may have the misper-
ception that the law requires them to obtain the patient’s permission
before reporting suspected abuse.35 Hospitals may also lack protocols for
identifying or addressing elder abuse. It has been noted that screening for
elder abuse and neglect has not been recommended by the U.S. Preven-
tive Services Task Force for some of the aforementioned reasons.4
 ABUSE IN LONG-TERM CARE FACILITIES
Approximately 1.4 million Americans lived in nursing homes on any
given day in 2012.36 Elder abuse in nursing homes is well documented.
In one study, 36% of nurses and nursing aides working in long-term care
facilities reported witnessing at least one act of physical abuse in the pre-
vious year.37 A study of 2400 deaths in Arkansas nursing homes found 50
cases of suspected abuse or neglect, which indicates that forensic studies
need to play a larger role in the investigation of unexplained deaths of
older adults in long-term care facilities.38 Abuse in institutional settings
manifests in similar ways to abuse in residential settings: theft of money
or personal property, unsanitary conditions, poor personal hygiene,
sexual assault, physical abuse or unexplained injury, bed sores, physical
or chemical restraint, and malnutrition and dehydration. Perpetrators
appear to be evenly divided between residents of the facility and staff
members involved in the direct care of the victim.36 Nursing homes par-
ticipating in Medicare and Medicaid programs must comply with certain
quality-of-care requirements.39 Suspicion of abuse or neglect among
patients in nursing homes should be reported to the state nursing home
ombudsman program (http://www.ltcombudsman.org) or to an adult
protective services agency.
 LEGAL CONSIDERATIONS
Circumstances may occur in which hospital admission is advised, but
the patient refuses. If the patient is competent, his or her wishes must be
honored, even if those wishes do not appear to be in the patient’s best
self-interest. Decisional capacity by the patient depends on his or her
ability to understand all of the relevant information in order to make
a choice, to communicate that choice, and to appreciate the current
situation and treatment options. Therefore, it is especially important
to interview the patient alone and to explain in detail the concerns of
the healthcare provider. The physician should also attempt to explore
reasons for the patient’s reluctance to stay.
Patients who refuse admission but who lack decision-making capac-
ity should not be discharged back to an unsafe environment. Contact
with an adult protective services agency should be initiated. ED social
workers can help locate contact information for the local adult protec-
tive services agency. If the agency determines that the victim of abuse
lacks decision-making capacity, an emergency court order for protective
services may be necessary.
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
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Special Situations
CHAPTER Injection Drug Users
296 Suzanne M. Shepherd
INTRODUCTION AND EPIDEMIOLOGY
In 2015, multiple groups estimated that a quarter of a million people,
approximately 5% of the adult population, used illicit drugs of any vari-
ety at least once; the expected use likely causes between 12 million and
28 million years of “healthy life” lost due to premature disability and
death.1 In 2015, the United States had approximately one quarter of
reported drug-related deaths worldwide, with more than double the
death rate seen in 1999. Globally, drug-related deaths produced more
mortality than road traffic accidents or violence. Opioids remain the
most harmful type of drug of abuse, with a higher risk of fatal and non-
fatal overdose and risk of acquiring infection. Of people who inject
illicit drugs worldwide, about 1.6 million are infected with human
immunodeficiency virus (HIV) and 6.1 million are infected with
hepatitis C.
 RISK BEHAVIORS OF INJECTION DRUG USERS
The practice of injection and the lifestyle and culture of injection
drug users place such individuals at risk for a wide variety of infec-
tious and noninfectious medical complications. In addition to carrying
an increased risk of infection with HIV, hepatitis B and C, Kaposi’s
sarcoma-associated herpes virus, tetanus, tuberculosis, and sexually
transmitted diseases, the injection drug user also has an increased risk
of trauma and intimate partner violence.2,3 It is important to vaccinate
injection drug users against hepatitis B virus, human papillomavirus,
and, when it becomes available, HIV.4 The Centers for Disease Control
and Prevention recommends routine HIV screening in EDs and that
consent for testing should be “opt-out.”5
An association between childhood emotional, physical, and sexual
abuse or trauma and IV drug abuse also highlights the importance of
trauma-informed interventions for injection drug users and the impor-
tance of early screening and treatment for drug abuse in those who
have undergone childhood trauma.6 The high incidence of migration,
incarceration, homelessness, nutritional deficiencies, coincident smok-
ing and alcohol use, and mental illness further compromises the health
of this group.
PATHOPHYSIOLOGY
Injection drug use increases the risk for immunomodulating infec-
tions, such as HIV infection and hepatitis, and may induce immune
dysregulation. Exaggerated and atypical lymphocytosis, diminished
lymphocyte responsiveness to mitogenic stimulation and depressed
chemotaxis, hypergammaglobulinemia, increased opsonin produc-
tion, decreased T-cell and natural killer cell activity, high levels of
circulating immune complexes, and reticuloendothelial abnormalities
can be evident with ongoing drug injection. False-positive results on
nontreponemal syphilis serologic tests, positive results on Coombs
tests, low measured antibody response to vaccination, and throm-
botic thrombocytopenic purpura are possible in this population.7 The
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SECTION
26
immunomodulatory effects of injection drug use may also contribute to
the progression of HIV infection, as HIV-infected patients who inject
drugs are found to be less likely to suppress HIV-1 RNA than those
who do not.8 Given their immune dysfunction, suspect infection in all
febrile patients with ongoing drug injection even if the temperature
elevation is modest or WBC counts and erythrocyte sedimentation
rates are normal or near normal.
CLINICAL FEATURES
Be aware of the drugs used in local ED catchment areas, the constantly
evolving street names (e.g., “H,” “skag,” “tar,” “bud light”), and adul-
terants used to cut the drugs. Ask about drug type(s) and amount,
preparation of materials for injection (e.g., crushing capsules in the
mouth, licking needles, blowing on injection sites or blowing out clots
in needles, or using saliva, lemon juice, or tap or toilet water for drug
reconstitution), reuse of needles, needle sharing and HIV/hepatitis
status of drug-sharing partner(s), use of antibiotics, antiretroviral and
hepatitis C therapy, and coincident medical and mental illness.
Complications of injection drug use may be obvious, such as a pain-
ful, erythematous, fluctuant abscess. However, more subtle and vague
symptoms such as weakness, anorexia, myalgias, weight loss, night
sweats, and fever are common and may be the only signs of serious
underlying disease (Table 296-1). In addition, approximately 1 in
30 female injection drug users seeking care has alloantibody in preg-
nancy, possibly due to needle sharing, that can accompany early preg-
nancy loss and poor obstetric care.9
 FEVER
Fever is associated with infection in most patients. Noninfectious
causes of fever include acute toxic reactions to substances of abuse,
reactions to injected adulterants, and withdrawal syndromes. Cocaine
and amphetamines can cause acute fever. Patients with “cotton fever”
develop a flulike syndrome within hours after injection with drug sus-
pensions filtered through cotton balls. Findings may include tachypnea,
tachycardia, abdominal pain, and inflammatory retinal nodules. Chest
radiographs typically are normal but may demonstrate inflamma-
tory pulmonary granulomata. Symptoms spontaneously resolve within
24 hours.10 Patients withdrawing from barbiturates or heroin also may
appear acutely ill, presenting with chest and abdominal pain, diaphore-
sis, tachycardia, and fever.
Because no reliable markers are available to exclude serious illness
in the febrile injection drug user, common practice samples blood
for culture to detect bacteremia or endocarditis when no clear other
source exists (e.g., pneumonia, urine infection, cellulitis, or abscess)
while admitting such patients for observation pending results. In
clinically well patients for whom follow-up can be ensured, outpatient
management is reasonable after appropriate culture specimens are
obtained.
Explore socioeconomic issues such as the injection drug user’s ability
to purchase medications and access to outpatient follow-up; the latter
may impact disposition plans.
Deliver nonjudgmental instruction on measures to reduce the risk
of recurrent harm and offer drug rehabilitation (even as an outpatient
referral) in all cases. If available, counsel about local needle exchange
centers or supervised drug injection centers, which can save lives, pre-
vent disease transmission, and improve health in this population.
1979
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 1980   SECTION 26: Special Situations

TABLE 296-1 Evaluation of Injection Drug Users in the ED

Presenting Symptom Potential Findings Possible Diagnoses Ancillary Tests
Fever alone Shortness of breath, cough Pneumonia Chest radiography; blood cultures; ESR CRP;
echocardiography
Heart murmur Endocarditis CXR; blood cultures; ESR; CRP; TTE or TEE
Needle and track marks Occult bacteremia Blood cultures; CXR; possible Doppler US to evaluate
abscess, septic thrombophlebitis
Hypoxemia CXR; possible ECHO
Dysuria UA
Fever with nausea and vomiting, Diaphoresis Drug withdrawal Complete blood cell count; blood cultures; hepatitis
rigors, abdominal pain serologic testing; liver panel; UA
Recent injection “Cotton fever”
Jaundice or icterus Hepatitis CBC; LFTS; INR; consider hepatitis serology
Fever with dyspnea and cough Rales and rhonchi Bacterial pneumonia Chest radiography; blood cultures; chest CT
Purulent sputum Atypical pneumonia
Hypoxemia Tuberculosis Also sputum cx & gram stain and AFB stain
Pneumonia due to opportunistic organisms
Septic pulmonary emboli
Fever with weakness, weight loss, Cachexia HIV infection; tuberculosis HIV serologic testing; blood cultures; chest radiography;
anorexia, night sweats, diarrhea sputum staining for acid-fast bacillus; sputum culture;
hepatitis serologic testing
Oral thrush HIV infection
Hepatitis B and C
Fever with back pain Heart murmur Osteomyelitis Blood cultures; ESR; CRP; bone radiography; CT or MRI;
urinalysis
Focal neurologic signs Epidural abscess
Flank tenderness Endocarditis
Renal abscess
Dyspnea and cough Expiratory wheezes Hypersensitivity reaction Chest radiography; spirometry; echocardiography;
blood cultures
Rales and rhonchi Noncardiogenic pulmonary edema CXR; ECHO
Fever Pneumonia
Pleuritic chest pain Septic pulmonary emboli Blood cultures, ECHO
Talc reaction
Painful limb Localized erythema Cellulitis Wound specimen cultures; soft tissue radiography; CT;
blood cultures
Tenderness Abscess
Localized bruit Pseudoaneurysm Doppler ultrasound
Muscle pain and swelling Myositis ESR, CK, aldolase
Fever Fasciitis
Retained foreign body X-ray or CT
Altered mental status Obtundation Drug overdose or intoxication CT; drug screen; lumbar puncture; blood cultures
Focal neurologic signs Drug withdrawal
Meningismus Central nervous system lesion
Seizure Meningitis
Tetanus
Eye pain and vision loss Periorbital vesicles Herpes zoster Viral and fungal cultures; serology for HSV/syphilis; slit
lamp exam; funduscopy; ophthalmology consult
Subconjunctival lesions Kaposi sarcoma
Keratitis Keratoconjunctivitis sicca
Iridocyclitis Herpes simplex
Retinitis Cytomegalovirus infection
Poorly reactive pupil Varicella zoster
Vitreous exudates Toxoplasmosis
Syphilis
Fungal infection
Abbreviations: CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; HIV = human immunodeficiency virus.

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 CHAPTER 296: Injection Drug Users    1981

 DYSPNEA SPECIFIC INFECTIONS IN INJECTION

A wide range of infectious and noninfectious entities may produce dys-
pnea and cough in patients with ongoing drug injection. Pneumonia in
DRUG USERS
injection drug users is typically community acquired (see Chapter 155, HUMAN IMMUNODEFICIENCY VIRUS INFECTION
“Human Immunodeficiency Virus Infections”). However, dyspnea may
arise from aspiration during intoxication, tuberculosis, opportunistic HIV infection and management are discussed in Chapter 155. All-cause
infections, presence of foreign body, and septic pulmonary emboli mortality is three times higher among HIV-positive injection drug users
complicating right-sided endocarditis. Place all febrile injection drug than those who do not inject, with the largest portion attributable to
users who present with dyspnea, cough, or abnormal findings on chest acquired immunodeficiency syndrome–related deaths.12,13 Evidence
radiograph in respiratory isolation until tuberculosis is excluded or an supports the effectiveness of HIV prevention programs including needle
alternative diagnosis is found. exchange, education on condom usage, and agonist maintenance treat-
Noninfectious causes of dyspnea include noncardiogenic pulmonary ment,14 and more recently the use of preexposure prophylaxis.15
edema, pneumo- or hemothorax, toxic reaction to injected substances,
hypersensitivity reaction, foreign body granulomatosis, and exacerba-
tion of reactive airway disease. Pneumothorax and hemothorax are seen INFECTIVE ENDOCARDITIS
most commonly in association with the practice of “pocket shooting,”
The incidence of endocarditis in injection drug users is estimated to
in which drug users inject into the supraclavicular fossa to access the
be 40 times that in the general population.16 For injection drug users
subclavian, jugular, or brachiocephalic vein. “Talc lung” is a syndrome of
presenting with fever, the risk of endocarditis increases to one in eight,
progressive respiratory distress and diffuse interstitial infiltrates caused
and for injection drug users from an inner-city population who are later
by the injection of the talc adulterant. Hypersensitivity reactions, asso-
found to be bacteremic, the risk increases to 40%.16 Endocarditis in
ciated with both heroin and cocaine injection, present with cough and
injection drug users is typically right sided (57% to 86% of cases); 55% to
wheezing and typically respond to inhaled b-agonist therapy. Noncar-
94% of cases involve the tricuspid valve, 20% to 40% involve the mitral
diogenic pulmonary edema is associated with both heroin and cocaine
and aortic valves, and 5% to 14% involve both sides of the heart17,18 (see
use, and patients display dyspnea, exhibit a low pulse oximetry reading,
Chapter 156, “Endocarditis”).16 Hospitalizations for endocarditis are
or have a radiograph revealing diffuse alveolar infiltrates. Treatment is
increasing in the setting of the current opioid epidemic.19,20 Chapter 156
supportive. Finally, septic, air, or needle fragment emboli to the lungs
covers endocarditis management in detail.
can produce dyspnea.
Presenting signs and symptoms in injection drug users with endo-
carditis include fever, murmur (up to 65%), cough, pleuritic chest pain,
 ALTERED MENTAL STATUS AND NEUROLOGIC ABNORMALITIES and hemoptysis. Right-sided heart murmurs that vary with respiration
Drug intoxication or withdrawal, stroke syndromes, hypoxia, delayed are typically pathologic and more specific for the diagnosis.16 Multiple
leukoencephalopathy, infectious diseases, mycotic aneurysms, and sec- opacities on chest radiograph, consistent with septic pulmonary emboli,
ondary trauma from either loss of consciousness and fall or drug-related are common in patients with right-sided endocarditis (Figures 296-1
violence may all produce altered mental status or other neurologic and 296-2).14 Other findings include pyuria (22%) and hematuria (35%)
impairment in injection drug users. CNS infections may result from con- due to glomerulonephritis from immune complex deposition, embolic
tiguous spread of overlying soft tissue infection, embolic complications renal infarction, and perinephric abscess.17,21 Systemic embolization is
of distant infections (e.g., endocarditis), or extension of local infections found in approximately 22% to 50% of cases, and embolic infections may
(e.g., vertebral osteomyelitis). Nervous system infections that com- precede the finding of endocarditis in 25% to 60% of cases.17,22,23
monly occur in this population include epidural abscess, bacterial and
fungal meningitis, and brain abscess. Meningococcus, pneumococcus,
and Staphylococcus aureus bacteremia from endocarditis are common
causes of bacterial meningitis. Both tetanus and botulism exist more
often in patients who inject drugs and may present with cranial nerve
involvement, altered mental status, and progressive symmetric paralysis.
Infections caused by opportunistic organisms, such as Toxoplasma, are
common in patients with coincident HIV infection who have low CD4
counts (especially <100/mm3). Stroke syndromes may occur secondary
to low-flow states during heroin intoxication; hypertensive hemorrhage
from amphetamines, phencyclidine, or cocaine; and embolized vegeta-
tions associated with infectious endocarditis. Delayed leukoencepha-
lopathies, both hypoxic and nonhypoxic, have been reported in injection
drug users but are rare.

 BACK PAIN
Back pain may result from an epidural abscess, vertebral osteomyelitis,
spondylodiscitis, or trauma; often the WBC count, sedimentation rate,
or C-reactive protein are elevated in these conditions but not universally.
Mycobacterial infections usually involve the ribs and vertebral column
(Pott’s disease). These infections may be indolent and present only
with pain or may demonstrate night sweats, fevers, and weight loss. In
patients with coincident HIV infection, opportunistic infections may
present with a more indolent course, and the only symptom may be
local pain. Nontraumatic focal back pain in febrile or nonfebrile injec-
tion drug users requires imaging studies, usually MRI, to evaluate for
possible infection. In patients with chronic back pain, failure to inquire
about a history of IV drug use or ignoring features that suggest infection
(e.g., pain that does not resolve when the patient lies down, severe night- FIGURE 296-1. Chest radiograph showing septic emboli. Multiple opacities are seen
time pain, or failure of pain to improve with conservative therapy) can in this chest radiograph of an injection drug–using female patient who was found to have
lead to missed diagnosis of a cord-compromising infections.11 bacterial endocarditis.

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 1982   SECTION 26: Special Situations
FIGURE 296-2. CT image showing multiple peripheral cavitary lesions consistent with
septic pulmonary emboli.
Diagnosis of infective endocarditis generally requires isolation of
microbes in a blood culture and/or demonstration of typical lesions on
echocardiography. The classic findings of embolic phenomena, including
Janeway lesions and Roth spots, are usually not observed unless the infec-
tion is advanced and occur in less than 15% of cases.21 Osler’s nodules are
usually not seen with right-sided endocarditis. Obtain at least three sets
of blood cultures from separate sites, with at least an hour’s wait between
collection of the first and last set, before the initiation of antibiotic therapy.
Determine empiric antibiotic therapy based on the stability of the
patient and the ability to wait for initial blood culture results. Direct initial
treatment against S. aureus (methicillin-specific or methicillin-resistant
S. aureus) and Streptococcus and Enterococcus species, with consideration
of local sensitivities and pathogens. If the injection drug user engages in
needle licking or uses saliva to reconstitute the drug, antibiotic selection
must cover oral (streptococcal and anaerobic) and skin flora.
PULMONARY INFECTIONS
Community-acquired pneumonia caused by Streptococcus pneumoniae
and Haemophilus influenzae remains the most common pulmonary
infection in injection drug users. Patients are also at high risk for infec-
tion due to S. aureus, including methicillin-resistant S. aureus; Klebsiella
pneumoniae infection; aspiration pneumonia; tuberculosis; and, in
HIV-positive patients, opportunistic infections caused by Pneumocystis
jiroveci, cytomegalovirus, and atypical mycobacteria. Suspect aspiration
pneumonia in those with a history of depressed level of consciousness
and/or radiographic infiltrate in the posterior or basal lung segments.
The risk of tuberculosis, including drug-resistant tuberculosis and
extrapulmonary tuberculosis (see earlier discussion of Pott’s disease), is
higher in injection drug users, accompanied by delays in diagnosis and
poor adherence to treatment regimens. The tuberculin skin test may be
negative. Coincident HIV infection is one of the major risks for the high
incidence of tuberculosis.1 Tuberculosis management is discussed in
detail in Chapter 67, “Tuberculosis.”
Patients are usually admitted to the hospital with respiratory isolation
until tuberculosis is excluded.17 In patients without risk for Pseudomonas
infection, an IV quinolone and IV ceftriaxone or cefotaxime are reason-
able empiric coverage until culture results return. In those at risk for
Pseudomonas infection (structural lung disease, malnutrition, current
or recent corticosteroid use or antibiotic use), consider an IV antip-
seudomonal b-lactamase agent (cefepime, imipenem, meropenem, or
piperacillin/tazobactam) and an IV antipseudomonal fluoroquinolone
or, alternatively, an antipseudomonal b-lactamase agent, IV aminogly-
coside, and fluoroquinolone.24 Injection drug users are also at increased
risk for influenza due to injection practices and living conditions, so
encourage yearly influenza vaccination.4
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SKIN AND SOFT TISSUE INFECTIONS
 EPIDEMIOLOGY AND PATHOPHYSIOLOGY
Skin and soft tissue infections are common among injection drug
users and include cellulitis, skin ulcers, subcutaneous abscesses, septic
phlebitis, necrotizing fasciitis, Fournier’s gangrene, gas gangrene, and
pyomyositis. Most are caused by the user’s own flora, with S. aureus and
streptococcal species common pathogens. Because these infections are
often self-treated and reporting is not required, the prevalence is dif-
ficult to determine.
Injection techniques and eventual loss of easily accessible veins pre-
dispose injection drug users to soft tissue trauma and ischemia. The
drugs themselves and the adulterants irritate, sclerose, and necrose the
skin. Desomorphine (street name Krokodil) typically contains large
amounts of toxic components such as iodine and phosphorus and can
cause serious damage to skin, blood vessels, bone, and muscles. Limb
amputation may be necessary, which has given this drug the nickname
“the flesh-eating drug.”25
 CLINICAL FEATURES AND DIAGNOSIS
Cutaneous infection presents with fever, pain, localized erythema, and
edema. Inspect painful areas for fluctuance, crepitus, and lymphangitis
suggestive of deeper infection or abscess. Cellulitis and abscesses are
typically caused by S. aureus, Streptococcus, or community-acquired
methicillin-resistant S. aureus.26 Abscess cultures may also demonstrate
polymicrobial growth, with aerobic gram-negative rods, anaerobic cocci,
and bacilli. Increased rates of Clostridium botulinum infection exist in
injection drug users who engage in skin popping, particularly those
using Mexican black tar heroin.
Tetanus is another potential complication of injection drug use, and
mortality from tetanus is high in older, unvaccinated patients.4 Other
skin concerns include retained portions of broken needles, which act as
a nidus for infection or migrate into adjacent vessels and, in addition,
pose an increased risk to the examining healthcare provider. These may
be identified by radiograph prior to exploration.
Infections overlying venipuncture sites may produce septic throm-
bophlebitis and infected pseudoaneurysms. Femoral vein injection
(“groin hit”) may start development of local gangrene as well as rapidly
progressive and fatal Fournier’s gangrene. Injection into the jugular vein
(“pocket shot”) may lead to cutaneous abscess formation involving the
carotid triangle and produce airway obstruction, vocal cord paralysis,
and laryngeal edema.
Imaging For nonpulsatile areas of induration, bedside US can define an
underlying abscess. Image any pulsatile masses with Doppler US prior to
incision and drainage. Angiography may identify vasospasm, thrombosis,
emboli, or mycotic aneurysms. Plain radiographs are not routinely needed,
unless suspecting air in the soft tissues or radiopaque foreign bodies. CT
or MRI can delineate the involvement of other structures and the extent of
deep abscesses, especially in complex areas such as the neck or groin.
 TREATMENT AND DISPOSITION
Incise and drain all uncomplicated small abscesses, large furuncles, and
carbuncles. Treat injection drug users with superficial cellulitis without
evidence of systemic involvement with oral antibiotics to cover strepto-
cocci and methicillin-resistant S. aureus (see Chapter 152, “Soft Tissue
Infections,” Table 152-2).27
Febrile or toxic-appearing patients or those not responding to out-
patient treatment require hospital admission. If hand, deep tissue, or
muscle involvement is detected or suspected clinically, consult for pos-
sible exploration or debridement.
For admitted febrile or toxic-appearing patients, obtain blood and
wound specimens for culture and start broad-spectrum IV antibiotic
therapy. Base antibiotic coverage on community microbial prevalence
and host factors. Appropriate choices include a penicillinase-resistant
synthetic penicillin or vancomycin plus an antipseudomonal aminogly-
coside, antipseudomonal penicillin, or cephalosporin (see Chapter 152,
“Soft Tissue Infections”). Update tetanus immunization.4
8/1/19 1:33 PM

FIGURE 296-3. Volume-rendering CT of the wrist showing a radial artery pseudoaneu-
rysm in the inferior portion of the image. The pseudoaneurysm has displaced the radial artery
away from the bony radius.
VASCULAR INFECTIONS
Vascular infections associated with injection drug use include inadver-
tent arterial injection with resultant vasospasm or thrombosis, septic
thrombophlebitis, venous and arterial pseudoaneurysms, and infected
hematomas. Arterial injection causes pain, edema, and patchy mottling
of the affected limb due to ischemia. Tissue necrosis and gangrene are
the consequence of persistent focal ischemia.28 When suspecting limb
ischemia, promptly consult a vascular surgeon to determine whether
anticoagulation, surgical intervention, or intra-arterial thrombolysis is
best. Limb edema and ischemia can progress to compartment syndrome
or may be complicated by rhabdomyolysis.29
Intra-arterial drug injection can result in an infected arterial pseudoa-
neurysm (Figure 296-3).28 Venous pseudoaneurysms are relatively rare
and are usually secondary to septic phlebitis. Signs and symptoms are
fever and a painful mass. Complications include life-threatening hemor-
rhage, sepsis, chronic claudication, chronic skin and soft tissue infections,
posttraumatic ulcers, and limb loss.30,31 A pseudoaneurysm is similar in
gross appearance to an abscess; the presence of pulsations and a bruit
suggest this diagnosis. Because of the disastrous hemorrhagic conse-
quences of attempted incision and drainage, all painful masses, particu-
larly in the groin, should be first imaged with duplex US or contrast CT.
Treatment is antibiotic therapy guided by recommendations for
endocarditis (see Chapter 156, “Endocarditis”). Surgical options include
ligation and resection of the infected pseudoaneurysm with or without
selective revascularization.
BONE AND JOINT INFECTIONS
Bone and joint infections occur either through contiguous spread from
an overlying skin or soft tissue infection or through hematogenous
spread from a distant site. Infecting microorganisms in injection drug
users include S. aureus and other streptococci, or they may be unusual,
such as Candida and gram-negative organisms.
 OSTEOMYELITIS
In injection drug users, osteomyelitis is more frequent in the axial skeleton
than in the extremities. Injection drug use–related osteomyelitis involves
the vertebral column in approximately 50% of cases, particularly the lum-
bar segments, followed by the sternoclavicular joint in approximately 18%
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CHAPTER 296: Injection Drug Users    1983
of cases, the sacroiliac joints, and the extremities, especially the hip and
knee joints, in 17% of cases. Vertebral osteomyelitis usually presents with
localized pain and tenderness to palpation over the involved bone, and a
soft tissue mass may be palpable. Osteomyelitis coexists with spinal epi-
dural abscess in approximately 80% of cases.32 Symptoms may be present
for days in the case of bacterial infections or weeks in the case of fungal
or mycobacterial infections. The presence of fever, leukocytosis, and an
elevated erythrocyte sedimentation rate and C-reactive protein level is
helpful, but their absence does not exclude these infections.
Culture any drainage from a contiguous abscess. Biopsy or needle aspi-
ration of joint spaces and bony infections may be necessary, especially in
the case of infection with unusual or fastidious organisms, such as Myco-
bacterium, Candida, or Eikenella. Eikenella corrodens osteomyelitis may
occur in injection drug users who lick their needles prior to injection.
Fungal infections are rare but increasing in spinal infections related to
immunosuppression and IV drug use. Candida species infection occurs
in as many as 20% of patients with injection drug use–related osteo-
myelitis. Candidal infections are probably hematogenous in origin and
have been reported from the use of contaminated reconstituted lemon
juice to mix drugs before injection. An initial flulike syndrome lasting
3 to 4 days is followed by the appearance of metastatic lesions involving
the skin, eye (chorioretinitis and endophthalmitis), and then bones and
joints several days to weeks later. Rarely, Aspergillus species may cause
osteomyelitis of the sternum in injection drug users.
MRI is currently the imaging modality of choice at many facilities
because it delineates both the longitudinal and paraspinous extension of
an abscess and can determine the exact site of infection. CT may reveal
disk space narrowing and bony lysis suggesting osteomyelitis, but it is
neither as sensitive nor as specific as MRI.32 Patients with osteomyelitis
warrant admission, and unless the patient appears septic, the patient has
focal neurologic complaints, or coincident endocarditis is a concern,
antibiotic therapy should be withheld until culture results are obtained.
Early consultation with the orthopedist or neurosurgeon guides the
timing of antimicrobial coverage, because blood culture results may be
insufficient, and a CT-guided needle biopsy for epidural abscess or a bone
sample culture for osteomyelitis is often required.26 Base antimicrobial
choice on culture results. Therapy is typically required for 4 to 6 weeks.
Unstable injection drug users who are suspected of having osteomyelitis
should receive vancomycin to cover S. aureus and ceftazidime to cover
Pseudomonas (see Chapter 281, “Hip and Knee Pain,” Table 281-4).
 SEPTIC ARTHRITIS
Septic arthritis in injection drug users usually involves the knee or hip
(see Chapter 284, “Joints and Bursae”). Sternoclavicular septic arthritis
strongly suggests injection drug use.33 Patients often report recent
trauma to the area, but causality is unclear. Consider gonococcal arthritis
and tenosynovitis as causes of joint or ligamentous pain.
The initial symptoms are pain, localized tenderness, and swelling at
the sites. The erythrocyte sedimentation rate is usually elevated, and
fever and leukocytosis may be present. Most plain radiographs are nor-
mal; however, joint space widening, articular surface erosion, and sur-
rounding soft tissue infection may be noted. CT or MRI may detect early
infection. See Table 284-3 for discussion of findings of synovial fluid
analysis. Treatment includes immobilization; empiric antibiotic therapy
providing wide-spectrum coverage, including coverage for methicillin-
resistant S. aureus; physical therapy; therapeutic arthrocentesis/washout;
and occasional open drainage.
HEPATIC DISEASE
Injection drug users can develop liver disease from both parenterally
and sexually transmitted hepatitis A, B, C, D, E, and non–A through G.
In injection drug users, hepatitis B virus seroprevalence ranges from
25% to 55%. Worldwide hepatitis C virus infection is hyperendemic and
rising, with a steady infection and death frequency over the past decade.1
In 2007, injection drug use was cited as a risk factor for 15% of new
cases of hepatitis B virus and nearly half (48%) of new hepatitis C virus
cases in the United States.34 Currently, the United States is experiencing
an increase in HCV incidence attributed to injection drug use, and
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 1984   SECTION 26: Special Situations
hepatitis C is associated with more deaths in the United States than
combined deaths from 60 other infectious diseases.35
For evaluation of a clinical syndrome suggestive of acute hepatitis
(e.g., weakness, nausea, fever, abdominal pain, or jaundice), obtain
laboratory tests that include serum transaminase levels, bilirubin level,
alkaline phosphatase level, prothrombin time, and serologic testing.
Many patients can receive an outpatient care plan. Admission criteria
include inability to tolerate oral intake, toxicity, and significantly pro-
longed prothrombin time. Counsel patients about sexual transmission
and needle exposure, and encourage informing all sexual and needle-
sharing partners and household contacts of their exposure. Long-term
sequelae of infection include chronic active hepatitis, decompensated
cirrhosis, and primary liver cancer.
Unfortunately, drug treatment programs often lack adequate fund-
ing to offer optimal hepatitis B and C prevention, diagnosis, and care.
Current hepatitis B virus vaccination rates among injection drug users
remain low at 30%. The short- and long-term benefit and cost of antivi-
ral treatment for hepatitis C for both the individual patient who contin-
ues to intravenously inject drugs (increasing reexposure or reinfection)
and any partners are unclear.36 Both partners are key in appropriately
framed therapeutic discussions.37
OPHTHALMOLOGIC INFECTIONS
Ophthalmologic infections in injection drug users are usually the result
of hematogenous seeding from a primary source of infection or from
opportunistic infections associated with HIV disease. Bacterial endo-
phthalmitis often presents acutely, with pain, redness, lid swelling, and
decrease in visual acuity. Inflammation is usually present in both the
anterior and posterior chambers. White-centered, flame-shaped embolic
hemorrhages (Roth spots), cotton-wool exudates, and macular holes
may be present. S. aureus is the most commonly isolated organism,
followed by Streptococcus species. Treatment involves subconjunctival,
intravitreal, and systemic antibiotic therapy. Surgical intervention, such
as vitrectomy, may be needed.38
Fungal organisms, often Candida or Aspergillosis, but sometimes
rarer organisms such as Torulopsis, Helminthosporium, and Penicillium
species, are causes of endophthalmitis among injection drug users,
notably from Mexican black tar heroin injection. In injection drug users
coinfected with HIV, cytomegalovirus infection, toxoplasmosis retinitis,
and choroidal Cryptococcus and Mycobacterium avium-intracellulare
complex infections must also be considered. Symptoms include blurred
vision, pain, poorly reactive pupil, and decreased visual acuity and can
progress over days to weeks. White cotton-like lesions are seen on the
choroid retina, with vitreous haziness. Uveitis, papillitis, and vitreitis
also have been reported. Microbiologic diagnosis is made from the
results of blood and vitreous culture. Treatment includes amphotericin B,
amphotericin lipid complex, and fluconazole, with or without intravitre-
ous antifungal therapy and early vitrectomy.39,40
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER The Transplant Patient
297 Brit Long
Alex Koyfman
INTRODUCTION
Organ transplantation is growing in frequency, with the first successful
kidney transplant in the early 1950s.1,2 As of the beginning of 2013, there
were 76,047 active candidates waiting for solid-organ transplants in the
United States, with the kidney transplant waitlist being the largest at
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57,903 candidates.3 The kidney is the most commonly transplanted
organ (58%), followed by liver (21%), heart (8%), lung (5%), pancreas
(5%), and, less commonly, combined organ transplants and intestine
transplants. Annually, there are approximately 18,000 hematopoietic
stem cell transplants in the United States, with about one third of these
transplants being allogenic transplants and two thirds being autologous
transplants.4 The recent opioid epidemic has produced several chal-
lenges for the transplant-awaiting population. The increase in opioid-
related deaths has led to an increase in the number of available organs;
however, the risk of infection from opioid-related donor organs is
slightly higher than from non–opioid substance user donors. The U.S.
Public Health Service states that organs obtained from opioid abusers
are at slightly increased risk of infection, although recent data suggest
these organs can be safely used for transplant. Potential recipients also
may suffer from addiction, which is associated with worse outcomes
with transplantation.5
Most transplant patients require lifelong immunosuppression.
Transplant patients can develop a number of acute to life-threatening
emergencies, including (1) transplant-related infection, (2) medica-
tion side effects, (3) rejection, (4) graft-versus-host disease, and (5)
postoperative complications or complications of altered physiology
secondary to the transplanted organ. Transplant patients may also
have common medical problems that require unique management.
Adverse outcomes often are directly proportional to increasing age of
the recipient and the donor organ.6 Patients with transplanted organs
may present significant challenges due to anatomic and physiologic
variations, immunosuppression, complications from transplantation,
and comorbidities.2,6-8
The most common acute disorders prompting ED visits are infection
(39%), followed by noninfectious GI/GU pathology (15%), dehydra-
tion (15%), electrolyte disturbances (10%), cardiopulmonary pathology
(10%) or injury (8%), and rejection (6%).9-12 Acute graft-versus-host
disease is an important complication, especially in those with hema-
topoietic stem cell transplantation.13 Coronary artery disease, sudden
cardiac death, and heart failure are the result of premature cardiovas-
cular disease in solid-organ recipients, due to underlying comorbidities
and metabolic effects of immunosuppression.14 Preoperative and regu-
lar postoperative cardiovascular assessment identifies risk factors and
enables treatment to mitigate risks.15
GENERAL APPROACH TO
EVALUATION
HISTORY AND COMORBIDITIES
Key historical elements for the management of transplant patients are
listed in Table 297-1.
PHYSICAL EXAMINATION
Direct the physical examination to the chief complaint, present illness,
and evidence of complications of the transplant or immunosuppressive
medications (Table 297-2).9-13,16,17
DIFFERENTIAL DIAGNOSIS
Consider complications of immunosuppressive medication, infection,
solid-organ rejection, and graft-versus-host disease (Tables 297-3 and
297-4). Chronic immunosuppressant medications, including cortico-
steroids, cause a wide range of physical changes evident on physical
examination. Medication changes should be made by, or in consultation
with, the patient’s transplant team. Outpatient or inpatient management
depends on the severity of illness; the need for ongoing immunosup-
pression often requires admission when symptoms interrupt mainte-
nance of medication.
Solid-organ rejection and graft-versus-host disease are immune-
medicated inflammatory reactions that may present with fever, signs
and symptoms, and laboratory and radiographic findings that resemble
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 CHAPTER 297: The Transplant Patient    1985

TABLE 297-1 Key Historical Elements Specific to Transplant Patients
Historical Item Significance
Recent temperature increase or
decrease from baseline
Changes from baseline function
Date of transplant surgery
Graft source for solid-organ transplant,
special features of graft if any, prior
infections; donor living related
vs. cadaveric
Graft source for hematopoietic stem
cell transplant: autologous, degree of
match, related donor
Rejection history
Recent changes in dosages of
antirejection and other medications
Chronic infections (CMV, Epstein-Barr
virus, hepatitis B and C, other viruses)
Recent exposure to infections
(chickenpox, CMV, tuberculosis)
Recent history of compliance with
immunosuppressive medications
Recent travel, exposure to persons
arriving from countries with endemic
infections, exposure to potential
foodborne illness or insect vectors
Complete list of all medications,
including over-the-counter
medication
Baseline: blood pressure,
body weight, serum creatinine
(for renal transplants), and expected
levels of immunosuppressive
medication
Abbreviation: CMV = cytomegalovirus.
TABLE 297-2 Physical Examination in Transplant Patients
Examination Comments
Potential clue to onset of infection or rejection.
Decreased urine may signify rejection in renal
transplant patients or acute dehydration.
Decreased exercise tolerance may signify
rejection in heart transplant patients.
Change in skin color (jaundice specifically) may
signify rejection in liver transplant patients or
graft-versus-host disease.
The date from transplant helps to predict
typical infections and types of posttransplant
complications (i.e., graft-versus-host disease).
These details predict the potential for certain
infections and rejection.
These details predict potential graft-versus-
host disease.
May predict current rejection if similar
presentation and difficulty in controlling a
current episode of rejection.
Although a planned part of transplant
management, rejection is very common when
immunosuppression doses are reduced.
History of chronic infections increases the
chances that current presentation is an
exacerbation.
Increases the chance of current infection.
Noncompliance increases chance of rejection.
Exposure may predict unusual infections not
commonly considered.
Complex drug interactions are common causes
of symptoms in transplant patients and must
be evaluated.
Changes in these parameters may predict
rejection or acute illness.
Abbreviations: AV = arteriovenous; CMV = cytomegalovirus; EBV = Epstein-Barr virus; HSV = herpes
simplex virus.
Volume status Check static vital signs, orthostatic blood pressures, and pulse. Use US
to assess inferior vena cava diameter as a measure of intravascular
volume status.
Head, ears, Periorbital edema (glomerulonephritis), retina (CMV or toxoplasmic
eyes, nose, chorioretinitis, Listeria endophthalmitis), sinuses (Staphylococcus
and throat aureus, mucormycosis, and invasive fungal disease), mouth (Candida,
HSV), neck (meningismus, retropharyngeal abscess), lymphade-
nopathy (CMV, EBV, hepatitis, posttransplant lymphoproliferative
disorder).
Lungs Pneumonia is a common source of infections in transplant patients.
Streptococcus pneumoniae and other community-acquired agents
are still common sources, but opportunistic infections, such as
Pneumocystis jiroveci pneumonia, Aspergillus, tuberculosis, coccidioi-
domycosis, and viral pneumonias, should be suspected. Noninfectious
pulmonary infiltrates may also cause dyspnea.
Heart Pericardial friction rubs as a complication of uremia and a wide range
of viral infections. New heart murmur can represent infection.
Abdomen Peritonitis without a defined source is one of the most common sites
for infection in transplant patients. Right upper quadrant tenderness
associated with hepatitis B and C, CMV, and EBV. Varicella-zoster virus
causes pancreatitis. If left in place, peritoneal dialysis catheters can be
sources of infection.
Flank and The urinary tract was the most common site of infection identified.
suprapubic area
Graft Renal graft usually placed in abdominal flap; inspect (look for signs
of wound infection), palpate (graft tenderness and swelling are often
seen in acute rejection, outflow obstruction, and pyelonephritis), and
auscultate (bruits suggest renal artery stenosis and AV malformation
or AV fistula). Deep tenderness over liver graft could indicate abscess.
Rectal Perirectal abscess is a common, yet often overlooked, source of
infection in transplant patients.
Extremities Access sites for hemodialysis can be sources of infection. Peripheral
edema in the transplant patient can represent a number of different
etiologies: recurrent versus de novo glomerulonephritis, renal graft
failure, liver graft failure, cirrhosis, nephrotic syndrome (from native
kidneys), renal vein thrombosis, malnutrition, hypoalbuminemia,
and heart failure.
Skin Rashes are commonly seen in graft-versus-host disease, viral syndromes
(hepatitis B and EBV), cellulitis from indwelling catheter sites, nocardial
cutaneous lesions, and drug reactions.
Mental status/ Cyclosporine/tacrolimus neurotoxicity, steroid psychosis, HSV encephalitis,
neurologic Listeria meningitis/encephalitis, and cryptococcal meningitis.
examination

diseases, presence of necrotic fluid/fluid collection, presence of an indwell-

infection (see later discussions). Infection and rejection (or an exac-
erbation of graft-versus-host disease) can occur simultaneously, and
treatment should be started for both. When suspecting acute rejection
or acute graft-versus-host disease, consult the transplant team about
treatment. Typically, high-dose corticosteroids are given, but the steroid,
the dose, and the duration of therapy should be confirmed.
POSTTRANSPLANT INFECTIONS
Infections account for a large number of deaths in transplant patients,
with many infections undiagnosed until autopsy. Patients are at increased
risk of infection, with an incidence of infection within the first year after
transplant of 25% to 80%.7,18-21 Although immunosuppressive regimens
can reduce the risk of rejection, they can also increase risk of infection.
The level of immunosuppression depends on current regimen, underlying
ing device, metabolic disease, and concomitant viral infection. The time
from transplant also affects risk of infection and type of infection.20-25 Viral
and bacterial illnesses may occur concurrently. Febrile episodes in the
early phase after allogenic stem cell transplantation are likely related to
infections secondary to neutropenia. Immunosuppression-induced blunt-
ing of the inflammatory response may mask the classic signs, symptoms,
and laboratory markers of infection if the patient presents early in the
course of the illness. Later in the course of infection, patients may present
with more advanced ominous signs such as seizure, obtundation, coma,
and cardiac arrest. Solid-organ transplant recipients have risk of bactere-
mia, often in the setting of urinary tract infection.10,12,19,21,26,27
CLINICAL FEATURES
The most common reason for an ED visit by a transplant recipient
is fever.9-12 Fever may be masked by immunosuppressive agents and

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 1986   SECTION 26: Special Situations

TABLE 297-3 Adverse Reactions to Immunosuppressant Medications nontransplant patients,10-12,28 those with transplant still demonstrate a
physiologic response to infection (temperature of 37.9°C vs. 38.2°C for
Body System Adverse Effects transplant vs. nontransplant patients, respectively). Specifically, patients
Constitutional Fever, rigors, malaise, dizziness, anorexia on regimens including mycophenolate mofetil and azathioprine demon-
Ophthalmologic Blurred vision, conjunctivitis, cataracts, papilledema, blindness strate decreased temperatures.28-30
Signs and symptoms of infection depend on the type of infection
Mouth/ears Gingival hyperplasia, stomatitis, hearing loss, tinnitus
and can, in part, be predicted by the time frame since the transplant
Respiratory Cough, dyspnea, interstitial lung disease, pneumonitis, pleural (Table 297-5).7 The specific site of infection also depends on the trans-
effusion, noncardiogenic pulmonary edema planted organ. Combining all posttransplant period groups, urinary
Cardiovascular Hypertension, tachycardia, bradycardia, cardiomyopathy, congestive tract infections (43%) and pneumonia (23%) are likely to be the most
heart failure, hypotension, syncope common infections.16 In contrast, a study of 238 ED presentations of
GI Nausea, vomiting, diarrhea, epigastric pain, esophagitis, gastritis, febrile pediatric heart transplant patients found pneumonia in 24%,
hiccups, constipation, hepatotoxicity, ascites, pancreatitis, colonic bacteremia in 3%, cellulitis in 2%, and urinary tract infection in 1%;
necrosis, bleeding the majority had a negative workup.17
Musculoskeletal Myopathy, osteoporosis, tendon rupture
Hematologic Neutropenia, lymphopenia, anemia, thrombocytopenia, bleeding,
DIAGNOSIS AND TREATMENT
thrombosis The evaluation should include routine testing as well as additional tests
Renal Nephrotoxicity, oliguria, dysuria, renal failure based on complaint, history, and physical examination (Table 297-6).31
Neurologic Headache, vertigo, paresthesias, tremors, convulsions, agitation, Leukopenia can represent acute bacterial infection,10 and leukopenia
neuropathy, confusion, generalized weakness, leukoencephalopathy, with an increase in atypical lymphocytes is commonly seen with viral
encephalopathy, cerebral edema infections, especially cytomegalovirus. Pulmonary infections that are
Skin Alopecia, hirsutism, thickening, thinning, necrosis, edema encountered frequently include Pneumocystis jiroveci, Nocardia, Legio-
nella pneumophila, and Aspergillus; these require special stains and stud-
Metabolic Electrolyte disturbances (sodium, potassium, calcium, magnesium, ies for accurate diagnosis.
phosphorus), fluid retention, hypercholesterolemia, hyperlipidemia, Treatment recommendations should be determined by careful analy-
hyperglycemia, hypoglycemia sis of each individual patient for potential atypical infections requiring
Endocrine Adrenal suppression specific coverage. Resuscitation with intravenous fluids and broad-
Immunogenic Susceptibility to infection, acute allergic reactions, anaphylaxis spectrum antimicrobials is recommended in patients with sepsis or
septic shock. Empiric antimicrobial therapy for transplant patients is
outlined in Table 297-7.32-34 Empiric treatment prior to confirmatory
other factors, such as steroids, uremia, and hyperglycemia, and may studies should first involve antibacterial agents and then, especially if
be absent in half of those with infection.10 Fever may be due to factors there is concern for meningitis or encephalitis, antiviral agents such as
other than infection, such as drug effects, hypersensitivity reaction, acyclovir. Discuss treatment of suspected fungal infections or atypical
rejection, or malignancy. Even a low-grade fever in a transplant patient infections with the transplant team. The emergency provider should
should prompt an aggressive workup. Although in the setting of infec- discuss the case with the patient’s transplant physician, and consultation
tion transplant patients demonstrate temperatures lower than those of with infectious disease specialist may improve outcomes and reduce
mortality.2,7,18,19,35

GRAFT-VERSUS-HOST DISEASE
TABLE 297-4  Physical Examination Clues to Complications of Medications and
Graft-Versus-Host Disease
Concern Signs and Symptoms
Graft-versus-host disease is a major cause of morbidity and mortal-
Edema and other Assess symmetry, pain, color, temperature, and active range ity, affecting approximately 50% of allogeneic hematopoietic stem cell
swelling of motion. Suspect infection, orthopedic conditions, deep vein transplantation patients, and is caused by donated T cells attacking
thrombosis (due to immobility). antigens on host cells,36 but it also occurs after small bowel or liver
Skin breakdown The back, pressure points, heels, elbows, and leg ulcers (due to transplantation, as well as transfusion of unirradiated blood products in
corticosteroid-induced weakness). high-risk groups.37 Hyperacute graft-versus-host disease is an unusual
Joint range of Shoulders, elbows, fingers, wrists, and knees (may be limited due and severe form of acute graft-versus-host disease. Onset occurs in the
motion to steroid-induced weakness or sclerodermatous skin changes). first week after hematopoietic stem cell transplantation and is character-
ized by fever, generalized erythroderma, severe hepatitis, fluid retention,
Thoracic constriction Relatively noncompliant edema like swelling on the chest wall. widespread inflammation, and shock.38-41
If present, ask about associated dyspnea on exertion. Acute graft-versus-host disease is classified as appearance of the
Abdominal Firm skin. History of bloating, gas, constipation, diarrhea, disease up to 100 days after transplant. A well-appearing hematopoietic
constriction nonspecific pains. stem cell transplantation recipient with a nonspecific rash (most com-
Sclerodermatous Sclerodermatous skin changes can affect joint mobility and GI mon symptom) or diarrhea (second most common symptom) should be
skin and respiratory function. Note the firmness of edema and skin, suspected of having new-onset or an exacerbation of graft-versus-host
especially on the thorax and around joints. A firm, soft leather disease.38 The most widely used graft-versus-host prophylaxis includes
consistency of swelling, tougher than cardiogenic pitting edema, a combination of a calcineurin inhibitor (e.g., cyclosporine, tacrolimus)
can be a serious problem. Assess for recent-onset dyspnea on with methotrexate.38 In patients who recover from acute graft-versus-
exertion. host disease, later long-term complications from chronic graft-versus-
Dehydration Increased thirst, loss of appetite, chills, fatigue, weakness, skin host disease are common.
flushing, dark or decreased volume of urine, dry mouth, tachycardia, Chronic graft-versus-host disease is a late complication character-
weight loss. ized by immune dysregulation (>100 days after transplantation) and is a
distinct clinical syndrome from the acute form.42 It results in severe mor-
Electrolyte Signs and symptoms of dehydration above, hypotension, headache, bidity, with complications affecting skin (sclerodermatous contractures),
disturbance bradycardia or tachycardia, irregular heartbeat, tremor, muscle muscles (myopathy), bone (osteoporosis), eyes (keratoconjunctivitis
weakness, increased urination, constipation, altered tendon sicca), nerves (peripheral neuropathy), and the cardiopulmonary system
reflexes, mood changes, abdominal pain, weight loss, muscle (physical deconditioning), resembling autoimmune disorders. Risk fac-
cramping. tors include older age, CMV seropositivity, and a male who received a

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 CHAPTER 297: The Transplant Patient    1987

TABLE 297-5 Infections Stratified by Post-transplant Period

Period After Transplant/Conditions Infection
<1 mo: resistant organisms
<1 mo: complications of surgery and
hospitalization
<1 mo: colonization of transplanted organ or
HSCT neutropenia
<1 mo: HSCT-specific infections
1–6 mo: in patients with Pneumocystis
jiroveci pneumonia and antiviral (CMV, HBV)
prophylaxis
1–6 mo: in patients without prophylaxis
>6 mo: general
>6 mo: late viral infections
Abbreviations: CMV = cytomegalovirus; HBV = hepatitis B virus; HCV = hepatitis C virus; HSCT = hematopoietic stem cell transplant; HSV = herpes simplex virus; MRSA = methicillin-resistant Staphylococcus
aureus; PTLD = posttransplantation lymphoproliferative disorder.
Comments
MRSA Opportunistic infections are generally absent during this period as
Vancomycin-resistant Enterococcus faecalis full effect of immunosuppression not complete. MRSA important in
HSCT patients.
Candida species (including non-albicans)
Aspiration C. difficile common during this period. Early graft injuries may
Catheter infection abscess. Unexplained early signs of infection such as hepatitis,
encephalitis, pneumonitis, or rash may be donor derived.
Wound infection
Anastomotic leaks and ischemia
Clostridium difficile colitis
Aspergillus Microbiologic analysis of aspirates or biopsy from surgery essential
Pseudomonas for therapeutic decisions.
Klebsiella
Legionella
Additional bacterial pathogens: Streptococcus viridans and Neutropenia and mucocutaneous injury increase risk for HSCT
enterococci patients. Lungs, bloodstream, and GI tract most commonly affected
Viral infections include respiratory syncytial virus and HSV sites.
Polyomavirus BK infection, nephropathy Activation of latent infections, relapse, residual, and opportunistic
C. difficile colitis infections occur during this period. Viral pathogens and allograft
rejection cause the majority of febrile episodes during this period.
HCV infection Polyomavirus BK, adenovirus infections, and recurrent HCV are
Adenovirus infection, influenza becoming more common.
Cryptococcus neoformans infection
Mycobacterium tuberculosis infection
Anastomotic complications
Pneumocystis Discontinuation of prophylaxis at the end of this period may prompt
Infection with herpesviruses (HSV, varicella-zoster virus, CMV, active infection, especially CMV. Graft-versus-host disease and
Epstein-Barr virus) mucocutaneous injury increase risk for HSCT patients.
HBV infection
Infection with Listeria, Nocardia, Toxoplasma, Strongyloides,
Leishmania, Trypanosoma cruzi
Community-acquired pneumonia and urinary tract infections Community-acquired organisms dominate during this period.
Infection with Aspergillus, atypical molds, Mucor species Transplant recipients have a persistently increased risk of infection
due to community-acquired pathogens.
Infection with Nocardia, Rhodococcus species
CMV infection (colitis and retinitis) In some patients, chronic viral infections may cause allograft injury
Hepatitis (HBV, HCV) (e.g., cirrhosis from HCV infection in liver transplant recipients,
bronchiolitis obliterans in lung transplant recipients, accelerated
HSV encephalitis vasculopathy in heart transplant recipients with CMV infection) or a
Community-acquired viral infections (severe acute respiratory malignant condition such as PTLD or skin or anogenital cancers.
syndrome, West Nile)
JC polyomavirus infection (progressive multifocal
leukoencephalopathy)
Skin cancer, lymphoma (PTLD)

stem cell transplant from a multiparous woman.43 Management is simi-
lar to the acute form with prolonged immunosuppression.44
ACUTE GRAFT-VERSUS-HOST DISEASE
The disease is typically characterized by involvement of three dif-
ferent systems: skin (rash), gastrointestinal, and liver (jaundice,
hepatitis). Consider graft-versus-host disease in any patient with a
rash. Rash is often misattributed as a drug reaction.45 The typical rash
is maculopapular, frequently demonstrating a brownish hue and slight
scaling (Figure 297-1). The rash can be pruritic and painful. The dis-
tribution varies greatly but often affects palms and soles initially, and
later progresses to cheek, ears, neck, trunk, chest, and upper back. In
the more severe forms, erythroderma or bullae develop.13 Mucositis has
been reported to occur in 35% to 70% of patients.
Diarrhea, GI bleeding, or hepatic dysfunction can occur. Diarrhea,
with or without upper GI symptoms such as anorexia, nausea, and eme-
sis, is common and may appear green, mucoid, and watery. Symptoms
include painful cramping, ileus, and, sometimes, life-threatening hemor-
rhage from the colon. Hepatic involvement is characterized by increase in
liver function studies. GI hemorrhage in the early posttransplant period
may be a result of coagulation abnormalities, especially thrombocyto-
penia. The differential diagnosis of GI bleeding in this setting includes
all the usual causes of GI bleeding in addition to bleeding due to acute
graft-versus-host disease–related damage to colonic tissues and infection
(viral, fungal, or bacterial).36,46 Diagnosis requires endoscopy.
Treatment is directed by the transplant team, typically PO prednisone
or IV methylprednisolone, at 1 to 2 milligrams/kg daily, and possibly
adjustment of other immunosuppressant doses.13 Patients may require
resuscitation with balanced crystalloids, blood product resuscitation

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 1988   SECTION 26: Special Situations
TABLE 297-6  Diagnostic Tests to Consider in the Evaluation of Infections in the
Transplant Patient
Test Comments
CBC Leukocytosis or left shift of the WBC count may be
blunted by immunosuppressive agents.
Renal function tests: BUN, Essential in the evaluation of renal transplant
creatinine patients; may help determine dosing of antibiotics
in all transplant patients.
Liver function tests May show mild transaminase elevations with
cytomegalovirus and Epstein-Barr virus infections
and much higher elevations with hepatotropic
viruses such as hepatitis B and C viruses. May be
elevated in Legionella infections.
C-reactive protein Significant elevations more likely in infections
versus noninfectious infiltrates.
Procalcitonin level Significant elevations more likely in infections
versus noninfectious infiltrates.
CT of the brain Focal infections in the brain are much more
common in this population, but CT should be used
only as clinically indicated.
Cyclosporine or tacroli- These levels may be deliberately low depending
mus level or other levels of on the desired level of immunosuppression.
immunosuppressants Bioavailability may be variable.
Cultures of mouth, sputum, urine, Collect as indicated by history and physical.
blood, stool, vascular access, and Urine Legionella antigen should be considered
wound sites before treatment of patients with pneumonia
with GI complaints. Bacterial and fungal cultures
of blood and urine should be obtained on all
patients.
Cerebrospinal fluid cultures and Collect as indicated by history and physical.
antigen tests
Serology: cytomegalovirus, Epstein- Because viral and fungal cultures are not very
Barr virus, hepatitis, toxoplasmosis, sensitive, clinicians should rely on their acumen
cryptococcosis to order organism-specific antigen assays and
antibody titers. When contemplating viral or
parasitic infections, these tests should be obtained
to allow identification of bacterial, fungal, and
viral pathogens. May be useful in patients with
diffuse lymphadenopathy.
Chest radiograph Infiltrates on chest radiograph may reflect infectious
or noninfectious complications of hematopoietic
stem cell transplant or organ transplant. Obtain in
posttransplant fever to evaluate for source.
CT of the chest Patients with evidence of pulmonary infiltrates
on chest radiograph or high-resolution CT, but
­without productive sputum, may ultimately
require bronchoscopy with bronchoalveolar
lavage and transbronchial biopsy for definitive
diagnosis.
CT or US to include the graft These scans can be used to identify likely abscess
formation or possible anastomotic leaks.
Tests after admission Beyond the scope of this chapter, but may include
biopsy of the transplanted organ, bronchoalveolar
lavage on bronchoscopy, and focused imaging of
suspected sites of infection.
Creatine kinase May have increased levels in infections with
certain organisms, such as Legionella.
Urinalysis As dictated by history and examination.
Recommended in patients with renal transplant.
Lactate Evaluate for severity of illness (sepsis and septic
shock).
Biopsy Typical standard diagnosis requires biopsy of
graft, which is not obtainable in ED but should be
discussed with admitting physician.
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(leukocyte-depleted and irradiated red blood cells), electrolyte replace-
ment, and broad-spectrum antibiotics.47
Disposition and interval for follow-up are also determined by the
transplant team. Survival approaches 50% at 1 year with intensive corti-
costeroid therapy, with 50% developing chronic disease.41,44,45
TRANSFUSION-ASSOCIATED GRAFT-VERSUS-
HOST DISEASE
Most living cells that are in transfused blood survive for no more than a
few days or weeks. However, in some patients, transfused cells engraft,
expand, and circulate. When immunocompetent T lymphocytes engraft in
an immune-suppressed patient, transfusion-associated graft-versus-host
disease may occur and is almost always fatal.48,49 It is possible to avoid
transfusion-associated graft-versus-host disease by irradiating blood prod-
ucts before transfusion. Patients with immunocompromise or other risk
factors (Table 297-8) should receive irradiated blood products.
POSTTRANSPLANTATION
LYMPHOPROLIFERATIVE DISORDER
Posttransplantation lymphoproliferative disorders consist of lympho-
mas occurring after organ transplantation, particularly solid-organ and
allogeneic hematopoietic stem cell transplants. Posttransplantation lym-
phoproliferative disorders are associated with poor outcomes and are not
uncommon, accounting for up to 21% of all cancers in patients receiving
solid-organ transplants.50,51 The incidence is increasing due to older age
of transplant donors and recipients, increasing number of transplants,
new immunosuppressive agents, newer types of stem cell transplantation,
greater awareness of the disease, and improved diagnosis.52 Primary risk
factors depend on the organ transplanted (kidney transplant has the
lowest risk). Specific T-cell depletion procedures display higher risk of
posttransplantation lymphoproliferative disorders in the setting of hap-
loidentical allogeneic hematopoietic stem cell transplantation, as does
the specific immunosuppressive regimen used. Age greater than 50 years
and Epstein-Barr virus seronegative status before transplantation elevate
the risk of posttransplantation lymphoproliferative disorders.52-55 The
incidence of posttransplantation lymphoproliferative disorders follows
a bimodal curve, with an initial spike during the first and second year
and a second spike 5 to 15 years after transplantation. The presentation
varies, ranging from asymptomatic to fulminant organ failure or tumor
lysis syndrome. Posttransplantation lymphoproliferative disorders dis-
play a high incidence of extranodal involvement often involving the GI
tract (up to 30% of cases), solid allografts (15%), and the CNS (5% to
20%).51,56,57 Diagnosis typically includes histopathologic examination
based on six subclasses. However, this is not available in the ED. Treat-
ment varies but typically involves reduction of immunosuppression,
surgical extirpation, local radiation, rituximab, chemotherapy, cellular
immunotherapy, and/or stem cell transplantation.57
TRANSPLANTATION MEDICATION EFFECTS
Transplant patients are typically on extensive medication regimens
including immunosuppression. In the 1980s, this consisted of cortico-
steroids and azathioprine, but current regimens are more extensive, with
many options dependent on the patient, specific organ transplant, and
time from transplant (Table 297-9).2
TRANSPLANTATION REJECTION
A feared complication other than infection includes graft rejection, as
many do not fully recover from an episode of rejection. Immunosup-
pressive regimens have reduced the risk of rejection, although this
is balanced with the risk of infection. Several phases of rejection are
present including hyperacute (minutes to hours after transplant due to
preexisting antibodies), acute (within the first 6 months due to acute cel-
lular rejection or humoral rejection), and chronic (months to years after
transplant due to antibody and cell-mediated rejection). Presentations of
rejection are demonstrated in Table 297-10.2
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 CHAPTER 297: The Transplant Patient    1989

TABLE 297-7 Empiric Antimicrobial Therapy

Condition Antimicrobial Agent Comments*
All patients Discuss agent(s) with transplant team. The transplant team caring for the patient should always be consulted as soon as possible;
however, in certain life-threatening situations, empiric broad-coverage therapy may be
indicated immediately.
Suspected infection site based on Site-specific agents are preferable if predicted by The urgency for treatment should be based on the patient’s presenting condition; bacterial
history and physical examination initial findings, balanced by known pathogens as infections are the most aggressive organisms requiring coverage, but some fungal infections
listed in Table 297-5. may yield sepsis. In general, broad coverage for any suspected site infection is recommended
initially pending cultures and further workup to define noninfectious causes of fever.
Neutropenia in the absence of Third-generation cephalosporin such as ceftazidime Multiple alternative agents used, including an aminopenicillin plus a β-lactam inhibitor
symptoms suggesting site-specific or a carbapenem plus coverage for MRSA below. such as piperacillin-tazobactam or cefepime. Monotherapy has fewer complications, but
infection concern for MRSA remains high. Addition of antiviral and antifungal agents should be at
the discretion of the transplant team.
Suspected MRSA Vancomycin In the majority of patients, MRSA infection should be seriously considered as a potential
cause of infection, pending cultures. Linezolid is an alternative antibiotic.
Parasitic infections Trimethoprim-sulfamethoxazole after discussion Consider Toxoplasma gondii, Pneumocystis jiroveci.
with transplant team
Viral infections Ganciclovir or valganciclovir for CMV, acyclovir for Consider treatment for CMV pneumonia, CMV chorioretinitis, CNS or disseminated herpes
herpes simplex and varicella-zoster simplex or varicella-zoster.
Fungal infections Discuss with transplant team; agent depends on site Consider Aspergillus, Candida albicans, Cryptococcus neoformans.
and severity of illness
Abbreviations: CMV = cytomegalovirus; MRSA = methicillin-resistant Staphylococcus aureus.
*
Standard doses apply but may be altered by transplant team recommendations.

SPECIFIC TYPES OF
TRANSPLANTATION
RENAL TRANSPLANTATION
Renal transplantation is the preferred treatment for end-stage renal
disease. Kidneys obtained from deceased or living donors are most
commonly placed in the recipient’s pelvis, with the ureters anasto-
mosed to the bladder.3,6,8,58 Vascular complications that occur following
renal transplantation include renal artery stenosis, allograft infarction,
arteriovenous fistulas, pseudoaneurysm, graft hematoma, and renal
artery or vein thrombosis. Nonvascular complications include ureteral
obstruction, urine leak, periallograft fluid collections (hematomas,
lymphoceles, and abscesses), neoplasms, GI complications, and post-
transplant lymphoproliferative disease.8 The major causes of renal
transplant loss are death from vascular, malignant, or infectious disease,
and loss of the allograft from chronic renal dysfunction associated with
the development of graft fibrosis and glomerulosclerosis. Medication
changes and use of an imaging contrast agent that may affect renal func-
tion (including gadolinium-based contrast agents) should be discussed
with the patient’s transplant team.2

 DIAGNOSTIC TESTING
Table 297-6 lists recommendations on diagnostic testing in transplant
patients, including renal transplant patients. The serum creatinine level
is the most valuable prognostic marker of graft function at all times
after transplantation and should be obtained whenever renal failure or
infection is suspected, which is often elevated in the setting of trans-
plant infection or rejection.59 The urinalysis provides important clues
to acute changes in graft viability. Red blood cell casts and proteinuria
are commonly seen in recurrent or de novo glomerulonephritis. The
presence of WBCs, bacteria, and nitrites is helpful in diagnosing urinary
tract infections, which is one of the most common complications with
renal transplant.60,61 However, pyuria may present with rejection.2,60,61

TABLE 297-8  Significant Risk Factors for the Development of Transfusion-

FIGURE 297-1. Rash of acute cutaneous graft-versus-host disease. The maculopapular
lesions have acquired a brownish hue, and there is slight scaling. [Reproduced with permission
from Wolff KL, Johnson R, Suurmond R: Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology,
6th ed. © 2009, McGraw-Hill, Inc., New York.]
Associated Graft-Versus-Host Disease
• Congenital and acquired immunodeficiency syndromes
• History of bone marrow (stem cell) transplantation, whether allogeneic or autologous
• Transfusions from blood relatives (“directed donation”)
• Transfusions with fresh whole blood
• Premature infants receiving any sort of transfusion
• Human leukocyte antigen–matched platelet transfusions
• Hodgkin’s disease, even when in remission
• Leukemia not in remission
• Patients treated with purine analogues; the effects of fludarabine and cladribine
(2-CdA) persist for a year

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TABLE 297-9 Transplantation Medications

Medication
Cyclosporine (Sandimmune , generic)

Tacrolimus (Prograf)
Azathioprine (Imuran)
Mycophenolate mofetil (CellCept)
Corticosteroids
Sirolimus (Rapamune)
Polyclonal antibodies
(antithymocyte γ-globulin)
Monoclonal antibodies
(OKT3, IL-2 receptor antibody)
Abbreviations: IL-2 = interleukin-2; mTOR = mammalian target of rapamycin.
Mechanism
Calcineurin inhibitor; decreases T lymphocyte activity and IL-2 function
Calcineurin inhibitor; inhibits T lymphocyte activity and IL-2 function
Blocks nucleotide production for immune cell replication
Cytostatic effect on B and T cells; decreases proliferation by inhibiting
nucleotide synthesis
Impairs phagocyte function
Attenuates production of proinflammatory mediator
Decreases T-cell activity
Decreases cell signal transduction
Blocks mTOR receptor and immune cell signal transduction, reducing
B- and T-cell activity
Antilymphocyte antibody
Used for immunosuppression when nephrotoxic agent is held
Used for treatment of corticosteroid resistant rejection
Antilymphocyte antibody
Used for prophylaxis against rejection in early period
Used for immunosuppression when nephrotoxic agent is held
Used for treatment of corticosteroid resistant rejection
Adverse Effect
Acute/chronic nephrotoxicity, electrolyte derangements
(hyperkalemia, hypomagnesemia), gout, hemolytic-uremic
syndrome, gingival hyperplasia, hirsutism, hypertension,
hyperlipidemia
Similar to cyclosporine
Neurotoxicity (headache, tremor, paresthesias, seizures), hair
loss instead of hirsutism, less hypertension/hyperlipidemia
Bone marrow suppression, macrocytosis, anemia, hepatotoxicity,
pancreatitis
Abdominal pain, decreased oral intake, nausea/vomiting,
diarrhea, anemia, leukopenia, thrombocytopenia
Weight gain, cataracts, acne, skin thinning, bruising, osteoporosis,
GI bleeding, hyperglycemia, hyperlipidemia, psychologic effects,
cushingoid appearance
Thrombocytopenia, leukopenia/anemia (less common), diarrhea,
mucosal irritation, buccal ulceration, interstitial pneumonitis,
hyperlipidemia
Fever, serum sickness, anaphylaxis, anemia, thrombocytopenia
OKT3: During first 3 days of therapy, may have headache, aseptic
meningitis, encephalopathy, seizures, nausea, vomiting,
diarrhea, pulmonary edema, nephrotoxicity
IL-2 receptor antibodies have rare adverse effects such as
anaphylaxis

Proteinuria may signal rejection, drug toxicity, glomerular disease, or  IMAGING

other graft nephropathy, although proteinuria from a remaining native
kidney should also be considered. Obtain cyclosporine or tacrolimus
blood levels for all patients on these medications. Contact the patient’s
transplant team regarding abnormal drug levels, because low drug levels
are sometimes deliberately used to reduce side effects.
US is the best test to detect urinary obstruction. Renal graft US can
also be useful in patients suspected of having pyelonephritis, vascular
abnormalities (stenosis, thrombosis, pseudoaneurysm, hematoma, and
arteriovenous fistula), perinephric abscess, urine leak, wound infection,
or an episode of rejection.

TABLE 297-10 Presentations of Transplant Rejection

Transplant Organ Symptoms/Signs Management
Renal Many asymptomatic Acute rise in serum creatinine; electrolyte abnormalities.
Symptoms: US may demonstrate increased graft size, loss of corticomedullary junction,
• Hypertension prominent hypoechoic pyramids.
• Fever, malaise, oliguria, graft pain, and tenderness over site Renal Doppler studies may demonstrate elevated vascular resistance indices.
• Worsening renal function with decreased urine output and rising serum Biopsy needed during admission.
creatinine
Liver Fever, malaise, abdominal pain, hepatosplenomegaly, ascites Laboratory abnormalities: elevated liver function tests and bilirubin.
US of graft and vasculature may find focal lesion or vascular abnormality.
Biopsy needed during admission.
Cardiac Dyspnea at rest/exertion, orthopnea, palpitations, near-syncope/syncope, Cardiac troponin and B-type natriuretic peptide often elevated.
peripheral edema, or GI symptoms with right heart involvement ECG may demonstrate T-wave/ST-segment changes.
Chest pain is absent due to denervation during surgery Echocardiogram with systolic/diastolic dysfunction.
Dysrhythmias common Chest radiograph may demonstrate findings of congestive heart failure.
Biopsy needed during admission.
Lung Shortness of breath and cough most common Eosinophilia suggestive on CBC with differential.
Lung examination variable: clear lung fields, crackles, or decreased breath Normal chest radiograph is not reliable to rule out disease.
sounds Chest CT often required.
May demonstrate stridor or wheezes Pulmonary function testing not helpful in differentiating infection and rejection.
May present with respiratory distress or failure Effusion requires thoracentesis.
Bronchoscopy and biopsy needed during admission.

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 CHAPTER 297: The Transplant Patient    1991

CT angiography may be used to diagnose vascular complication such TABLE 297- 11 Differential Diagnosis of Renal Allograft Dysfunction
as hematoma, artery stenosis, and vascular thrombosis.62-64
MRI can be helpful in evaluating hematomas and other fluid collec- Differential Disorder Comments
tions, vascular abnormalities, and small infarcts caused by medication- Mechanical Presents with decreased urine output. At
induced vasculitis. Magnetic resonance angiography has the advantage Complications of surgery US, a urine leak (i.e., urinoma) appears
of requiring either no contrast material or a gadolinium chelate that as a well-defined, anechoic fluid collec-
Ureteral obstruction
is less nephrotoxic than other agents.2 However, gadolinium-based tion with no septations that increases
contrast agents can cause acute renal failure in up to 3.5% of patients Urine leak: urinoma, ascites, or abscess in size rapidly. Requires consultation
with underlying chronic renal insufficiency.65 Therefore, the patient’s with urology and transplant physician.
transplant team should be consulted before using gadolinium-based Obstruction typically requires Foley
contrast agents. catheter placement, followed by stent
placement.

 GRAFT DYSFUNCTION AND FAILURE

Lymphocele Results from perivascular lymphatic vessel
leakage, which forms a collection of lym-
Chronic renal dysfunction precedes the majority of graft failures. Acute phatic fluid in up to 15% of patients within
renal failure in transplant patients is defined as a 20% rise from baseline the first 3 months of transplant.
serum creatinine levels, as opposed to a 50% rise in other patients with Vascular The transplanted kidney is usually placed
acute renal failure. Consider the conditions described in Table 297-11  Renal artery stenosis or thrombosis extraperitoneally in the right iliac fossa.
when evaluating possible graft dysfunction or even a small increase in (12%) End-to-side anastomosis to the external
serum creatinine.66,67 iliac vasculature provides circulation. Color
Renal vein thrombosis duplex imaging of the renal artery and
 Renal artery and renal vein thromboses vein is helpful in assessing renal vascular
LIVER TRANSPLANTATION are uncommon; they usually occur in stenosis or thrombosis. CT angiography
the first month after transplant. can be utilized as well. Treatment often
The most common reasons for ED visits are fever and abdominal pain.11 Peritransplant hematoma includes thrombolysis for vascular stenosis/
Hepatosplenomegaly, ascites, and malaise may also occur, specifically thrombosis and surgery for peritransplant
with rejection.2 Complications include bleeding, rejection, and infection, hematoma.
as well as biliary, vascular, and wound complications. Bacterial infection Glomerulonephritis
may accompany acute rejection.68 Specific complications of liver trans-
plantation are listed in Table 297-12. Obtain a CBC with platelet count Infection Urinary tract infections are the most com-
and differential; serum chemistries, including electrolytes, BUN, creati-    Urinary tract infection mon source of bacteremia in renal trans-
nine, basic coagulation studies, liver function tests, amylase, and lipase plant recipients, and infectious diseases
  Interstitial nephritis from polyoma are the second leading cause of death
levels; and cultures of blood, urine, bile, and ascites. Radiographic testing BK virus, cytomegalovirus, herpes
as indicated may include chest radiograph and abdominal US with Dop- in this population. See “Posttransplant
viruses 1 and 2, and adenovirus Infections” section. At least two antibiotics
pler flow studies. US with Doppler can identify fluid collections, throm-
bosis of the hepatic artery or portal vein, and dilatation of the biliary tree should be used for treatment of urinary
(although the absence of biliary dilatation does not exclude obstruction tract infection.
or other posttransplantation pathology).69-73 With partial obstruction, Rejection Most common presentation of rejection in
the intrahepatic ductal system often does not appear to be dilated appre- Hyperacute renal transplant patients is hypertension
ciably by US. With complete obstruction, duct dilation is usually seen. and falling urine output, but rejection may
Acute
CT with contrast may be required for diagnosis of vascular complica- be asymptomatic. Fever, pain, malaise,
tion or biliary stricture.2,69,70 Patients often require cholangiography for Late (recurrent acute) oliguria, and site tenderness may occur.
complete evaluation. Patients with choledochocholedochostomy may   Chronic cellular Comparison of creatinine at the time of
be best evaluated by endoscopic retrograde cholangiopancreatography   Chronic humoral presentation to prior levels is critical, as
because it permits both a radiographic diagnosis and the potential creatinine elevation is common. Fever may
for nonoperative intervention. Patients with a Roux-en-Y hepaticoje- be a presentation of rejection.
junostomy or those who cannot have endoscopic retrograde cholan- Recurrent pyelonephritis/vesicoureteral Common problem threatening graft and
giopancreatography must undergo percutaneous cholangiography.72-75 reflux patient survival
Early, broad-spectrum prophylactic antibiotics should be administered
Nephrotoxic agents Drug serum levels do not correlate well
before any biliary tract manipulation. Discuss treatment and disposition
 Aminoglycosides, fluoroquinolones, with the degree of renal damage. NSAIDs
with the transplant team.
cidofovir, foscarnet, sulfonamides, are contraindicated in this group. Avoid
calcineurin inhibitors (cyclosporin A and contrast agents if possible.
LUNG TRANSPLANTATION tacrolimus), NSAIDs, gadolinium-based
and some other contrast agents, herbal
Lung transplantation involves three anastomoses: airway (the most preparations
vulnerable to complication, 2% to 33%), pulmonary arterial, and pulmo- Noncompliance with Diabetes often follows transplantation;
nary vein to the left atrium.3,6,76-78 Fever, cough, and increasing dyspnea marked exacerbations in hypertension are
Medications
are common reasons for ED visits in lung transplant patients. Important frequently associated with graft failure.
clinical features to note are the respiratory rate, pulse oximetry measure-  Management of risk factors such as
ment, and physical findings of cyanosis, diaphoresis, use of accessory diabetes and hypertension
muscles, signs of congestive heart failure, and adequacy of peripheral Chronic allograft nephropathy Common cause of graft dysfunction
perfusion. Obtain a chest radiograph and arterial blood gas analysis
when adequacy of ventilation is in question. Give β2-agonists and anti-
cholinergics as indicated. Signs of infection often overlap with the signs
and symptoms of rejection, and the management of infection is quite stenosis.79 Therefore, bronchoscopy is required for specific diagnosis.
different from that of rejection. A drop in the forced expiratory volume Lung transplant patients can deteriorate very quickly in the absence of
in 1 second of >10% warrants clinical investigation, but pulmonary the proper therapy. Thus, it is common practice to cover both infection
function testing cannot distinguish between acute rejection, infection, and rejection until additional histopathologic and culture results are
and nonimmunologic causes of respiratory dysfunction such as airway obtained.80

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TABLE 297-12 Complications of Liver Transplantation TABLE 297-13 Time Course of Lung Transplant Complications
Complication Comments Days After Transplant Complications Most Commonly Seen in Each Time Period
Bleeding complications GI bleeding should be managed in the usual fashion 0–3 d Hemorrhage from technical/mechanical problems
but may signal graft dysfunction. Reperfusion injury
Biliary complications Bile leaks present early, and biliary strictures present Dysrhythmia
Bile leak late (>2 mo from transplant). In both cases, cholestatic
liver enzymes are elevated, typically with right upper 3 d–1 mo Infection: bacterial, Mycoplasma, community respiratory
 Biliary stricture viruses
quadrant pain (more pronounced with bile leak). Jaun-
(anastomotic and Rejection
dice and fever may also be present. US with Doppler of
nonanastomotic)
hepatic vessels displays sensitivity of 38%–66%. If US is Anastomotic failure
Biloma negative, cholangiogram may be needed, with patients
Pulmonary embolism
often requiring endoscopic retrograde cholangiography
(ERC). Strictures come in two forms, with anastomotic Muscle weakness
strictures occurring within the first year after surgery. Dysrhythmia
Imaging includes CT, US, and MRI, with treatment Starting at 1 mo Rejection
including ERC and stent placement. Bile leaks occur in
up to 25% of patients, with ERC needed for diagnosis Obliterative bronchiolitis
and treatment (stent). Bilomas can be diagnosed with Infection
US and managed with drainage and antibiotics.  Bacterial, fungal, community respiratory viral (can occur
Hepatic artery complications Vascular complications affect the hepatic artery or portal at any later time)
 Hepatic artery thrombosis vein most commonly. CT with contrast (if renal function   Mycoplasma 0–4 mo
adequate) or US is helpful in the evaluation of these Mycobacteria after 4 mo
 Hepatic vein thrombosis conditions. CT with IV contrast has greater sensitivity
 Portal vein complications for arterial stenosis, but US displays a sensitivity up to Other Cytomegalovirus infection and Pneumocystis jiroveci
Pseudoaneurysm 90% for venous thrombosis. Mortality reaches 80% for pneumonia may occur any time, but are more common
portal vein thrombosis if not diagnosed. For thrombosis, when prophylaxis is not being given, especially when
thrombolysis may be required. Pseudoaneurysms are such treatment has been recently discontinued.
typically treated with transcatheter embolization.
Rejection Early alkaline phosphatase and bilirubin levels rise,
followed by a rise in aspartate aminotransferase and present in respiratory distress or failure. Eosinophilia may be present
alanine aminotransferase. US may reveal focal lesion with rejection. Radiographic abnormalities are less common >6 weeks
or vascular abnormality. Biopsy is needed during after transplant, and an acute rejection episode actually may be “radio-
admission. graphically silent” after this. Discuss treatment with the transplant team.
If the maintenance immunosuppressant regimen has been tapered, it
Neurologic complications Causes include hemorrhage, cerebrovascular infarct, can be very helpful to return to pretaper dosages. In addition, high-dose
cerebral abscess, hypertensive encephalopathy, osmotic corticosteroids are often used to treat acute rejection. The usual dosing
demyelination syndrome, and sinus thrombosis. MRI is regimen is 15 milligrams/kg of IV methylprednisolone each day for
best for evaluation. 3 consecutive days. After the corticosteroid bolus, if the maintenance pred-
Malignancy Increased risk for squamous cell carcinoma, lymphomas, nisone had been tapered, increasing the prednisone to 1 milligram/kg/d and
and posttransplant lymphoproliferative disorder. tapering over the next 10 days may be helpful.79,95,96 Clinical response to
treatment is gauged by improvements in oxygenation, spirometry, and
radiographic appearance and typically occurs within 24 to 48 hours after
 COMPLICATIONS OF LUNG TRANSPLANTATION treatment is initiated. Failure to improve should suggest infection as an
alternative diagnosis. After clinical improvement, the maintenance dose
Complications occur most frequently in the first year, but can occur of prednisone is increased, with a slow taper back to baseline.
at any time starting from the first few weeks after transplant and can Pulmonary infections from bacteria, fungi, or viruses are the
continue throughout the lifetime of the patient (Table 297-13).80,81 most common causes of morbidity and mortality in lung transplant
Airway complications often occur with dyspnea, wheezing, or stridor
or postobstructive pneumonia. A variety of mechanisms of airway
obstruction may occur, such as bronchial stenosis, tracheobroncho-
malacia, hyperplastic granulation tissue, and bronchial necrosis. Diag- TABLE 297-14 Indications for Hospital Admission for Lung Transplant Patients
nosis typically includes chest CT and bronchoscopy.76-78,82-84 Vascular Pretransplant patients
complications (stenosis, kinking, and thrombus formation) are not as • Respiratory failure
frequent but have poor outcomes and can present with hypoxemia, • Infiltrate
dyspnea, hypotension, and edema.85-87 US may reveal right-sided
• Systemic infection
cardiac dysfunction with vascular complications, although definitive
diagnosis includes CT angiography. Phrenic nerve dysfunction is more • Decompensated congestive heart failure or pulmonary edema
common in heart-lung transplant (40% of cases) as compared to lung- • Pneumothorax
only transplant (3% to 9%).88-91 Indications for hospital admission are Posttransplant patients
listed in Table 297-14. • Respiratory failure
Acute rejection is common and may occur three to six times in
• Acute rejection
the first postoperative year. After the first year, the frequency of acute
rejection decreases, but it can occur for several years after transplant. • Rapidly progressive airflow limitation (forced expiratory volume in 1 second decreases
Signs of rejection include cough, chest tightness, increase or decrease >10% over 48 h)
in temperature from baseline of >0.28°C (0.5°F), hypoxemia, decline • Infiltrate
in forced expiratory volume in 1 second (10% or more), and infiltrates • Systemic infection
on the chest radiograph, although the chest radiograph may be nor- • Febrile neutropenia
mal. Lung auscultation is often variable, with examination revealing
• Pneumothorax
clear lung fields, crackles, or decreased breath sounds.92-95 Patients may

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 CHAPTER 297: The Transplant Patient    1993

patients97,98 (Tables 297-5 and 297-13). Lung transplant patients are at

risk for pneumonia because of colonization of the recipient’s airway in
the setting of transplantation for bronchiectasis and cystic fibrosis and
at risk of aspiration in the presence of gastroesophageal reflux disease.81
Antibiotic selection is best left to the lung transplant specialist.

CARDIAC TRANSPLANTATION
Cardiac transplantation has been applied successfully to patients
of all ages, from newborns through persons in their late 60s. Heart
transplantation is indicated for patients with end-stage heart failure
not remediable by standard medical or surgical therapy. Many in the
latter group will have undergone previous coronary artery bypass or
valve surgery or been bridged on mechanical assist devices. The lead-
ing causes of death in those age 60 to 69 years are graft failure and
infection.99
The success of a heart transplantation operation depends on the
ability of the denervated heart to support the normal circulation. The
lack of sympathetic and parasympathetic innervation does, however,
induce an altered physiologic state. The denervated heart has a normal
sinus rhythm with a heart rate between 90 and 100 beats/min. Denerva-
tion results in the absence of the initial centrally mediated tachycardia
in response to stress or exercise, but the heart remains responsive to FIGURE 297-3. Chest radiograph of healthy post–heart transplant patient with typical
circulating catecholamines. Thus, the cardiac response to stress or postoperative changes, including “cardiomegaly” due to transplantation of a heart from a
exertion is blunted. With proper conditioning, patients are able to donor who was larger than the recipient.
resume normal activity levels, including vigorous exercise, following
transplantation.100-103
The donor heart is implanted with its own sinus node intact to pre- reason for the ED visit. Patients may present with a variety of symptoms
serve normal atrioventricular conduction. The technique of cardiac in the setting of rejection including dyspnea, orthopnea, syncope, and
transplantation also results in preservation of the recipient’s sinus node at edema, but chest pain is typically absent due to denervation during
the superior cavoatrial junction, and the two sinus nodes remain electri- surgery.92 Chest radiograph, ECG, and further evaluation are based on
cally isolated from each other. Thus, ECGs frequently will have two dis- complications of cardiac transplantation (Table 297-15) and underlying
tinct P waves (Figure 297-2). The sinus node of the donor heart is easily patient comorbidities, especially in elderly transplant recipients. Cardiac
identified by its constant 1:1 relationship to the QRS complex, whereas biomarkers are typically elevated in rejection, with findings consistent
the native P wave marches through the donor heart rhythm indepen- with heart failure on echocardiogram and chest radiograph.2
dently. The presence of the two separate P waves may lead to confusion
about the patient’s rhythm, mistakenly interpreting sinus rhythm as CORNEAL TRANSPLANTATION
second-degree heart block. The ECGs may also be interpreted errone-
ously as showing atrial fibrillation, atrial flutter, or frequent premature Corneal transplantation (penetrating keratoplasty) is the most com-
atrial complexes. Some patients may have evidence of “cardiomegaly” mon form of human solid-tissue transplantation and is a key element
related to the transplantation of a heart from a donor who was larger in vision restoration. Unlike other tissue and organ transplants, corneal
than the recipient (Figure 297-3). Clinical evaluation is based on the allotransplantation usually does not require systemic or permanent

FIGURE 297-2. ECG in a heart transplant patient. ECG demonstrates donor and recipient P waves (arrowhead = donor P wave; arrow = recipient P wave).

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TABLE 297-15 Complications After Cardiac Transplant
Complication Comments
Altered physiology See text in “Cardiac Transplantation” section.
Dysrhythmias Dysrhythmias after transplantation are frequently due
to rejection. Treat the unstable patient presenting in
extremis with 1 gram of methylprednisolone IV; delay
rejection therapy in the stable patient for consult
with the transplant team and biopsy. Atropine and
vagal maneuvers have no effect due to denervation.
Adenosine should be provided at half the normal dose
in supraventricular tachycardia.
Sinus node dysfunction Pacemaker usually required.
Pulmonary complications Diagnosis may require CT or more invasive diagnostic
Pneumonia procedures.
Thromboembolic disease
Exercise-induced hypoxemia
Pneumothorax
Interstitial fibrosis
Cardiac ischemia Patients do not experience pain due to denervation;
symptoms typically occur with complications such as
congestive heart failure.
Rejection Presents a variety of ways: dyspnea, syncope, orthop-
nea, palpitations, edema. Cardiac biomarkers typically
elevated. Often presents with dysrhythmias and find-
ings of heart failure. Treat the patient presenting in
extremis; withhold treatment for biopsy if possible.
Infection See section “Posttransplant Infections.”
Congestive heart failure Echocardiography can help to determine etiology and
therefore ideal treatment.
Ischemic stroke and Increased risk after heart transplant.
intracranial hemorrhage
Complications specific to Increased risk of infection and thromboembolism.
ventricular assist devices
Cardiac allographic Beyond 1 y after transplant, one of the major causes of
vasculopathy graft failure due to rapid atherosclerosis. Pediatric heart
transplant recipients are at risk for graft coronary artery
disease and ischemia. May occur with no symptoms or
fulminant heart failure. Diagnosis includes angiography.
May require retransplantation.
immunosuppression. Reasons for graft failure include corneal graft
rejection (30.9%), corneal endothelial cell failure (21.0%), glaucoma
(8.5%), and other causes (26.2%).104,105 Ophthalmology consultation
is required for any change in visual acuity or other ocular signs or
symptoms in a patient with a corneal transplant.
Corneal graft rejection is a specific process in which a graft that has
been clear suddenly develops graft edema with anterior segment inflam-
matory signs. Rejection can occur at any time starting at 10 days after
transplant. The inflammatory process starts at the graft margin nearest
to the most proximal blood vessels and then moves toward the center
to involve the entire graft.104 Signs and symptoms include eye pain,
photophobia, corneal or scleral injection, and decreased visual acu-
ity. Examination may reveal unilateral anterior chamber reaction with
keratic precipitate or corneal edema in a previously clear graft. Late graft
failure can present with gradual onset of graft edema with no associated
inflammation or keratic precipitates. Treatment includes topical or sys-
temic steroids, cycloplegics, and immunosuppressive drugs such as local
and systemic cyclosporine A and tacrolimus.
Wound dehiscence can occur early or late after corneal transplanta-
tion as a result of infection or after eye trauma. Trauma may be unrec-
ognized or be a result of events such as motor vehicle airbag deployment
or a fall with the patient’s glasses impacting the eye. There may be globe
rupture, slight separation of part of the suture line, or just broken sutures.
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Viral,104 bacterial,106 or fungal107 infection can threaten the trans-
planted cornea. In patients with a history of herpetic keratitis, consider
recurrence and examine with fluorescein for characteristic corneal
staining and signs of anterior chamber inflammation.104 Ophthalmology
consultation is needed for diagnosis and treatment.
Acknowledgment: The authors thank J. Hayes Calvert for his work on
the previous edition of this chapter.
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER The Patient With
Morbid Obesity
298
Joanne Williams
INTRODUCTION AND EPIDEMIOLOGY
Since 1980, worldwide obesity has more than doubled. In 2008, more
than 1.4 billion adults, age 20 and older, were overweight. Of these, over
200 million men and nearly 300 million women were obese. Sixty-five
percent of the world population resides in countries where overweight
and obesity kill more people than underweight. In 2010, more than
40 million children under the age of 5 were overweight.1
In children, an age- and sex-specific percentile for body mass index
(BMI) determines weight status rather than the BMI categories used for
adults, because children’s body composition varies as they age and varies
between boys and girls.
The Centers for Disease Control and Prevention uses a BMI thresh-
old of above the 85th percentile to define overweight and above the
95th percentile to define obese, compared to children of the same age
and sex.2 The World Health Organization defines overweight as a BMI
≥25 kg/m2, whereas obesity is defined as a BMI ≥30 kg/m2.1
Care for bariatric surgery patients is discussed in Chapter 87,
“Complications of General Surgical Procedures.”
PATHOPHYSIOLOGY
Obesity is an independent risk factor for acute coronary syndrome,
especially in those <40 years old.3,4 Atypical symptoms may pose a prob-
lem with acute coronary syndrome diagnosis.5,6 Approximately 11% of
cases of congestive heart failure are attributable to obesity alone.7 The
physical deconditioning of obesity manifests with orthopnea, dyspnea,
and lower extremity swelling mimicking acute congestive heart failure.
Plain chest radiograph findings of congestive heart failure may be
obscured by redundant overlying soft tissue and hypoventilation artifact.
Brain natriuretic peptide levels are lower in the obese patient than in the
nonobese.8,9 Cardiomyopathy may affect up to 10% of patients with a
BMI >40 kg/m2.10 Obesity is a risk factor for venous thromboembolism11
and its recurrence once anticoagulation therapy is withdrawn.12
The increased prevalence of type 2 diabetes is closely linked to the
upsurge in obesity. Excess weight accounts for 90% of type 2 diabetes.13
Obesity is strongly associated with insulin resistance in normoglycemic
persons and in individuals with type 2 diabetes.14
The accumulation of fat impairs the function of ventilation in obese
children and adults.15-17 Reductions in forced expiratory volume in
1 second, forced vital capacity,15,16 total lung capacity, functional residual
capacity, and expiratory reserve volume are associated with increasing
BMI.18
Obesity is a well-recognized risk factor for obstructive sleep apnea.
Forty percent of people who are obese have obstructive sleep apnea, and
approximately 70% of people with obstructive sleep apnea are obese.19
Increased fat deposition in the pharyngeal area along with reduced
operating lung volumes associated with obesity reduce upper airway
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TABLE 298-1 Diagnostic Criteria for Obesity Hypoventilation Syndrome
• Body mass index 30 kg/m2
• Daytime Paco2 >45 mm Hg
• Associated sleep-related breathing disorder (obstructive sleep apnea–hypopnea
syndrome or sleep hypoventilation or both)
• Absence of other known causes of hypoventilation
Abbreviation: Paco2 = partial pressure of arterial carbon dioxide.
caliber, modifying airway configuration, which in turn increases upper
airway collapsibility. Thus, airways are predisposed to repetitive closure
during sleep.20 Daytime sleepiness increases and may be associated with
accidental trauma.19
Cor pulmonale and hypercapnic respiratory failure are common.
Obesity hypoventilation syndrome (Table 298-1) was first described
over 50 years ago.21,22 The most common symptoms are (1) respira-
tory failure, (2) severe hypoxemia, (3) hypercapnia, and (4) pulmonary
hypertension.22-24
ESTIMATING PATIENT WEIGHT
The Broselow tape inaccurately predicts actual weight in one third of
children.25 The significance of this inaccuracy has not been studied in
depth. A weight-estimation formula based on mid-arm circumference
is reliable for use in school-age children and may be an alternative to
the Broselow tape.26 The formula is as follows: weight (kg) = (mid-arm
circumference [cm] – 10) × 3. When compared to the Argal, Advanced
Pediatric Life Support, and Best Guess formulas, Krieser et al27 found
that parental estimation of weight was more accurate.27
The concern for equipment weight capacity in the adult patient with
obesity is an important determination for imaging. Scales in most EDs
have a maximum weight capacity of 150 kg. Mechanized beds that weigh
patients are not common in the ED but are a consideration for equip-
ment. Patients with obesity tend to significantly underestimate their
own weight. A variety of formulas are available to estimate weight in
adults who are obese using height and waist, hip, and arm circumfer-
ence. The formula developed by Crandall et al28 seems to require the
least amount of time and patient manipulation. Two distinct formulas
for nonpregnant females and males have been developed as follows:
Nonpregnant females: Weight (kg) = 64.6 + 2.15 (arm circumference in cm)
+ 0.54 (height in cm)
 Males: Weight (kg) = 93.2 + 3.29 (arm circumference in cm)
+ 0.43 (height in cm)
SPHYGMOMANOMETRY
Improper blood pressure cuff width and circumference will artificially
elevate pressure readings. The standard adult blood pressure cuff is too
short for patients with an arm circumference of 32 cm or larger. Patients
who are overweight or obese will require cuffs larger in size.
The American Heart Association recommends the following cuff
widths when evaluating blood pressure in patients who are obese: (1)
for arm circumferences ranging from 35 to 44 cm, a bladder measuring
16 cm in width is needed; (2) for circumferences from 45 to 52 cm, the
bladder width should be 20 cm; and (3) in patients with short upper arm
length, a 16-cm-wide cuff should be used.29,30
MEDICATION DOSING
Little evidence-based literature is available for appropriate dosing in
obesity, and nearly none is available in the obese child. Fortunately,
many drugs used in resuscitation are not lipophilic, and lean body mass
is a reasonable dosing guide. Altered physiology is characterized by an
increased clearance of hydrophilic drugs, a larger volume of distribution
for lipophilic drugs, and a decrease in lean body mass and tissue water
content, as compared to their lean counterparts.31 Altered mechanics
can predispose the morbidly obese to systemic toxicity due to either
overdosing or lack of efficacy from underdosing.32,33
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CHAPTER 298: The Patient with Morbid Obesity     1995
TABLE 298-2 Dosing of Select Drugs
Dosing Drugs
Ideal body Penicillins, cephalosporins, linezolid, corticosteroids, H2-blockers,
weight digoxin, β-blockers, atracurium, vecuronium, fentanyl*, midazolam*,
lorazepam*, phenytoin, propofol
Total body Succinylcholine, rocuronium, unfractionated heparin, enoxaparin,
weight vancomycin
Dosing weight Aminoglycosides, fluoroquinolones
*
Initial dose based on total body weight.
A weight-based medication schedule uses ideal body weight, total
body weight, or dosing weight to avoid systemic side effects and lack
of clinical efficacy by underdosing. Ideal body weight according to the
Devine formula34 is as follows:
Ideal body weight (male) = 50.0 kg + 2.3 kg (each inch >5 feet)
Ideal body weight (female) = 45.5 kg + 2.3 kg (each inch >5 feet)
Dosing weight is an adjusted body weight of overweight or obese
patients and is used only for drugs for which there are recommendations
specifying that the actual body weight should be adjusted to use in the
dose calculation.
Dosing weight = Ideal body weight + [0.4 × (Actual – Ideal body weight)]
Exception: If actual < ideal body weight, then the dosing weight = actual
Table 298-2 divides select drugs into ideal body weight, total body
weight, and dosing weight dosing.35 Fentanyl and the benzodiazepines
are lipophilic and have a prolonged half-life in obese patients. With
these drugs, the initial dose based on total body weight may be needed,
but subsequent doses should be based on ideal body weight.36 It is best
to check with a pharmacist for specific dosage regimens.
VASCULAR ACCESS
Vascular access is problematic. Patients who are critically ill and mor-
bidly obese patients require fluid administration often guided by central
venous pressure and urine output.37 Central venous pressure placement
is extremely challenging even for the most skilled physician. In the obese
patient, the distance from skin to vessel is much farther than normal,
anatomic landmarks are obscured (Figure 298-1A and B), and the angle
of approach may be too steep to allow cannulation even after reaching the
vessel. There is no clear consensus as to the preferable site and approach
to central venous catheterization. In general, there is an increased inci-
dence of infection and deep venous thrombosis when using the femoral
approach.38 If this proves to be the only option, then use this site.
The internal jugular vein can be accessed with equal success to the
subclavian approach in patients who are obese. The success rate might
be increased with the head maintained in the neutral position, thereby
reducing the risk of overlap of the internal jugular vein over the carotid
artery.39
A US-guided 15-cm catheter can be used to cannulate the brachial or
basilic vein.40 Another approach is the use of a pediatric central venous
catheter placed into the basilic vein. The pediatric central venous cath-
eter is 8 cm (3.15 in.) in length, is a double-lumen catheter, and has
18- and 20-gauge lumens.41 Longer catheters can also be considered to
guard against inadvertent dislodgement.
IMAGING
Attenuation severely limits the image quality of plain radiographs
(Figure 298-2). Increasing exposure time can improve the image but
at the expense of increased radiation. Motion artifact increases with
increased exposure time. Multiple cassettes may be required if the
patient is too large for a single 14 × 17–inch film. Patients may be able
to stand for plain radiography if too large for the tables.42
CT and MRI scanners have both patient weight and girth limits,
consider patient shoulder and pelvis girth. Newer CT scanners can
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 1996   SECTION 26: Special Situations
A B
FIGURE 298-1. A and B. Difficulties in landmark identification.
accommodate up to 660 lb. If the patient outweighs equipment capacity,
consider transferring the patient to an institution with a larger-capacity
scanner, or veterinary schools may be an option. Most standard MRIs
have a maximum shoulder-to-shoulder width of 52 inches (137 cm) and
weight limits of 300 to 350 lb (136 to 159 kg), although open MRI scanners
can sometimes be an option for large body diameters.
Diagnostic peritoneal lavage has been suggested as an option in the
patient with obesity and blunt abdominal trauma who is too large for
imaging equipment43; however, many surgeons are no longer accus-
tomed to making decisions based on results, and in the morbidly obese
patient, diagnostic peritoneal lavage is difficult to perform.
PROCEDURAL SEDATION
Give procedural sedation drugs and pain medications cautiously. Select
doses at the lower end of the range, and titrate to effect. Local and
regional anesthesia might be considered for complicated or prolonged
procedures.44
FIGURE 298-2. Attenuation can blur findings on plain radiographic films.
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AIRWAY MANAGEMENT
Difficulty with mask ventilation, rapid oxygen desaturation, and altered
pharmacokinetics can make airway management challenging.45 Imped-
ance to airway management is caused by excess fatty tissue externally
on the breast, neck, thoracic wall, and abdomen and internally in the
mouth, pharynx, and abdomen. First-attempt success is significantly less
in obese patients.45
Patients who are obese have increased intra-abdominal pressure and
increased incidence of hiatal hernia and gastroesophageal reflux disease.
These characteristics render patients more prone to aspiration during
airway management.45,46
Patients who are obese will desaturate more rapidly after preoxygen-
ation than their lean counterparts. When no cervical spine injury is sus-
pected, desaturation may be partially prevented by keeping the patient
in a 25-degree head-up position during preoxygenation.47
Two-person bag-valve mask with a two-handed bilateral jaw thrust is
recommended in patients who are morbidly obese. If tolerated, an oral
airway may be used to prevent the tongue from occluding the airway.
The early use of noninvasive positive-pressure ventilation may abate the
need for endotracheal intubation. High expiratory positive pressures
may be needed.
Obesity is not a contraindication for rapid-sequence intubation.
Advance preparation is critical, and assessment for a potential difficult
airway is of utmost importance.48
The “sniffing” position results in suboptimal positioning for laryngos-
copy in patients who are obese, and this may also confound results and
falsely worsen graded views.49 The “ramping” position (Figure 298-3A)
offers improved intubation conditions in patients who are morbidly obese
compared to the “sniffing” position (Figure 298-3B). This position is
achieved by placing multiple folded blankets under the upper body, head,
and neck until the external auditory meatus and the sternal notch are
horizontally aligned.50 Another option is elevating the patient’s head and
thorax with the intubation physician standing on a stool behind the patient
and essentially intubating with the patient semi-upright (see Chapter 29A,
“Tracheal Intubation”, Figure 29A-3).
First give consideration to awake intubation, given that patients who
are obese may be difficult to mask ventilate and rapid oxygen desatura-
tion may occur after the ablation of spontaneous ventilation, especially
in patients with a BMI greater than 40 kg/m2.51-53 The awake intubation
may be performed either by the nasotracheal or orotracheal routes.
The relative benefits and risks of the awake intubation approach
must be weighed against the merits of rapid-sequence intubation, which
reduces risk of aspiration, improves intubating conditions, and results in
easier insertion of advanced and rescue airway devices. During rapid-
sequence intubation, the chance for first-pass success can be optimized
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A
B alignment.
FIGURE 298-3. The ramping position (A) is more effective for intubation than the sniff-
ing position (B) in patients with morbid obesity.
by video laryngoscopy. The intubating laryngeal mask airway is effective
in obesity and should be readily available because surgical access to the
airway may be difficult. The bougie is a good rescue device.54
Percutaneous and open surgical access to the airway may be difficult
when landmarks are obscured by excess soft tissue and a short neck in
the “cannot intubate, cannot ventilate” scenario.55 Obesity and a short
neck are associated with difficult transtracheal needle ventilation and
retrograde tracheal intubation.56,57 However, in the elective surgical air-
way management setting, cricothyroidotomy is technically feasible even
in patients with difficult neck anatomy caused by obesity.58
Until the proper size tracheostomy tube is located, a 6-mm-inner-
diameter endotracheal tube passed through a cricothyroidotomy inci-
sion may serve as a temporizing measure.59 There is limited literature
concerning the success rates of surgical airways in patients in the emer-
gency setting. Even in an ideal setting, cricothyroidotomy requires more
than 100 seconds to achieve ventilation,57 and most clinicians rarely
perform the procedure.60
With respect to ventilator management, calculate initial tidal volume
using ideal body weight and begin with volumes of 6 to 8 mL/kg of ideal
body weight. See Chapter 29B, “Mechanical Ventilation,” for detailed
discussion of mechanical ventilation.61,62
TRAUMA
Victims of motor vehicle accidents who are obese (BMI >31 kg/m2) have
significantly more rib fractures, pelvic fractures, pulmonary contusions,
and extremity fractures and fewer head and liver injuries.63 Even with
seatbelt and airbag use, risk of death for morbidly obese patients was
1.52 times greater than that in nonmorbidly obese patients.64
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CHAPTER 299: The Transgender Patient    1997
Mildly overweight patients, not the morbidly obese, are less prone to
intra-abdominal injury because of the protective effect of the abdominal
fat, known as the “cushion effect.”65
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER The Transgender Patient
299 Monica L. Gaddis
Frances W. Grimstad
INTRODUCTION
A transgender person is someone whose gender identity differs from
their sex assigned at birth. Sex is an assignment of “male” or “female”
based on birth assessment of genitalia. An intersex assignment can also
be made at birth based on ambiguous genitalia. Unlike sex, gender
identity is self-identified, not assigned, and may or may not be congru-
ent with sex. Thus, transgender persons include those who were
assigned as being of male sex at birth but who identify as female and
those who were assigned as being of female sex at birth but who identify
as male. Further, some individuals identify outside the male–female
binary, including those who identify as both, neither, or in between, and
may identify with terms such as gender nonbinary, gender nonconform-
ing, or gender fluid.1 Approximately 0.5% of people in the United States
identify as transgender.2 Not all transgender patients desire physical
Transgender identity is not classified as a mental disorder.3 Transgen-
der patients should have access to respectful, nondiscriminatory, and
affordable medical care. According to the 2015 National Transgender
Discrimination Survey, 28% of the transgender respondents reported
postponing necessary medical care due to prior negative experiences. In
addition, 19% of those surveyed reported being denied care because they
were transgender.4 More than 50% of transgender persons reported that
they had to teach their healthcare provider about the health care that
they needed.5 Transgender individuals may abstain from seeking medi-
cal care in an office-based setting due to fear of mistreatment and only
seek episodic care in free clinics and EDs.4,6 Thus, it is of great impor-
tance that emergency providers become aware of the special healthcare
needs of the transgender patient.
The World Professional Association for Transgender Health is a
nonprofit organization that works for high-quality and evidence-based
care for transgender and gender nonconforming individuals. The World
Professional Association for Transgender Health provides an online
resource for identifying culturally competent caregivers based on geo-
graphic location (state).7
Table 299-1 contains a summary of current important terminology
and definitions. Terminology is evolving and may change over time.
CLINICAL ENVIRONMENT
Reducing barriers and creating a positive environment for health care
for the transgender patient in the ED begins at triage and continues
throughout ED care.9 Use respectful and sensitive communication
and documentation, including the use of correct terminology and
pronouns.10 Provide privacy. If family or friends accompany the patient
to the ED, ask the patient about any limits to conversation when others
are present. Transgender-identified minors are at high risk for being
forced to leave the home when family members become knowledgeable
about the gender identity.4,11
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TABLE 299-1 Terminology and Definitions

Sex An assignment of “male” or “female” based on birth assessment of genitalia. “Sex” is identified as male or female on legal documents such as
birth certificates, passports, and driver’s licenses, although some states are beginning to offer additional options (e.g., “other” or “X”) on legal
documentation.8
Gender or gender identity A person’s inner feeling related to being male, female, both, something else, or neither. It is self-identified, and although it is initially identified as
the same as the birth sex, it can be changed as a person ages. Thus, gender does not always align with sex.
Gender expression The external expression of how one affirms their gender. Gender expression is manifested through a person’s dress, mannerisms, hairstyle, speech
pattern, or other behaviors. All of these components of gender result in an external identification of one’s being masculine and/or feminine. Gender
expression may not always align with gender identity, as persons can identify as a feminine male or a masculine female.
Transgender An individual who identifies their gender as different from their sex assigned at birth. A transgender male was assigned female sex at birth but iden-
tifies as male gender. A transgender female was assigned male sex at birth and identifies as female gender.
Gender nonconforming/gender An individual whose gender identity falls outside the male–female gender binary (identifying as both male and female, neither, or something else).
nonbinary/gender fluid In this chapter, the term transgender includes persons identifying along the nonbinary spectrum as well.
Transmasculine A person with a female sex assigned at birth who identifies as masculine on the gender spectrum.
Transfeminine A person with a male sex assigned at birth who identifies as feminine on the gender spectrum.
Cisgender A person whose gender identity is congruent with their sex assigned at birth. A cisgender person is also referred to as non-transgender.
Sexual orientation This term describes the sexual attraction for others that an individual possesses. It is self-identified and identified by gender, not sex. A transgender
male who is attracted to other males may identify as a gay man. A transgender female who is attracted to males may identify as a straight female.
Transition The process of affirming or aligning one’s body with their gender. The process can include medical, legal, or social changes that are made during this
process.
Gender dysphoria A state of distress. In the context of transgender care and gender identity, dysphoria describes the anxiety, trauma, or unease felt by a transgender
person in situations when there is discordance between their gender and sex assigned at birth.
Gender affirmation A term used to describe actions, medications, surgeries, or feelings that are used by a transgender person to express their gender and/or align their
body with their gender.
Chosen name The name a person uses when referring to themselves. May not be the same as their legal name. The name that should always be used when refer-
ring to a patient both directly and indirectly and included in handoffs.
Legal name This name is used on legal documentation and often is the name assigned at birth. The legal name is also called the “dead name” when the name is
no longer used by the patient.
Pronouns Pronouns have historically been defined based on gender expression. Pronouns are a core part of a person’s identity and should not be presumed.
Pronouns include masculine (he/him/his), feminine (she/her/hers), and gender neutral (they/them/theirs).

 THE PATIENT GREETING
The first priority is to ensure that the patient is being addressed in
the desired manner. Use the patient’s chosen name and be consistent
in communication, documentation, and healthcare provider handoffs
(including to allied healthcare professionals, trainees, financial counsel-
ing, volunteer staff, etc.). Ways to ask about names and preferred pro-
nouns12 include the following:
1. “Hello, my name is Dr. Lastname. What name do you go by? It is a plea-
sure to meet you [insert chosen name]. What pronouns do you use?”
2. “Hello, I’m here to see [insert legal name]. What name would you like
me to call you? What pronoun do you want me to use?”
3. “Hello [insert chosen name], my name is Dr. Lastname. My pronouns
are she, her, and hers. What pronouns do you use?”
about gender-affirming hormones and surgeries, not only for a complete
history but also so that this information can be considered in the context
of a chief complaint. For example, it is important to know if a transfemi-
nine person has a neovagina if they are presenting with pelvic pain. Ask
about past surgery, especially gender-affirming surgery, and hormone
use and route. Not all transgender persons follow the same path with
regard to hormones and surgeries or gender expression. Although a
transgender male may experience amenorrhea shortly after the initia-
tion of masculinizing hormone therapy, testosterone does not provide
a form of birth control.13 Determine sexual activity and pregnancy risk.
It is not necessary to visualize or examine the anatomic changes that
accompany gender-affirming therapy and surgery, unless clinically
applicable.4 Address the chief complaint and describe the body exposure
that will be required. Respect the patient’s preferences. If refusal puts the
patient at risk, explain the risks in a compassionate manner.

 PATIENT HISTORY AND EXAMINATION: SPECIAL CONSIDERATIONS

Contextualizing why questions are being asked can help the patient MANIFESTATIONS OF GENDER-
understand and help them prepare for difficult questions. Asking if
there is a preferred, more gender-neutral terminology for body parts or
AFFIRMING TREATMENTS
processes (e.g., saying “monthly bleed” instead of “menses”) can help a This section discusses hormone therapy, medical illnesses that may be
patient feel more comfortable (Table 299-2). Next, it is important to ask affected by hormone therapy, transgender-affirming surgery, and the
complications of transgender-affirming surgery.

TABLE 299-2 Medical Named Body Part With Possible Alternative Name*
Medical Term Alternative Name HORMONES
Penis External genitalia, phallus Because everyone’s transitional journey is unique, not every patient will
Testes External genitalia use hormones, and the utilization of hormones does not make a patient
Breasts Chest tissue more or less transgender than someone else. Some people will desire to
use hormones but will lack access. These individuals may, in turn, use
Vagina Front hole, internal genitalia alternative resources for nonprescription hormones. Complications of
*Defer to patient preference. hormone therapy are listed in Table 299-3.

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TABLE 299-3 Gender-Affirming Hormone Therapy–Related Complications
Feminizing Hormone Therapy
• Hypercoagulability
• Venous thromboembolism
• Electrolyte imbalances
• Hyperkalemia (with spironolactone use)
• Prolactinoma
• Increased risk of cardiovascular disease15
Masculinizing Hormone Therapy
• Erythrocytosis
 GONADOTROPIN BLOCKERS
Gonadotropin analogues (also termed gonadotropin-releasing hormone
analogues or puberty blockers) are commonly used. Suppression of
puberty allows a youth the opportunity to further explore gender iden-
tity without acquiring unwanted secondary sex characteristics from
natal pubertal hormones. Puberty blockers can be initiated once a child
reaches the pubertal stage of Tanner stage II.
Because the puberty blockers work to occupy the receptors in the pitu-
itary, initially there is an increase in gonadotropin production followed
by suppression. This increase is termed the flare and happens roughly
10 days after initiation. Some patients may experience hot flashes or
fatigue if puberty blockers are initiated further along in puberty due to
exposure to natal gonadal steroids followed by suppression.14
Youth on puberty blockers alone should be treated like any prepu-
bertal youth. They normally will not have progression of secondary sex
characteristics, and laboratory values will show gonadotropin and sex
hormone levels in the prepubertal range.14
 MASCULINIZING HORMONES
The goal with masculinizing hormones is to suppress estradiol levels and
to achieve male range total testosterone levels (320 to 1000 nanograms/
dL). Testosterone at this level suppresses menses; increases libido;
increases clitoral size; deepens the voice; produces male-pattern fat,
muscle, and hair distribution; and increases energy. Side effects of tes-
tosterone include erythrocytosis (hematocrit >50%), which can increase
risk for cerebrovascular disease and thrombosis; vaginal dryness; and
changes in lipid profile (via decreasing circulating levels of high-density
lipoprotein). Transaminase elevation can result from testosterone ther-
apy. Cigarette smoking and morbid obesity increase the risk of venous
thromboembolism (VTE).1,14
Transmasculine persons who have been prescribed testosterone
continue to have risks for estrogen-sensitive pathology. Guidelines
recommend including any estrogen-sensitive pathology, such as uter-
ine, ovarian, or breast malignancies, in the diagnosis as appropriate
(Table 299-4).
Testosterone does not provide any form of birth control. Screen for
pregnancy if the patient has a uterus and ovaries, regardless of testoster-
one use. If a patient is found to be pregnant, stop testosterone pending
pregnancy planning.
Some patients will present with pelvic bleeding while on testosterone.
Testosterone causes vaginal atrophy, which can be a source of bleeding.
Evaluate for infection, pregnancy, and uterine pathology.1 Progestins can
stabilize the uterine lining in patients with persistent uterine bleeding
while on testosterone.
TABLE 299-4 Breast Tissue Cancer Risk
• Transfeminine patients: proliferative tissue
• Transmasculine patients: residual tissue
Note: Guidelines recommend that transmasculine patients continue breast cancer screening guidelines
for cis females and that transfeminine patients begin breast cancer screening guidelines for cis females
after 5 years on estrogen therapy or at age 50.1
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 FEMINIZING HORMONES
Feminizing hormones come in two forms because of the potency of
testosterone: estrogens and antiandrogens. 17-β-Estradiol is the form
of estrogen used for feminization because it is the most bioidentical and
the least thrombogenic of estrogen preparations. It comes in oral, trans-
dermal, and intramuscular injectable forms. The goal of estrogen use is
to suppress testosterone (to <55 nanograms/dL) and promote increased
estradiol levels. Antiandrogens can be used as adjuvant therapies and
include spironolactone (which inhibits testosterone secretion and
androgen binding to receptors), finasteride (which inhibits the conver-
sion of testosterone to dihydrotestosterone) and gonadotropin-releasing
hormone analogues (which suppress gonadal steroid production). Femi-
nizing hormone regimens cause breast growth, reduce body hair growth,
redistribute fat and muscle, and soften skin. They have no effect on vocal
cords or bone structure.
Side effects of feminizing hormones in general include decreased
libido and reduced testicular volume and sperm production. Less
frequent and less firm erections can also occur (mostly in those on
spironolactone).
Estradiol side effects include breast tenderness, nausea and vomiting,
dry skin, brittle nails, headaches, and increased appetite and weight
gain. Estradiol also increases the risk of thromboembolic disease due
to increased production of coagulation factors. Patients with signs or
symptoms concerning for thromboembolism should be considered at
risk and should be evaluated for venous thromboembolism.16,17 Estradiol
can cause prolactinomas in transfeminine persons. If a transfeminine
patient taking estradiol presents with concerns for a pituitary space-
occupying lesion or new-onset vision changes, especially any compro-
mise of vision in one lateral field or in both lateral fields, or headaches,
consider prolactinoma in the differential.14 Estrogen can increase the
incidence of hypertension, gallstones, and hypertriglyceridemia.14
Spironolactone is a diuretic and is the most commonly used anti-
androgen in the adult transfeminine population. Side effects include
hyperkalemia, increased urine output, and hypotension. GI upset can
also occur.
Transgender patients may restrict fluid intake due to unsafe restroom
conditions during the day. For those who are taking spironolactone, this
is dangerous and can result in dehydration. Patients on spironolactone
should have potassium and renal function checked as clinically indi-
cated. Those who present with dehydration are also at increased risk of
hyperkalemia.14
 NON–MEDICALLY PRESCRIBED HORMONES
Testosterone and estradiol can be acquired through nonmedical sources.
Shared oral medication and third party–acquired injectable testosterone
are common. With injectable testosterone use, there is an increased risk
for human immunodeficiency virus and hepatitis due to shared needles.
Also common is the use of birth control pills in place of prescribed
estrogen.18
GENDER-AFFIRMING SURGERIES AND THEIR
COMPLICATIONS
Gender-affirming surgeries include procedures that are performed
for non–gender-affirming reasons as well (e.g., breast implants, mas-
tectomies, and hysterectomies), and the complications do not differ
greatly. However, there are surgeries specific to gender affirmation
with which many healthcare providers have limited or no experi-
ence. Gender-affirming surgeries and their complications are listed
in Table 299-5.1,19-27
 GENITAL FEMINIZING PROCEDURES
Complete expulsion of a vaginal skin graft is a possible occurrence
(usually in the first postoperative week). This represents a failure of
the procedure and requires consultation with a surgeon for repair.1,22
Depending on the type of neovagina created, masses and precancerous
lesions can appear inside the vaginal canal. If used to create the neova-
gina, colonic tissue poses risk for inflammatory bowel disease, colitis,
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TABLE 299-5 Complications of Gender-Affirming Surgeries
• Facial feminization surgery: Bleeding, wound infection, hematoma, swelling, pain
• Facial masculinization surgery: Bleeding, wound infection, hematoma, swelling, pain
• Transfeminine breast surgery: Prolonged swelling, surgical site wound infection,
wound dehiscence, hematoma, pain, movement or rotation of implants, neuropathy
around nipples
• Transmasculine chest surgery: Bleeding, surgical site wound infection, wound
dehiscence, hematoma, pain, swelling, neuropathy around nipples
• Transfeminine genital surgery: After surgery—bleeding, hematoma, surgical wound
dehiscence, urinary retention; long term—granulation of the tissue with dilation,
stenosis of vagina, webbing of vagina or complete expulsion of graft, vaginal drainage
and odor, rectovaginal fistula, urethra-vaginal fistula, urinary tract infection
• Transmasculine genital surgery: After surgery—bleeding, hematoma, catheter
infection; long term—urethrocutaneous fistula, urethral stricture, implant erosion,
expulsion or rupture
or adenocarcinoma. Penile inverted tissue can develop skin lesions such
as melanoma or psoriasis.23 Frequent discharge can be common after a
vaginoplasty as dilation postoperatively will cause repeated trauma to
granulation tissue. Discharge will diminish over time. Silver nitrate can
be applied to any bleeding granulation tissue in the interim.1
 GENITAL MASCULINIZING PROCEDURES
Early in the postoperative course, patients go home with urinary cath-
eters, which can obstruct or kink. Care should be taken with evaluation
because the neourethra is still healing. Should a patient present further
along with dysuria, evaluation should include a urine culture because
white and red blood cells are present in urine sample after a normal
reconstruction and are not necessarily evidence of a pathologic condi-
tion. Negative cultures in the setting of dysuria may indicate a stricture.
Urethral strictures may happen up to 6 to 12 months after surgery.
Patients may present with dysuria, reduced stream, and inability to
pass a catheter on exam. Cystourethrography can be useful in identify-
ing postoperative urethral complications.1,26 If the patient underwent a
vaginectomy as a component of genital surgery, rectal injury is a possible
complication. Another complication is the development of a fistula,
which may communicate with the skin of the neophalus, scrotum, or
perineal suture sites.25 For patients who have erectile implants, erosion
through the skin of the phallus is a possible complication.1
MENTAL HEALTH
Transgender persons disproportionately experience societal dis-
crimination, mistreatment, harassment, and prejudice in everyday
life. Table 299-6 provides a list of mental health disorders and social
issues.28,29
Do not assume that mental health issues are always related to the
gender experience of the patient.28 At a minimum, depression, anxiety,
and mood disorders occur as frequently in transgender patients as in
the general population. Treatment of these mental health disorders
follows typical treatment plans. However, be vigilant for mental health
complaints that may be a result of the patient’s gender experience.
Gender-related depression and anxiety with resultant suicidal ideation
are prevalent in the transgender community.29 Also common are mental
TABLE 299-6 Mental, Social, and Health Issues in Transgender Persons
Compared to the cis population, transgender persons have increased prevalence of:
• Human immunodeficiency virus infection
• Substance abuse (drug and alcohol)
• Mental health disorders (depression, suicide, anxiety disorder)
• Physical assault (domestic violence, sexual assault, physical assault)
• Homelessness
• Sexually transmitted diseases
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health issues related to drug and alcohol addiction, homelessness, and
traumatic experiences such as physical assault, sexual assault, and abuse.1
Emergency treatment of mental health issues in the transgender
patient should follow the practices outlined in Section 24, “Psychoso-
cial Disorders.” The transgender patient should be referred to a mental
healthcare provider who specializes in transgender care.30-32 In addition,
because of the high rate and impact of societal stressors associated with
being transgender, social services should be considered when patients
need housing, food, and safety.
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER Palliative Care
300 Justin K. Brooten
INTRODUCTION
The goal of palliative care is to relieve the suffering of patients with seri-
ous illness. Regardless of the patient’s prognosis, relief of suffering
should be a primary goal for both emergency medicine and palliative
care.1 Palliative care is defined by specialty advocates as the physical,
spiritual, and psychosocial care given by multiple disciplines to patients
and their families who are living with life-threatening illness.2 Although
these principles are applicable to all stages of a patient’s illness, a pallia-
tive care consultation from the ED is generally considered in the context
of previously predicted end-of-life care. Hospice care, a branch of pallia-
tive care, is a comprehensive program of palliative treatment that is
appropriate when patients with chronic, progressive, and eventually fatal
illness are determined to have a life expectancy of 6 months or less. Pal-
liative care is patient centered rather than disease centered. It strives to
ensure that the patient or his or her (formal or informal) representatives
have chosen realistic goals of care after the patient’s diagnosis, prognosis,
and therapeutic options have been considered. This discussion and deci-
sion making should take place during a meeting that includes the
patient’s healthcare team, surrogate decision maker(s), and those loved
ones who are privileged to receive confidential information.
Palliative care is guided by the axiom that distressing symptoms
should be treated. It thus provides expert assessment and treatment
of symptoms, including pain, dyspnea, and vomiting. Pain is the most
common reason for seeking care in the ED, accounting for 58% to 78%
of visits in the United States.3-5 Unfortunately, only 60% of patients
reporting pain receive pain medications.6 Dyspnea is the seventh most
common chief complaint and vomiting the ninth most common chief
complaint of patients presenting to the ED.7
Palliative care also trains healthcare professionals to compassionately
communicate diagnosis, prognosis, and treatment alternatives and guide
the formulation of a therapeutic plan. Palliative care clinicians work to
coordinate caregivers and interventions for the patient and family, to make
care more effective, and to lessen the stress and obstacles for achieving
satisfactory outcomes. Standards for compassionate care spelled out by
the Institute of Medicine8 and numerous professional societies require
that distressing symptoms be alleviated concurrently with all treatments
directed toward the pathology of the medical disorder. The patient or
surrogate must play a key role in decisions regarding care.
The first American Board of Medical Specialties board exam, admin-
istered in 2008, qualified the first emergency medicine physicians for
practice of the subspecialty of hospice and palliative medicine.9
In 2014, the American College of Emergency Physicians reaffirmed
its 2008 policy statement: Ethical Issues and End-of-Life Care
(Table 300-1).10 In 2011, the Center to Advance Palliative Care (the primary
advocate for palliative care in the United States) released its Improving
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TABLE 300-1  The American College of Emergency Physicians Board of
Directors: Ethical Issues at the End of Life
The American College of Emergency Physicians believes that:
• Emergency physicians play an important role in providing care at the end of life (EOL).
• Helping patients and their families achieve greater control over the dying process will
improve EOL care.
• Advance care planning can help patients formulate and express individual wishes for
EOL care and communicate those wishes to their healthcare providers by means of
advance directives (including state-approved advance directives, do not attempt
resuscitation orders, living wills, and durable powers of attorney for health care).
To enhance EOL care in the ED, the American College of Emergency Physicians
believes that emergency physicians should:
• Respect the dying patient’s needs for care, comfort, and compassion.
• Communicate promptly and appropriately with patients and their families about EOL
care choices, avoiding medical jargon.
• Elicit the patient’s goals for care before initiating treatment, recognizing that EOL care
includes a broad range of therapeutic and palliative options.
• Respect the wishes of dying patients including those expressed in advance directives.
Assist surrogates to make EOL care choices for patients who lack decision-making
capacity, based on the patient’s own preferences, values, and goals.
• Encourage the presence of family and friends at the patient’s bedside near the end of
life, if desired by the patient.
• Protect the privacy of patients and families near the end of life.
• Promote liaisons with individuals and organizations in order to help patients and
families honor EOL cultural and religious traditions.
Palliative Care in Emergency Medicine project. This project informs and
enables EDs to develop thoughtful, creative, and streamlined programs to
integrate palliative care into the day-to-day operation of the ED.11
By implementing principles of palliative care (Table 300-2), emer-
gency physicians will become better skilled at assessing patients’ pref-
erences and health status to determine whether initiating aggressive
therapy is both concordant with the patients’ or surrogates’ preferences
and potentially beneficial. Patients already receiving a palliative care
approach will be able to have their existing care plan continued in a
coordinated fashion when presenting to the ED for worsening symp-
toms, although they would be more optimally managed as outpatients.12
TABLE 300-2 Description of Palliative Care in Emergency Medicine
• Who: Patients with serious, potentially life-threatening illness and their families.
• What: Relief of symptoms from potentially curable conditions in the presence of
chronic devastating disease when standard treatment impedes the patient’s remaining
quality of life, to incurable conditions such as stage IV heart failure, metastatic lung
cancer, or advanced dementia.
• When: After a life span–limiting prognosis has been defined or when requested by
patients and their families to enhance the patient’s quality of life. Late-stage palliative
care for incurable illnesses with a prognosis estimated of 6 mo or less is provided in the
United States under the hospice benefit of Medicare.
• Where: In the ED and every other setting in which the patient receives care, or wishes
to receive care, such as at home.
• Why: Because the relief of suffering is the primary goal of medicine, and there are few
places with greater patient suffering than in the ED.
• How: The patient and/or family decide the goals of care after a realistic discussion
based on diagnosis, prognosis, and effectiveness of potential therapies. An interdisci-
plinary team consisting of at least the doctor and nurse provides care measures, such
as symptom relief, and initiates the coordination of care needed to reach the patient’s
goals. Most commonly, this occurs in consultation with a palliative care service, unless
the emergency physician is trained in palliative care.
• Who Decides: The patient, provided he or she retains decision-making capacity, or the
surrogate decision maker, the legally appointed Durable Power of Attorney for Health-
care or closest family relative who speaks for the patient.
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CHAPTER 300: Palliative Care    2001
EPIDEMIOLOGY
In 2016 in the United States, the proportion of medical decedents who
received hospice prior to death ranged from 23% in Puerto Rico to 58%
in Utah.13 Although hospice was initially designed for cancer patients,
72.8% of patients enrolled in hospice in 2016 had a noncancer diagnosis.13
Eighteen percent of hospice patients’ death diagnosis is dementia.13
In 2002, there were 12.7 million people aged >65 years in the United
States.14 In 2030, there will be >72 million elderly people. The Hospital-
ized Elderly Longitudinal Project study found that the very elderly
(>80 years) are most likely to want and to consider comfort care as the
best option when facing serious chronic illness.15 The surge in growth in
the aging population will increase the demand for quality palliative care.
Approximately 30% of healthcare costs occur in the last 6 months of
life. Data from the Health and Retirement Study showed that 51% of
patients over age 50 visit the ED during their last month of life, 77% of
those are admitted to the hospital, and 68% of those admitted die during
their hospital stay.16 A meta-analysis found that the use of hospice saved
as much as 40% of healthcare costs during the last month of life and 17%
over the last 6 months of life.17 A subsequent study found that hospice
care reduced Medicare costs during the last year of life by an average of
$2309 per hospice user.18 Admitting eligible patients to hospice is one
promising route for addressing the quality/cost chasm.19
Currently, only 4% to 7% of hospitalized patients are referred to pal-
liative care or hospice directly from the ED.20-22 The average time in the
hospital before transfer to a palliative care bed is 5 to 9 days.21,22
IDENTIFYING PATIENTS FOR PALLIATIVE CARE
In 2011, the Center to Advance Palliative Care released its Improving
Palliative Care in Emergency Medicine program, a program that pro-
vides a thoughtful approach to palliative care practice in the ED, formu-
lated for and by emergency clinicians. The program covers all aspects of
palliative care in the ED.11 Emergency physicians have enthusiastically
received the Improving Palliative Care in Emergency Medicine pro-
gram,11 despite expressing concerns about the challenges facing them
when discussing palliative or hospice care with patients such as inter-
ruption of workflow, lack of long-term relationships with patients, and
lack of training to facilitate interactions.23
Patients whose long-term care needs are complex and require skilled
nursing care for transfusions, tracheostomy care, or infusions of antibiot-
ics or inotropes are likely in need of palliative care, especially if the disease
is progressive. In one study, 54% of patients transported to the ED from
a long-term care facility as a level 1 triage priority were dead in 30 days.24
 FUNCTIONAL DECLINE
Functional decline is the loss of the ability to care for oneself. This ranges
from the loss of complex abilities, like driving, shopping, and managing
finances, to basic activities like ambulating to the bathroom and get-
ting safely out of bed. The loss of activities of daily living is the cardinal
feature of decline, especially if accompanied by unintentional weight
loss, and it indicates the need for increased care assistance and suggests
a short life expectancy.
 PROGNOSIS
Space in this textbook does not allow for a comprehensive discussion
of formulating a prognosis and how to share it with patients and fami-
lies. There are several key diagnoses and prognostic findings that are
extraordinarily helpful to understand. Patients with chronic, progres-
sive, life-threatening diagnoses will almost always benefit from palliative
care. Those with extensive disease, be it metastatic cancer, organ failure,
or neurologic deterioration (with anorexia/cachexia and decreased self-
care), are frequently on a dying trajectory.25 Examples of diagnoses of
patients who may benefit from palliative care are listed in Table 300-3.
A predictive instrument known as the Palliative Prognostic Score
correlates with prognosis.26 Elements of the Palliative Prognostic Score
include ability to ambulate, provide self-care, and maintain oral intake
and level of consciousness. A bed-bound patient completely dependent
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 2002   SECTION 26: Special Situations
TABLE 300-3  Common Diagnoses and Key Findings of Patients Who May
Benefit From Palliative Care
Diagnosis Key Findings
Solid organ neoplasm Widespread metastasis unresponsive to treatment
End-stage heart failure Significant symptoms at rest despite therapy
End-stage COPD Significant symptoms at rest despite therapy
Advanced dementia Impaired mobility and inability to communicate health needs
Degenerative neurologic Inability to complete ADLs or communicate health needs
disease
End-stage AIDS Multiple opportunistic infections and/or AIDS dementia
End-stage renal disease Patient no longer willing or able to undergo dialysis
End-stage liver disease Repeated episodes of hepatic encephalopathy, bleeding, or
symptomatic ascites resistant to medical therapy
End-stage rheumatologic Inability to complete ADLs without significant discomfort
disease
Multisystem trauma Nonsurvivable injury
Burn When age plus percent burn exceeds or nears 140
Multiorgan failure When two or more key body systems fail
Any chronic, progressive, Whenever symptom burden exceeds resources and the ability
debilitating disease of the patient and/or family to cope with medical condition
Abbreviations: ADLs = activities of daily living; AIDS = acquired immunodeficiency syndrome; COPD =
chronic obstructive pulmonary disease.
for all care with reduced oral intake and a diminished level of conscious-
ness has a Palliative Prognostic Score of 10% and a 1-week median
expected survival.26
DISCUSSING PROGNOSIS AND SETTING THE
PLAN OF CARE
 DETERMINING PATIENT DECISIONAL CAPACITY AND IDENTIFYING
SURROGATE DECISION MAKERS
The ED team should immediately identify the decision makers when
a debilitated patient arrives in crisis to the ED. A patient with deci-
sional capacity is one who has the mental ability to grasp and retain
information about his or her condition, weigh risks and benefits,
and demonstrate these abilities by verbalizing a medical decision27
(see Chapter 303, “Legal Issues in Emergency Medicine,” for a more
detailed discussion of patient capacity). Table 300-4 lists phrases to aid
meaningful communication with patients and families.28 If the patient
lacks decisional capacity, then the patient’s advance directive should be
accessed and the named surrogate decision maker should be contacted
as soon as possible. If none of these resources are available, then the clos-
est family member(s) should be consulted regarding the plan of care. If
no one is available to speak for the patient, then the treating physician
should act in the patient’s best interest. This may include an order to “do
not resuscitate” the patient if it is clear that aggressive therapy would not
be beneficial.
 FAMILY MEETING
Once the physician has determined the patient’s decision-making capac-
ity, chronic health status, a clinical diagnosis for the current visit, and a
general understanding of the patient’s care preference, the doctor and
team are prepared to have an abbreviated family meeting with the deci-
sion maker(s) to discuss the approach to care. The physician must be
clear in his or her own mind whether there is any available therapy that
will restore the patient’s health; have access to the advice of consultants,
specialists, and the patient’s primary care physician; and be prepared to
issue honest, compassionate, and helpful recommendations based on his
or her own assessment.
Realistic Prognosis and Values Discussion A productive approach
to start such meetings is to ask the surrogate decision maker what he or
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TABLE 300-4 Key Communication Phrases28
Determining Patient Decision-Making Capacity
• Will you describe your current condition?
• Tell me about the treatment options we have just discussed.
• Explain to me why you feel that way.
Quality of Life
• What symptoms bother you the most? What concerns you the most?
Prognosis
• Has anyone talked to you about what to expect?
• Do you have any sense of how much time is left? Is this something you would like to
talk about?
Talking With Surrogate Decision Makers
• These decisions are very hard; if [the patient] was sitting with us today, what do you
think [he/she] would say?
• Can you tell me why you feel that way?
• It is not a question of whether we care for [your loved one], but we will care for them.
• Then we will do everything possible to keep [your loved one] comfortable, but we
won’t be providing ineffective and burdensome therapies such as CPR or intubation.
Discussing Palliative Care or Hospice Referral
• To meet the goals we’ve discussed, I’ve asked the palliative care team to visit with you;
they are experts in treating the symptoms you are experiencing. They can help your
family deal with the changes brought on by your illness.
Breaking Bad News—Death Pronouncement
• I wish there is more we could have done; I’m very sorry for your loss. This has to be
really difficult for you. Is there anyone I can call to be with you now?
she understands about the patient’s past health and current condition
(Table 300-4). After patiently listening, the physician should share his or
her insight into the patient’s condition and prognosis while monitoring
the family’s reaction to determine whether the ED team and the family
are in agreement. An example of a physician’s opinion in a particular
case follows: “Your mother’s advanced medical condition cannot be
cured, and her illness has made her defenseless against the bacteria in
her own body. Treating her again and providing another round of inten-
sive care will not bring her health or immune system back to normal, but
may only prolong her suffering.”
The next step is to ask the surrogate decision makers whether they
know about the patient’s values and preference for care, for example,
how their mother would wish to be treated in the current circumstances.
If the answer to that is unknown, ask how the surrogate decision makers
would wish to be treated if they were in the same condition.
Separate Desired Outcome From Likely Outcome Carefully explore
discrepancies in the perception of what might be gained from aggressive
therapy in patients who are less likely to benefit from such care. Deliver-
ing realistic information about the likely outcome and the expectation of
poor quality of life significantly impacts subsequent decisions for code
status or scope of treatment in a patient with an underlying progres-
sive terminal condition.29 Patients or surrogates who are aware of poor
prognosis and low likelihood of survival from CPR often choose against
aggressive therapy or resuscitation.30,31 Patients and surrogates may
decide to forgo aggressive care if a small potential for survival from an
acute event would likely result in a loss of significant function or would
necessitate constant skilled nursing care for the foreseeable future.32
Painting a clear picture in lay terms of what the future may hold if vari-
ous avenues of care are chosen may be a much more effective means of
conveying the gravity of choice between various options.33
Cultural Differences Cultural differences should be taken into
account when discussing treatment options with patients and fami-
lies, including religious preferences. African Americans are more
likely to select aggressive treatment options and less likely to select
hospice care than non-Hispanic whites.34 Reasons cited for end-of-life
preferences among African Americans facing these decisions include
historical mistrust toward the healthcare system and the importance
of spirituality.34
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 CODE STATUS
Do not resuscitate is part of advance healthcare directives. Do not
resuscitate status or other limitations of resuscitation should evolve
directly from harmonious decisions reached at the family meeting. Do not
resuscitate orders and advance directives are discussed in Chapter 301,
“Death Notification and Advance Directives.”
 CONSULTATION OPPORTUNITIES
Palliative care consultation services are likely available at your hospital
and should be used just as you would any specialist consultation. ED
consultation can provide assistance when conducting a family meeting
or when access to an inpatient hospice or palliative care unit is needed.
When symptom relief, medical decision making, or disposition and
coordination of care are beyond your expertise or available time, a
consult is appropriate. Notify the patient’s attending physician of the
consultation if time allows.35
TREATMENT AND SYMPTOM MANAGEMENT
The most common targets of symptom management are pain control,
dyspnea, nausea/vomiting, constipation, and agitation.
 PAIN CONTROL
Acute and chronic pain are addressed elsewhere in detail (Chapters 35
and 38, respectively). The biggest obstacle to aggressive pain management
with opiates has been the fear of respiratory depression. Opioid dosing is
reviewed in Chapter 35, “Acute Pain Management,” and is an essential skill
in the practice of emergency medicine. It is also important to understand
the progression of side effects from opioids, because these will serve as
warnings to reduce the dose or delay the next dose of opioids. Respiratory
depression is not a sudden occurrence, but instead is part of a progression
that starts with sedation, somnolence, and then respiratory depression.36
The safety of patient-controlled analgesic devices is predicated on this con-
cept. A patient can be safely dosed and redosed until the pain is palliated,
as long as level of consciousness is monitored. IV opiates reach maximum
therapeutic levels and have peak effects or side effects at 6 to 10 minutes.
Therefore, IV pain medications can be safely redosed every 15 minutes
until relief is reached if potential adverse effects are monitored.
 DYSPNEA
While identifying the cause of dyspnea and treating the underlying
pathology may bring definitive relief, treatment should also be offered
to palliate the symptoms. Although opioids have traditionally been with-
held due to concerns about respiratory depression, opioids are beneficial
in treating the agitation and anxiety provoked by dyspnea.37 When
treating breathlessness/dyspnea in an opioid-naive patient, start with
morphine at a dose of 0.05 milligram/kg IV, and monitor for sedation
and hypoventilation. This is half of the starting dose of morphine when
it is used to treat pain. Use a goal of maintaining a respiratory rate of at
least 10 to 12 breaths/min.
 NAUSEA AND VOMITING
Understanding the underlying cause of nausea can help identify the class
of antiemetic drugs most likely to be therapeutic. Chemotherapy-induced
nausea often responds to high doses of serotonin 5-hydroxytryptamine-3
antagonists such as ondansetron. Corticosteroids such as dexametha-
sone also may improve nausea from chemotherapy. Steroids can also
improve symptoms caused by increased intracranial pressure and bowel
obstruction from cancer. Dopamine antagonists such as haloperidol or
droperidol are used for refractory nausea in the palliative care setting.
Metoclopramide is excellent for the symptoms of diabetic gastroparesis or
compression of the stomach due to tumor or ascites.
 CONSTIPATION
Constipation is a commonly seen side effect in patients on opiates
for pain control. Patients prescribed opiates need a concurrent bowel
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CHAPTER 300: Palliative Care    2003
regimen, such as an osmotic agent (i.e., polyethylene glycol) or stimulant
laxatives. A digital rectal exam is also important to rule out a suspected
fecal impaction. When evaluating a patient for constipation, an abdomi-
nal radiograph can help to evaluate the amount of stool and lower the
index of suspicion for bowel obstruction.
 AGITATION
Patients with terminal illness may become agitated, with or without
delirium. The causes of this agitation are multifactorial, including pain,
effects of the terminal illness, anxiety, terminal restlessness, breathless-
ness, and mental anguish. The indicated class of medications varies
depending on the situation but includes antipsychotics such as haloperi-
dol, anxiolytics such as midazolam, and opiates such as morphine. There
is no evidence that these palliative interventions hasten death.38
DISPOSITION AND COORDINATION OF CARE
Although the majority of patients consulted to palliative care services from
the ED will be admitted to the hospital, outpatient treatment is always an
option, depending on the resources available and the patient’s needs.
 HOSPICE REFERRALS
Patients who qualify for the hospice benefit should be aware of these out-
standing programs of care for the physically declining patient. Inpatient
hospice units, where patients can be directly admitted, provide a good
option for care and rapid ED disposition if available at your hospital.39 Not
all families are eager to hear the word “hospice,” but such a recommenda-
tion should be phrased in a way that sends a message about your concern
for the patient and his or her health status. Exploring any prior experience
a patient or family may have had with hospice care and determining their
primary goals and explaining how those goals might align with hospice
can be an effective way to introduce a potential transition in care.
Patients are eligible for hospice care by Medicare regulations if they
wish to take a palliative approach to their condition and if they have a
prognosis that, in the judgment of two physicians, is likely ≤6 months,
given the usual and natural course of the illness. Hospice referrals can
be made from the ED for patients with qualifying debilitating illnesses,
such as dementia with sepsis or stage IV cancer with poor performance
status. Referrals also can be made for patients with clearly expressed
prior wishes for comfort care should they sustain a catastrophic acute
illness, such as those with an intracerebral bleed, infarcted bowel, dev-
astating neurotrauma, or renal failure in the presence of advanced heart
failure, leading to multiorgan failure.
SPECIAL TOPICS
 IMMINENT DEATH
It is common in the ED to receive a patient whose death is likely immi-
nent. Such a patient has entered the process of multiorgan failure due
to a disease such as sepsis, vascular crisis, uremia, or metastatic cancer.
Vital signs indicate a patient in extremis; breathing may be irregular
with pauses; a Foley catheter finds an empty bladder or only a small
amount of concentrated urine. The assessment that a patient’s death
is imminent should be communicated to family members and the
primary care physician. Agreement should be sought to offer comfort
measures only. Intermittent or infused opiates plus intermittent or
infused midazolam should be initiated and titrated to patient comfort.
Delirium therapy can be directed to underlying cause (pain, fever) or,
if not known or reversible, treated with 0.5- to 5-milligram doses of IV
haloperidol. A total dose of 5 milligrams can produce a calming effect
on a patient and, by extension, his or her family. Especially in patients
who are having respiratory symptoms, opiates should be considered
even though they may induce hypoventilation. Explain to a patient’s
family that the goal of opiate therapy is not intended to artificially hasten
death but to ensure comfort. There is firm ethical support for providing
medication expressly with a goal of comfort even if there is potential for
an unintentional double effect.40,41
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 2004   SECTION 26: Special Situations
 OPIOID DOSING AND ROTATION
In the opioid-naive (hydrocodone, oxycodone, morphine, hydromor-
phone, and methadone) patient, a 2-milligram dose of IV morphine or
a 0.5- to 1-milligram dose of hydromorphone is a reasonable starting
dose. This should be administered every 15 minutes until the pain is
relieved by approximately 50%. Dose stacking will produce additional,
cumulative effects when the doses have all been distributed to the
µ-receptors. In the opioid-tolerant patient, the average 4-hourly dose
of opioids already prescribed should be doubled for severe pain and
increased by 50% for moderate pain (pain scale score of 4 to 6).41 Smaller
doses are required in elderly patients, those with a low body mass index,
patients with unstable vital signs, or those with baseline severe cardio-
respiratory compromise (e.g., chronic obstructive pulmonary disease)
because such patients are at risk for hypoventilation.
 CARE OF THE PREVIOUSLY DESIGNATED HOSPICE PATIENT IN THE ED
Occasionally, hospice patients may be directed to the ED. The three
most common scenarios are (1) a hospice patient with an acute symp-
tom crisis; (2) a hospice patient who has a health concern unrelated to
the hospice diagnosis; or (3) a patient who has previously revoked and
signed out of hospice and presents to the ED.
A patient enrolled in hospice may be hospitalized under the care of
hospice (general inpatient hospice) if there is an acute symptom crisis
related to the hospice diagnosis. An inpatient setting can allow for
more aggressive treatment of symptoms such as a pain crisis, new-onset
dyspnea, or other concerning symptoms. A patient may also be sent to
the ED for a new medical issue unrelated to the hospice diagnosis. For
example, a patient admitted to hospice for refractory heart failure may
fall and fracture a bone. The fracture is unrelated to the hospice issue.
A patient may revoke hospice care at any time for any reason and
may present to the ED for aggressive treatment rather than a palliative
approach. Occasionally, a patient or family may panic and call 911 when
there is a change in the patient’s health status. The ED physician should
care for the patient as appropriate. It can be very helpful to contact
the patient’s hospice agency. Someone should be available 24 hours a
day and may be very useful in helping to clarify the patient’s goals and
disposition.
Acknowledgments: The author would like to thank Robert Zalenski
and Erin Zimny for their contributions to the last edition of this chapter.
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
CHAPTER Death Notification and
Advance Directives
301 Lindsay M. Weaver
Cherri D. Hobgood
DEATH NOTIFICATION
Death notification is perhaps the most difficult, emotionally laden
physician communication. In most situations, the notification of death
occurs during the first meeting of the emergency physician with the
deceased patient’s family. The notification often comes after extensive
resuscitation efforts, creating an upheaval of emotion for the physician
and ED staff and leaving the team emotionally and physically exhausted.1,2
For survivors, death notification is a life-altering event. The language
used during the communication, the venue, and the characteristics of
the individual delivering the news create indelible memories for the
family.3
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EFFECTS ON SURVIVORS
Because death that occurs in the ED is frequently sudden, unexpected,
and often violent, survivors can develop complicated bereavement and/
or posttraumatic stress disorder.4-7 Death notifications that provide lim-
ited or incorrect information about the death or occur in chaotic settings
with limited support may exacerbate the grief reaction.6 When properly
performed, death notifications may mitigate substantial negative effects
on surviving family members.8 A well-delivered death notification can
reduce the incidence of posttraumatic stress disorder in the families of
patients who died suddenly, particularly notifications involving the loss
of a spouse or the death of a child.9
 WHAT REACTIONS TO EXPECT
Responses to loss vary greatly. Families often describe themselves
as numb immediately after learning of the loss. They have difficulty
processing information and making decisions. Following the initial
shock, the family may experience denial, anger, and/or guilt.10 Denial is
most typically expressed as incredulity and is thought to be a defensive
mechanism. Your role is to understand this condition and allow time
and, if needed, to provide additional information to confirm death. See-
ing the body of the deceased may help the family to accept the truth.
Anger is not unusual. Be prepared to react in a supportive manner rather
than responding with anger or becoming defensive. These are typically
expressions of grief and misplaced guilt.
The survivors’ culture is an important predictor of the types of
emotional responses that may be exhibited. These may range from no
expression of emotion to wailing and hysterical collapse. Allow these
expressions and remain calm and respectful. If you want to touch the
grieving individual, the shoulder is the most suitable location.
EFFECTS ON PHYSICIANS
Physicians find death notification physically and emotionally difficult,
with evidence of increased heart rate, heart rate variability, and cortisol
levels immediately after the event.11-14 Common emotional reactions in
emergency physicians faced with the task of death notification are sadness
(60%) and disappointment (38%), resulting in insomnia in 37%.14
The cause of death, the patient’s age, the presence of family, and the
similarity to self are the most common reasons cited by emergency phy-
sicians for powerful impact of a recent death notification experience.14,15
Other factors that may also increase the stress level for the physician
include racial and ethnic differences between the physician and the fam-
ily, lack of a clear family leader, a nontraditional family (e.g., broken or
blended), and situations in which the physician is personally emotional
or cannot control his or her own reaction.16
Skillful death notification is a priority in emergency medicine practice.2,3
Protocols to enhance communication skills for delivering bad news
in the ED improve satisfaction of survivors.17 The use of successful
methods to communicate effectively with families may also mitigate
physician burnout and reduce stress on ED staff.18 Understanding and
using compassionate methods of information exchange are critical to
success. Providers must learn to recognize emotions, even when they are
indirectly expressed, and allow these to be aired and displayed without
judgment.19
GRIEV_ING©: A METHOD FOR
DELIVERY OF DEATH NOTIFICATION
The GRIEV_ING© mnemonic is a method for delivering concise and
accurate death notification. This mnemonic provides physicians with
an organized, sequenced approach to deliver the news of death
(Table 301-1).20 The structured organization of communication ele-
ments provides a coherent sequence of information to the family that
is easy for providers to remember and ensures complete information
transfer to the family. (See Video: Grieving: Announcing a Death in the
Emergency Department.)
8/1/19 1:34 PM

TABLE 301-1 The GRIEV_ING Mnemonic
G Gather Assemble the family in a calm, considerate place for the discussion.
Gather as many family members as time allows. This mitigates the
need for multiple episodes of information delivery. This step may be
done by ED support staff.
R Resources Ask for any additional support available to aid the family (e.g.,
hospital chaplain services, family ministers, additional family
and friends [especially if the survivor is alone], and, if needed, an
interpreter).
I Identify Upon entering the room with the family:
Identify yourself.
Identify the deceased patient by name.
 Identify the family’s state of knowledge. Are they aware of the
situation, or will news of the death be unexpected?
E Educate In a concise manner, educate the family about the events that have
transpired since the patient entered care. EMS should be included in
this description.
Fire a “warning shot” by stating that you bring “very bad news.”
Tell them the current state of their loved one.
V Verify Confirm the news of death. State emphatically that their family
member is dead. Be clear! Use the words dead or died. Express your
sincere condolences.
_ Space Stop talking. Allow the news to settle and give them time to
process the information.
I Inquire After a brief interval, ask if they have any questions. Then take the
time to answer all of them.
N Nuts and Provide additional information on:
bolts Organ donation
Funeral service that will collect the body
The deceased’s personal belongings
Be sure to offer the family the opportunity to view the body.
G Give Give the family your card and contact information.
Offer to answer any questions that they may have later. Return their
call if contacted.
Express condolences.
Modified with permission from Hobgood C, Harward D, Newton K, Davis W: The educational intervention
“GRIEV_ING” improves the death notification skills of residents. Acad Emerg Med 12: 296, 2005.
Copyright John Wiley & Sons.
G (GATHER)
As early as possible during the resuscitation, instruct ED staff, nursing,
social work, or chaplain services to “gather” the family. Place the group
in a quiet, private environment with few distractions. Assist the family
with outreach to other family members or friends. Gathering allows the
physician to deliver the information a single time, ensuring that every-
one hears the same information. This also allows the family to support
each other during this most difficult time.
R (RESOURCES)
Ask if there are any needs, and work to collect any needed items. Ask
about desires for a chaplain, minister, or priest who may provide support
for the family. Obtain interpreter services if needed.
I (IDENTIFY)
Confirm that the deceased individual is properly identified. As the
physician and staff join the family, they must clearly identify themselves
and their role in the resuscitation. Clarify and confirm that the family
is associated with the deceased individual by saying the patient’s full
name, for example, “Are you the family of Ellen Smith?” Ask the family
members to state their relation to the patient. Identify the next of kin.
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CHAPTER 301: Death Notification and Advance Directives    2005
All discussion moving forward is between you and the next of kin. Face
that person directly and ask permission to discuss the events of the day
in the presence of the extended family and those gathered in the room.
Ask for a brief statement of the state of knowledge of the family
regarding the patient’s status. This final step is important because
it allows you to begin your story at the point their knowledge ends.
Depending on the prior state of knowledge, the family will process infor-
mation differently and at different rates.
If possible, before you begin your discussion, ask the family to take a
seat. You and your team should sit as well. Having the family sit reduces
the risk of falling and sustaining injury during the notification. Position
yourself across from the next of kin, preferably at eye level, and address
the majority of the dialogue to that person. This posture creates open
communication and allows you to assess understanding as you deliver
the information.
E (EDUCATE)
From this point forward, your role is to educate. Your description of the
event should begin at the conclusion of the family’s knowledge of events.
The narrative should be a focused summary of the scene, including any
EMS response and the events in the ED. Communicate with nontechni-
cal, nonmedical words; be thoughtful with your language and listen and
watch for incomprehension. Throughout your summary, on multiple
occasions, provide the family with “warning shots,” such as “this is dif-
ficult news” or “the information that I am relating is bad news.” These
“warning shots” are a communication strategy intended to adjust the fam-
ily toward the idea that they are about to learn something difficult and por-
tend the disclosure of death. Carefully observe the family’s reactions and
those of the next of kin. If it appears that they do not understand the sever-
ity of events, reemphasize the finality of the news. Once the family appears
to be following your story with clarity, then you must disclose the death.
V (VERIFY)
Continuing your dialogue seamlessly, you will “verify” the death. You
should unequivocally state that their family member has died. You must
decisively affirm this fact clearly and say the words death, died, or dead.
Provide your condolences on their loss. This may include language such
as, “I am sorry for your loss” or “I can see how difficult it is for you to
learn of the death of your [mother, brother, sister, friend, etc.].” Without
knowing the religious convictions of the patient and everyone present,
it is inappropriate to say “they are in a better place” or that the events
“were God’s will.”
_(SPACE)
Now stop talking. Give the family some room to comprehend what you
have just said. Even families who were anticipating the death will need a
moment to register the information and compose themselves. Once you
have allowed an adequate period of time to pass, you may move into the
last three steps of notification.
I (INQUIRE)
The next phase, “inquire,” is a very natural progression of the dialogue.
Ask the family, “Are there any questions for me?” or “How can I help
you?” In most cases, if the preceding steps have gone well and there has
been complete information transfer, then there will be no major ques-
tions. The family may ask if there was pain or suffering. This is a difficult
question to answer. Maintaining your credibility is important, and you
can never state with full certainty that the patient did not suffer. If you
did everything possible to mitigate pain and suffering while the patient
was in the ED, you can reassure the family with this fact.
N (NUTS AND BOLTS)
The “nuts and bolts” are the necessary practical things that require atten-
tion. The physician has several key tasks at this stage. Inform the family
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 2006   SECTION 26: Special Situations
that they will need to complete documents before they leave the hospital.
You should also ask the family’s wishes regarding autopsy. You should
also offer the family the chance to view the body after it is appropriately
prepped. This preparation includes removal of blood and secretions,
closing the eyes, and covering the body except for the hands and face.
It is fine to remove tubes and catheters as long as it is not a medical
examiner’s case. If the patient is disfigured, cover the wound as best as
possible with towels or bandages. You should warn the family that there
is trauma or if tubes must be left in place and that these sights may result
in a lasting memory of their loved one. In all situations, it is best to have
the family members seated.
G (GIVE)
The concluding step in the notification process is “give.” During this
period, you give the family your name and, if possible, your business
card. Inform them that, if they call, you may not be immediately avail-
able but that you will contact them after you receive the message. If they
reach out to you, be sure to return the call. Typically, calls are made to
provide additional clarity or to express thanks. Express your condo-
lences and then close the encounter.
SPECIAL SITUATIONS
LONG-DISTANCE NOTIFICATION
Occasionally, death notification must be made to survivors over the
telephone. The GRIEV_ING protocol steps are still appropriate. Ask
the survivor to “gather” other family members to join on the phone. If
the survivor is alone, ask the survivor to get “resources,” such as friends,
relatives, or personal clergy, and call you back. At that time, proceed
with the rest of the steps of in-person notification. After notification,
the survivors may wish to come to the hospital to attend to the “nuts
and bolts.” Recommend that they do not drive alone and assure them
someone will be available to answer all of their questions.
AUTOPSY AND MEDICAL EXAMINER CASES
The Joint Commission requires that physicians ask families if an autopsy is
desired. Autopsies are voluntary and serve to clarify premortem diagnoses
or aid in the diagnosis of new diseases. Autopsies do not prevent an open-
casket funeral. If there are religious concerns, a chaplain can help. Local
and institutional policies regarding autopsy billing and payment vary; how-
ever, if the family will be charged for the autopsy, they should be informed.
Depending on state laws, certain deaths must be referred to the medi-
cal examiner or coroner for investigation and/or autopsy. Medical exam-
iners may choose to investigate deaths due to trauma, homicide, suicide,
or medical procedures; death from a disease that is a public threat; death
of a person in custody or incarcerated; pediatric and sudden infant death
syndrome deaths; and deaths that are unexpected and unexplained. An
autopsy may or may not be performed in these cases, but the family is
not allowed to refuse investigation or autopsy by the medical examiner
if that is necessary. Families are still permitted to view the body, but they
are discouraged from removing mementos or disturbing the body until
after the medical examiner investigation. Do not remove resuscitative
lines and tubes in a medical examiner case. Designation of the death
as a medical examiner case does not prevent organ donation, but the
consent of the medical examiner is required before organ procurement.
ORGAN DONATION
Currently >110,000 patients are on the national transplant list.21 The
Joint Commission requires physicians to contact an organ-procuring
agency for all deaths in the ED. The role of the ED physician is to notify
the family of the grave prognosis or death of the patient and remain sup-
portive and available to the family.
Traditionally, the family consent process has been the largest single
obstacle to obtaining organ donation. The best predictor of consent is
the family’s initial reaction to the request for donation. Currently, all
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50 U.S. states have first-person consent and registry laws associated
with the Department of Motor Vehicles.22 These laws increase families’
satisfaction and likelihood of consent for organ donation.23 Trained
organ procurement specialists should manage conflicts with the family
disagreeing with the deceased’s stated wishes. They are trained in this
type of conflict resolution and are aware of each state’s laws. Physicians
can provide information while allowing the coordinator to initiate and
lead the conversation about organ donation.
WITNESSED RESUSCITATION
Emergency physicians should consider developing programs to edu-
cate staff and develop procedures to routinely invite family members
to observe resuscitation in the ED.24-26 Family-witnessed resuscitation
gives family members closure and comprehension of the patient’s situ-
ation and grave condition.24 Emergency medicine providers may be
concerned about the family interfering with resuscitation efforts, patient
confidentiality, increased litigation, distraction from resuscitation efforts,
wrongly prolonging the code, and increased stress for the family and
staff members.24 However, many of these concerns have been found
to be unwarranted. In one study, family members who witnessed CPR
had fewer symptoms of posttraumatic stress disorder and less compli-
cated grief 1 year after the death.27 However, family members should be
screened for appropriateness to attend the resuscitation and escorted out
if safety becomes a concern.28 A staff member should prepare the family
members for what they may see during the resuscitation and then remain
with them to offer support, answer questions, and explain procedures.24
PEDIATRIC DEATH
Recognizing that the death of a child in the ED is uniquely different
from other ED deaths, the American College of Emergency Physi-
cians and the American Academy of Pediatrics addressed challenges
by developing a set of principles.28 They recommend ED physicians
provide “personal, compassionate, and individualized” support through
a “family-centered and team-oriented approach.”28 The family-centered
approach begins with allowing the family to be with the child during
the resuscitation. After the child’s death, the family should be encour-
aged to stay with the child. The healthcare team should respect families’
“social, religious, and cultural diversity.”28 Many pediatric deaths are
medical examiner cases. Therefore, tubes and lines may need to be kept
in place, which may affect what the family can do. The team-oriented
approach provides appropriate resources, including organizations and
individuals that may assist families, and a coordinated response to the
child’s death.28 In more than one third of pediatric deaths, an autopsy
provides information of undiagnosed findings and complications.28
The ED physician should notify the child’s pediatrician concerning the
circumstances of the child’s death so that the pediatrician can follow up
with the child’s family and siblings.29
ADVANCE HEALTHCARE DIRECTIVES,
PHYSICIAN ORDERS FOR LIFE-
SUSTAINING TREATMENT, AND
WITHDRAWAL OF LIFE-SUSTAINING
TREATMENT
Advance healthcare directives (AHD) are legal documents that assist
in communicating to healthcare providers a patient’s healthcare pref-
erences when a patient is incapacitated and cannot speak for him- or
herself.30 There are many forms of AHDs, including, but not limited
to, out-of-hospital do not resuscitate (DNR) orders, living wills,
designation of a healthcare durable power of attorney or healthcare
representative, and the Physician Order for Life-Sustaining Treatment
(POLST) form. Unfortunately, only 29% to 33% of American adults
have an AHD.31,32 The traditional DNR form facilitates the patient’s or
healthcare proxy’s refusal of CPR should the patient sustain a cardiac
or respiratory arrest. However, DNR forms generally do not outline
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TABLE 301-2 PREDICT Score
PREDICT Feature Points*
Referral to palliative care team for a noncancer diagnosis
Current residence in nursing home
12
Department of intensive care unit admission with multiorgan failure 10
Current diagnosis of cancer 10
Two or more medical admissions in the past year
Age at ED visit 55–65 y
Age at ED visit 66–75 y
Age at ED visit ≥76 y
*Score of >13 predicts mortality at 1 year with 95% specificity.
the patient’s treatment wishes for a life-threatening condition.31 The
inadequacy of DNR forms led to the development of POLST forms,
including other states’ iterations (e.g., Medical Orders for Life-
Sustaining Treatment, Physician Orders for Scope of Treatment). The
POLST form is meant to translate a patient’s end-of-life wishes into
actionable physician orders. Forms may include directives concern-
ing the patient’s code status; desire for further medical interventions
including hospital transport, intubation, IV fluids, and comfort mea-
sures; desire for antibiotics; and desire for artificial nutrition. Forms
are transportable (authority transferred from the patient’s living situ-
ation to the ED) and may be brought into the ED from extended-care
facilities, from patients’ homes, and with EMS.33 These directives
should be honored in the ED. It is important to become aware of what
form of the POLST is available in the state in which you work as well
as the rules and regulations regarding who may complete the form
and how it may be used.
AHDs can assist emergency medicine providers with facilitating
discussion about goals of care. However, physicians may wonder when
it is appropriate to begin these discussions in the acute setting of the ED.
Clinical prediction tools, such as PREDICT, can assist providers in
recognizing patients who would benefit from advance care planning and
or a palliative care consult.34 PREDICT assesses a patient’s risk of mortal-
ity at 1 year with a reported 95.3% specificity for a cutoff score >1334
(Table 301-2). Recognizing the likelihood of someone having <1 year
to live can assist providers in knowing when it may be appropriate to
discuss AHDs such as the POLST form, initiate goals of care discussion,
and consult palliative medicine.
WITHDRAWAL OF LIFE-SUSTAINING TREATMENT
At times, it is appropriate to move from aggressive life-sustaining
treatment to comfort measures for patients who are facing imminent
death in the ED. This conversation may be initiated by the physician,
the patient, the healthcare proxy when patients cannot speak for
themselves, and/or by available AHDs such as the POLST form. The
patient and/or healthcare proxy should agree that continued aggres-
sive therapies are futile and discuss possible symptoms and outcomes.
The physician should explain that medicine would be given to treat
symptoms and alleviate suffering. Family should be made aware that
patients might display restlessness, dyspnea, or air hunger. Encourage
the family to stay and care for the patient and to notify a nurse or
physician for concerning symptoms.
When possible, move the patient to a room that is quiet, private, and
secluded from high-traffic areas; has low lighting; and is of sufficient
size to accommodate chairs for the family. Offer to call the chaplain.
Turn off or silence all alarms in the room, and remove any unnecessary
equipment from the patient, such as cardiac leads, blood pressure cuffs,
cardiac pads, and oxygen saturation monitors. Comfort treatment is
further discussed in Chapter 300, “Palliative Care.”
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
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CHAPTER 302: Military Medicine    2007
CHAPTER Military Medicine
3
302 D. Aaron Baker
Alex P. Keller, IV
Ryan M. Knight
Sarah Goss
3 Jared A. Sutton
1 Nicholas D. Drakos
2 Michael A. Bellamy
3
INTRODUCTION
The principles of military medical care are applicable to care in civilian
mass casualties, in remote settings, for tactical medicine, and in bio­
terrorism incidents.
Advanced trauma life support approaches are well applied in a hospital
setting, but in combat, how do you function without ancillary staff? What
do you do without ready access to a surgical team? How will you manage
in the dirt, at night, while engaged with enemy forces? Chapter 7, “Bomb,
Blast, and Crush Injuries,” Chapter 8, “Chemical Disasters,” and Chapter 9,
“Bioterrorism,” discuss many conditions relevant to the combat situation.
Table 302-1 lists the roles of medical care for combat casualties.
EQUIPMENT
Combat casualty treatment requires a properly supplied aid bag. Mission
analysis, phases of care, and potential worst-case scenarios guide needed
equipment. Pack the aid bag with attention to weight and volume;
overpacking creates challenges locating supplies. Supplies with multiple
purposes reduce weight and volume. Bundling simplifies tasks (i.e.,
bundle hemostatic dressings with other wound packing material and
compression bandages).
Tables 302-2 and 302-3 provide example packing lists. Building
multiple, mission-specific bags or packaging extra bundled items
assists with modification of bags and resupply. Every soldier is
outfitted with an individual first aid kit (Table 302-4). Train on your
personal equipment, maintain it, and pack smartly to ensure easy
access to critical items.
TACTICAL COMBAT CASUALTY CARE
Tactical combat casualty care (TCCC) is a standardized, prehospital
combat trauma guideline designed to address preventable causes of
death. TCCC has three phases of care: care under fire, tactical field care,
and tactical casualty evacuation.
PHASE 1: CARE UNDER FIRE
The medical actions taken under enemy fire are extremely limited: apply
tourniquet for massive exsanguination, protect the casualty, and move
him or her to safety. The urge to tend to a casualty must be tempered
TABLE 302-1 Military Roles of Medical Care
• Role 1: self/buddy aid, nonmedical unit–level combat lifesaver, medic or corpsman aid
up to battalion aid station; special operations forces medical elements (SOFME)
• Role 2: brigade or division level, medical companies/battalions, support battalions,
forward surgical teams, PRBCs, limited x-ray and lab capability, damage control care
for evacuation to next role
• Role 3: corps level, combat support hospitals, in-theater military treatment facility
(MTF), comprehensive stabilizing care for evacuation out of theater
• Role 4: definitive care, ultimate treatment capability, full rehabilitative care, tertiary
care MTF, typically located in continental United States or comparable out-of-theater
safe havens
Abbreviation: PRBCs = packed red blood cells.
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 2008   SECTION 26: Special Situations

TABLE 302-2 Trauma Aid Bag Suggested Packing List TABLE 302-3 Items to Be Carried on Medical Provider
Tourniquets Optional Advanced Airway List • Light-emitting diode headlamp with colored filter
Hemostatic gauze Oropharyngeal airway • Tourniquet(s) (immediately available and reachable by both hands)
Gauze or packed gauze Laryngoscope with blade • Trauma dressings (4 inch) or elastic bandages
Trauma dressing(s) 4 or 6 inch Endotracheal tube • Hemostatic gauze
Cricothyroidotomy kit* Stylet and/or gum elastic bougie • Gauze
Nasopharyngeal airway(s) with lubricant Syringe 10 mL or 10-mL saline flush • Cricothyroidotomy kit
Supraglottic airway Endotracheal tube–securing device or tape • Nasopharyngeal airway(s) with lubricant
Suction device Colorimetric carbon dioxide detection • 14- or 10-gauage, 3.5-inch decompression needle(s)
14- or 10-gauge, 3.5-inch decompression device or esophageal detection device • Chest seal(s)
needle(s) Digital capnography monitor • Finger pulse oximeter
Chest seal(s) Optional Items – Mission Dependent† • Combat pill pack(s)
Bag-valve mask Minor wound kit (suture, needle driver, etc.) • Analgesic medication (fentanyl oral transmucosal lozenge preferred)
Finger pulse oximetry Chest tube kit • Trauma shears or rescue knife
IV starter kit(s) with saline lock Thermometer • Examination gloves heavy duty
Intraosseous device (peripheral Traction splint • Casualty cards
and/or sternal) Cervical collar, adjustable • Permanent marker
Sodium chloride flush(es) (10 or 5 mL) Otoscope/ophthalmoscope • Nine-line medical evacuation card
IV administration tubing (10 gtt) IV fluids (i.e., volume replacement for
IV fluid for blood administration priming burns, dehydration)
and carrier fluid Red/green/blue/yellow glow sticks for less soft tissue damage and is more comfortable for the patient. To control
Pressure infuser device marking and mass casualty events hemorrhage from a large vessel, a tourniquet must have a windlass to
Sharps container Litter gain a mechanical advantage when tightening. Tourniquets without
Abdominal dressing Blood pressure cuff with stethoscope (may a windlass cannot attain sufficient force to stop arterial bleeding. In
not be useful in noisy environments) combat, we use a tourniquet that can be applied with one hand for
Junctional hemorrhage device (consider
self-treatment.3
one that also works as pelvic splint) Electronic monitors (minimum with nonin-
Place the tourniquet about 2 inches proximal to the wound.4 Tighten
Cravat or elastic bandage(s) vasive blood pressure and pulse oximetry)
to greater than arterial pressure, because tightening that exceeds venous
Splint(s), malleable Ventilator but not arterial pressure may increase bleeding. Apply the tourniquet
Tape, silk 2 inches Basic Medication List until the distal pulse disappears. If no distal pulse is present on initial
Exam gloves Hard plastic case evaluation, apply the tourniquet with a force estimated to be greater than
Combat wound medication pack the systemic blood pressure. If placement of a single tourniquet does
Trauma shears
(acetaminophen, meloxicam, moxifloxacin) not control bleeding, place a second tourniquet immediately adjacent
Casualty cards and proximal to the first. See “Tourniquets,” in Chapter 254, “Trauma
Permanent marker Syringes (1, 3, and 10 mL)
in Adults.” See Figures 254-1, 254-2, and 254-3 for images and detailed
Hypothermia management 18-gauge filter and 21-gauge needles application instructions of TCCC-recommended tourniquets.
Scalpel #10 blade Alcohol pads
Large skin stapler Tranexamic acid  POSTTOURNIQUET CARE
Chlorhexidine and/or betadine swab(s) Ketamine
The safe time limit for tourniquet application has not been determined.
Eye shield(s) Fentanyl oral transmucosal lozenge Tourniquets are routinely left in place for up to 2 hours in the operating
Headlamp with colored filter Narcotic analgesia (hydromorphone, room, and this is the basis for the recommendation to remove a tourni-
morphine, or fentanyl) quet within 2 hours, situation permitting.5 At 6 hours with a tourniquet
Sick call items
Midazolam in place, it is probably best not to remove it; at this point, the release of
Blood Transfusion potassium, lactate, myoglobin, and other toxins from a severely acidotic
Naloxone
Blood cooler/transport container limb into the circulation would likely cause more systemic harm than
Ondansetron orally disintegrating tablet/IV
Blood tubing with filter benefit. There are, however, several cases of limb salvage with tourniquet
Lidocaine 1% times greater than 6 hours.6
Blood product(s)
Ertapenem
Normal saline
Epinephrine (vial or autoinjector)
Benadryl TABLE 302-4 Individual First Aid Kit Packing List
Tetracaine, ophthalmic • Tourniquet (reachable by both hands)
*
”Kits” are packaged together as a functional unit in a resealable plastic bag or vacuum sealed with • Trauma dressing
quick-open tabs. • Hemostatic gauze
†
Optional items may need to be in additional bags and located on evacuation platforms or secured • Gauze
locations.
• Nasopharyngeal airway with lubricant
• 14- or 10-gauge, 3.5-inch decompression needle
by situational awareness: return fire, and secure the site before tending
• Chest seal
to casualties.
• Trauma shears or rescue knife
 TOURNIQUET APPLICATION • Examination gloves, heavy duty
• Combat wound medication pack
A tourniquet is the first-line intervention for massive hemorrhage in a
• Casualty card
combat setting. If applied before the onset of shock, survival is improved
from 17% to 94%.1,2 A wide tourniquet (at least 1.5 inches wide) causes • Permanent marker

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A tourniquet is a temporizing measure. The next step is to convert the
tourniquet to an effective pressure dressing, using direct pressure and a
basic gauze roll and elastic wraps and/or hemostatic agents, if required.
A knee or hand can apply additional pressure to the bleeding site or
proximal pressure point. Once an effective pressure dressing is applied,
release but DO NOT REMOVE the tourniquet. If bleeding recurs,
retighten the tourniquet to control bleeding.
PHASE 2: TACTICAL FIELD CARE—THE PRIMARY
SURVEY
This phase begins once the patient and provider are no longer under
effective enemy fire. Tactical security, similar to “scene safe” in civilian
EMS training, must be maintained at all times.7 Conduct a complete
primary survey and perform lifesaving interventions.
Combat medicine deviates from the universally accepted airway,
breathing, and circulation algorithm. Massive hemorrhage is the most
common correctable cause of death on the battlefield and is the top clin-
ical priority in battlefield trauma care.7 Airway compromise accounts for
relatively few combat deaths, and respiratory difficulties typically prog-
ress over time. This is the reason that TCCC recommends the modified
primary survey algorithm of MARCH:
Massive hemorrhage
Airway
Respiratory
Circulation
Hypothermia prevention/head injury
After hemorrhage control, the algorithm mirrors the airway, breathing,
and circulation algorithm, with the additional consideration of a
closed head injury and hypothermia prevention as primary survey
responsibilities. Level of consciousness and pulse strength are used as
indicators of peripheral perfusion in injured soldiers. If the soldier’s
peripheral pulse is weak or absent, if the level of consciousness is altered,
or if the solder is not verbally responsive, then immediate intervention is
needed before moving down the algorithm.
 MASSIVE HEMORRHAGE
Topical Hemostatic Agents If the wound is not amenable to tourni-
quet use and a pressure dressing is inadequate, use a hemostatic agent.
The TCCC Committee recommends the following agents: Combat
Gauze® (zeolite impregnated gauze), Celox Gauze® and ChitoGauze®
(both chitosan-impregnated gauze), and XSTAT® (chitosan-impregnated
sponge).8
To apply any of these gauze-like hemostatic agents, prepare the wound
by evacuating excess blood, taking care to preserve any clot that may have
formed around the damaged vasculature; pack the hemostatic gauze/
sponge directly over the site of the most active bleeding; repack or adjust
the gauze for optimum placement; and use additional hemostatic agent
as required. With the exception of XSTAT®, hold direct pressure for a
minimum of 3 minutes, then reassess for bleeding and repack as needed.
Secure the hemostatic agent in place with a pressure dressing. Do not
remove XSTAT® in the field. If bleeding continues, pack directly over it.
Junctional Hemorrhage Junctional hemorrhage (from the “junctional”
anatomic area between the limbs and intracavitary areas of the abdo-
men or thorax) is difficult to control. Hemorrhage in the axilla and
groin is not amenable to tourniquet application and hemostatic agents.9
Specialized junctional tourniquets may be beneficial in certain cases.
Presently, these include the Abdominal Aortic Tourniquet,10 the Combat
Ready Clamp,11 the Junctional Emergency Tourniquet Tool,12 and the
SAM Junctional Tourniquet.13 Each product has specific directions for
application.
A potential tool in the management of abdominal and junctional
hemorrhage that fails to respond to other measures is resuscitative
endovascular balloon occlusion of the aorta (REBOA). See Chapter 254
for a discussion of REBOA. REBOA has been performed successfully in
combat >20 times by U.S. Air Force surgical teams,14 but is currently
not considered a first-line treatment for out-of-hospital junctional
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CHAPTER 302: Military Medicine    2009
hemorrhage.15 The use of prehospital REBOA is still largely unexplored
and thus requires extensively careful selection before implementation.16
Systemic Hemorrhage Control: Tranexamic Acid Tranexamic acid
decreases mortality in trauma.17 It is recommended for use in all casual-
ties that require significant fluid or blood products, both children and
adults. Tranexamic acid is most effective when given within 1 hour of
injury and must be given within the first 3 hours. The dose is 1 gram
of tranexamic acid in 100 mL of normal saline, infused over 10 min.18
 AIRWAY
Airway intervention during the primary survey is similar for both
combat and civilian casualties. Less than 1% of combat trauma requires
lifesaving airway intervention in the prehospital setting.19,20
If there are no spontaneous respirations after opening the airway, the
casualty is triaged to the expectant category (expected to die) in a mass
casualty (MASCAL) situation (defined as more casualties than resources
available); if the situation and resources allow, perform advanced airway
techniques including cricothyrotomy,21 supraglottic airway intubation,22
and mechanical ventilation. If space is limited, cricothyrotomy equip-
ment is the most important. In austere conditions with minimal seda-
tives and analgesics, prolonged evacuation times spanning hours to days,
and delayed medical logistical resupply, the threshold for performing a
cricothyrotomy should be low. It is critical to confirm placement and
firmly secure the airway.
 RESPIRATORY/BREATHING
Tension Pneumothorax The nearly universal use of body armor in
present combat operations provides critical protection to the chest and
upper abdomen, as evident in the 5% to 7% thoracic wound rate, the
lowest in U.S. military conflicts.23
In a tactical setting, the threshold to perform a needle decompression
is very low, as most casualties with penetrating chest trauma in respira-
tory distress will have some degree of hemo- or pneumothorax and
possible tension pneumothorax. Use the largest and longest catheters
available. The TCCC minimum standard is the 14-gauge, 3-inch-long
needle.24 However, there are 10- and 12-gauge catheters available in
3-inch lengths that are highly recommended over the standard because
they are less likely to kink when penetrating a muscular chest or occlude
with patient movement. Two locations are recommended: (1) the second
intercostal space, midclavicular line; or (2) the anterior axillary line at
the fourth to fifth intercostal space (see Chapter 68, “Pneumothorax,”
for further discussion).25
Penetrating Chest Trauma Penetrating chest trauma with open
pneumothorax or sucking chest wounds is common with large injuries
to the chest wall. The updated TCCC standard is to use a valved/vented
chest seal as the first choice. Unvented chest seals require continuous
reassessment for possible accumulating tension pneumothorax and need
for needle decrompression.26 Most casualties encountered in a combat
setting are bloody and sweaty; applying a chest dressing that actually
adheres to the chest requires skill and proper preparation of the skin.
Wipe the skin as dry as possible. Consider using tincture of benzoin or
Mastisol to facilitate dressing adherence if it is available and you have
the luxury of time.
Chest Tubes The lifesaving intervention for a chest injury in the
setting of tactical field care is needle decompression; a chest tube is not
immediately required. Needle decompression can be as effective as a
chest tube in a patient for up to 4 hours if the patient is not subjected to
much movement.27 Needle decompression can be repeated as needed.
 CIRCULATION
The TCCC mainstays of circulation management are the appropriate use
of low-volume resuscitation (also known as permissive hypotension or
hypotensive resuscitation) and the preferred resuscitation fluids. The
first step is vascular access.
IV Access Vascular access is the lifeline for severe combat casualties.
Smaller-bore IVs (primarily 18-gauge catheters) are preferred in a
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tactical environment to provide fluid resuscitation. If blood products are

available, which is atypical at this phase of field care, then a larger-gauge
catheter is indicated.
It is critical to firmly secure the catheter in the combat setting. Use a
clear adhesive bandage first; then wrap enough tape to ensure that the
catheter will hold in place if you were to throw the IV bag. There are
also commercially available IV catheters with Velcro wraps that work
very well.
IO Access An IO line is the alternative to IV access. Nearly universal
use of body armor in the modern tactical environment protects the ster-
num, so this site is ideal for IO access. Provide secure fixation to prevent
dislodgement during patient movement. Some devices may require a
removal instrument, which you should secure to the patient; without
this removal instrument, the IO must be surgically removed at the next
level of care.
Permissive Hypotension/Low-Volume Resuscitation Following the
landmark 1994 Ben Taub study documenting increased survival,28
permissive hypotension is the TCCC standard for managing penetrating
wounds of the abdomen, thorax, junctional areas where specific tourni-
quets have failed, or any noncompressible hemorrhage. The goal is to
preserve survival of casualties by maintaining a delicate balance between
a blood pressure high enough to provide adequate tissue perfusion but
low enough to avoid clot “blow-out” and clotting factor dilution. Current
recommendations are to maintain a mean arterial pressure of 60 mm
Hg or a systolic blood pressure of approximately 80 to 90 mm Hg.29,30
A blood pressure of 80 to 90 mm Hg is clinically noted by a normal level
of consciousness and a weakly palpable radial pulse.31 The exception is FIGURE 302-1. Universal donor card example, with low-titer O-positive blood.
the multiple trauma casualty with head injury; maintain a systolic blood
pressure between 90 and 95 mm Hg to preserve cerebral blood flow.32,33
Resuscitation Fluid The prehospital resuscitation fluid of choice for facilities and shipped to locations in Iraq and Afghanistan. Cold-stored
combat trauma has changed over the past 10 years of U.S. military conflict. low-titer type O whole blood typically has a shelf-life of only 24 days,
The goals of the TCCC Committee in recommending the appropriate limiting its utility on a large scale compared with standard PRBCs,
resuscitation fluid are the following: which typically have a 42-day shelf-life.
In response to blood supplies that may not meet the wartime require-
1. Enhance the body’s ability to form clots with platelets, plasma, and ments due to collection, transport, storage, and distribution issues, some
red blood cells at sites of active bleeding. entire theaters have embraced “walking blood bank” or “tactical donor”
2. Minimize adverse effects (edema and dilution of clotting factors) programs. In 2018, United States Forces Korea instituted a tactical donor
resulting from iatrogenic resuscitation injury. program that prescreens both low-titer type O universal whole blood
3. Restore adequate intravascular volume and organ perfusion prior to donor personnel and type-specific donors (Figures 302-1 and 302-2).
definitive surgical hemorrhage control.
4. Optimize oxygen-carrying capacity as much as possible.
The current resuscitation fluid recommendations for severe hypo-
volemic shock are as follows, in order of preference: (1) fresh whole
blood; (2) blood components in a 1:1:1 ratio of packed red blood
cells (PRBCs):plasma:platelets; (3) blood components in a 1:1 ratio of
PRBCs:plasma; (4) plasma (freeze-dried plasma or fresh frozen plasma
appropriately reconstituted); (5) PRBCs; (6) Hextend; and (7) lactated
Ringer’s or multiple electrolyte injection, type 1.
Whole-Blood and Blood Component Infusions In the combat
setting, prehospital blood transfusion is carried out under specifically
approved theater protocols by specially trained and certified providers and
medics. For example, several special operations units can give European-
produced freeze-dried plasma under an approved protocol.
Fresh whole blood is the TCCC primary resuscitation fluid of choice
because it has all the required blood components in their natural state
and provides a survival advantage to casualties with severe trauma and
shock.34,35 In a battlefield environment, whole blood is often obtained
from fellow soldiers known as “walking blood banks” or special opera-
tions forces tactical universal donors. During Operation Iraqi Freedom,
13% of blood transfusions used fresh whole blood.33
All potential donors should be screened for pathogen risk, although
perceived risk is often outweighed by potential benefit; additionally, all
recipients and donors have blood samples sent to the Armed Forces
Blood Program for retrospective analysis. The collection kits for fresh
whole-blood transfusions are readily available through military medical
supply channels. Over the past several years of combat, special opera-
tions medical teams have employed cold-stored low-titer type O whole
blood. This product is collected and produced at military blood-banking FIGURE 302-2. Type-specific donor card example.

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Using operationally secure identification cards, each prescreened indi-
vidual can act as a blood donor once every 56 days for a full year from
the date of testing, dramatically reducing time from injury to resuscita-
tion with fresh warm whole blood, as well as reducing the cost for one
unit of reconstituted 1:1:1 therapy from approximately $650 to $150 for
the prescreened donor testing and special operations forces blood
collection kit combined. Providers can use these individuals within a fixed
treatment facility or at the point of injury during combat conditions
without specialized blood storage or testing equipment.36
If fresh whole blood is not available, the next preferred choice is
plasma, PRBCs, and platelets in a 1:1:1 ratio.37,38 A unit of plasma is given
first, followed by the PRBCs, and then platelets. In addition to PRBCs,
the military fields frozen red blood cells to augment current supplies
of liquid-packed red blood cells, although the thawing process
(deglycerization) creates a rate-limiting step during active hostilities.
The next preferred choice is PRBCs and plasma in a 1:1 ratio if plate-
lets are not available.39,40 Plasma is again given first, followed by PRBCs.
Advances in warm platelet storage will hopefully increase the availability
of platelets in the near future.
If availability of blood products is limited, you may have to choose
between PRBCs and plasma alone. Debate exists as to whether PRBCs
or plasma alone is best, so product availability is more likely to drive
this decision. Although availability of plasma is somewhat limited, some
special operations combat medics can now carry freeze-dried plasma,
as well as PRBCs. The freeze-dried plasma concentrate currently
carried by U.S. medics is produced in France and available for use by
the North Atlantic Treaty Organization.41 All patients who receive blood
or blood products in the field or who the provider expects may require
blood products should receive 1 gram of IV tranexamic acid if it can be
administered within 3 hours of wounding.17
Colloids and Crystalloids If no blood products are available, Hextendø
(hetastarch, synthetic colloid, in lactated Ringer’s solution) is recom-
mended.42 It is compatible with tranexamic acid.43 Colloid has a clear
advantage from a weight/volume perspective in the prehospital environ-
ment, where the medic must carry the fluid on his back. Hetastarch 500 mL
provides intravascular volume expansion of 600 to 800 mL. Hextend is
potentially protective against multisystem trauma–induced acute respi-
ratory distress syndrome, induces a favorable acid-base balance, and
results in less severe coagulopathy.44 Indiscriminate colloid use can have
coagulopathic and immunologic effects, but these adverse effects typi-
cally do not occur with colloid administrations of <1500 mL.45,46
If fluid resuscitation requires >1500 mL of colloid, lactated Ringer’s
solution is given next. Initial use of colloids to replenish intravascular
volume during resuscitation must be balanced at some point with an
appropriate volume of crystalloid to avoid extensive intracellular dehy-
dration. Start with a 500-mL bolus, and repeat the bolus in 30 minutes if
there is no clinical response, using pulse strength and level of conscious-
ness to guide the volume infused. Maintain a systolic blood pressure of 80
to 90 mm Hg, but in head injury, a systolic blood pressure between 90
and 100 mm Hg may be required to ensure sufficient cerebral perfusion
pressure.
One liter of infused lactated Ringer’s results in only 200 to 250 mL of
intravascular volume expansion; normal saline is not recommended for
resuscitation due to the hyperchloremic acidosis it produces.47 Addition-
ally, aggressive resuscitation with saline-based resuscitation strategies
is associated with a number of adverse effects, including increased
bleeding, acute respiratory distress syndrome, multiorgan failure, acute
coronary syndrome, and increased mortality.48-50
Other Resuscitation Solutions Hypertonic saline has some benefits
in the intensive care setting.51-53 Hypertonic saline 3% is the first-line
adjunct therapy in the Joint Trauma System Neurosurgery and Severe
Head Injury Clinical Practice Guildline.54 Additional options include
mannitol or 23.4% saline.55 When commercial hypertonic saline is not
available, providers can add 50 mL of 23.4% saline to 500 mL of 0.9%
saline to achieve a 2.98% saline solution to simplify dosing options.
Hypertonic saline may be administered through both IV and IO access.
Hemoglobin-based oxygen-carrying solutions are promising, but
none are presently approved by the U.S. Food and Drug Administration
or available on the commercial market.56,57
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CHAPTER 302: Military Medicine    2011
Oral Hydration In the combat setting, there are often limited IV fluids
available and long waiting times for evacuation or surgical intervention.
In the patient with a normal level of consciousness, the risk of aspira-
tion is very low and outweighed by the benefit of maintaining adequate
hydration and patient comfort if evacuation is delayed. As such, oral
fluid hydration is acceptable for combat casualties in many situations,
even if surgery is anticipated at the next level of care. The only contra-
indication is active vomiting or an altered level of consciousness that
increases risk of aspiration. Time to surgery is not an issue in oral provi-
sion of clear liquids to combat casualties.58
 HYPOTHERMIA AND HEAD INJURY
Under TCCC, we prevent hypothermia by wrapping the patient in a
multilayer insulating wrap with a vapor barrier liner. Closed head injury
is one of the final considerations in this modified algorithm. If a casualty
has an altered level of consciousness, it is either because of inadequate
cerebral perfusion or cerebral injury. If hypovolemic shock has been
ruled out or treated and the mechanism is consistent with closed head
injury, we treat for head injury. Have the patient recline with the head
elevated at 30 degrees. Give oxygen to maintain an oxygen saturation of
at least 90%. Maintain a systolic blood pressure of at least 90 mm Hg.31
Consider adjunct therapy such as hypertonic saline or mannitol and
minimize interventions that may cause constriction of venous return
in the neck such as cervical collars and endotracheal tube tie systems.
SECONDARY SURVEY
Expose the casualty as much as the tactical situation will allow. Be prepared
to preserve body heat to avoid hypothermia. Stabilize fractures and treat less
severe wounds. Continually reassess the casualty. Attend to the casualties
who require intervention, but remember to reassess everyone. This can be
as quick as asking a quick question to assess airway, hemodynamic status,
and level of consciousness, or quickly palpating a radial pulse to determine
rate and strength; obtain blood pressure if possible. The character of the
peripheral pulse and the Glasgow Coma Scale are reliable severity
indicators.59 Recheck dressings or bandages for continued bleeding.
 PAIN CONTROL
Pain control is crucial for facilitating transport and patient comfort.
Under TCCC, there are three primary pharmacologic modes of pain
control. For lesser injuries with normal mental status, use a combat
wound medication pack.7 This contains two 500-milligram acetamino-
phen tablets and a meloxicam tablet. This combination is effective for
moderate pain control, does not affect mental status, and is administered
orally. Because meloxicam has a favorable side effect profile and no
effect on platelet function, it is the TCCC NSAID of choice.7
 FENTANYL AND KETAMINE
For more severe pain, we recommended either oral transmucosal
fentanyl citrate lozenge, informally known as the fentanyl “lollipop,”
or ketamine. Oral transmucosal fentanyl citrate provides rapid-onset,
long-lasting pain relief for severe pain without the need for an IV. When
placed into the buccal fold and slowly sucked on, 25% of the fentanyl is
absorbed sublingually, with onset in 15 minutes. The remainder that is
swallowed enters the GI tract and loses about 50% of its bioavailability
through first-pass effect, but the remaining 50% is slowly absorbed,
providing more extended pain relief for the next 4 to 6 hours.60 An
800-microgram fentanyl lozenge is the recommended starting dose.
Rapidly chewing and swallowing the lozenge will decrease the total
amount of fentanyl received, because less is absorbed sublingually and
more is subject to first-pass effect. To avoid swallowing, the recom-
mended technique is to tape the lozenge to the patient’s finger, which
will deter swallowing and prevent overdosing should the patient become
somnolent (as the lozenge attached to the hand will fall from the mouth).
If pain control is not achieved in 15 minutes, a second 800-microgram
lozenge can be placed in the other cheek. Fentanyl can also be given
intranasally with the use of a nasal atomizer.61 If an IV is available, then
IV fentanyl or IV ketamine can be used and titrated to effect.
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Ketamine at subdissociative doses is an effective pain control agent.
It can be given IM, IV, IO, or intranasally via nasal atomizer or syringe
with rapid onset and good efficacy. The initial dose is 50 milligrams IM
or intranasally repeated every 30 minutes and titrated to effect, or
20 milligrams IV/IO by slow push repeated every 20 minutes and titrated
to effect. For treatment of associated nausea, the TCCC Committee now
recommends ondansetron oral dissolving tablets every 6 hours as needed.
 ANTIBIOTICS
All war wounds are dirty and contaminated. Early antibiotic use with
such wounds may decrease subsequent infection.62 For those able to tol-
erate PO administration, a single 400-milligram dose of oral moxifloxa-
cin, found in the combat wound medication pack,7 is recommended.
For casualties with hypotension or an altered level of consciousness,
administer ertapenem, 1 gram IV.
SPECIFIC INJURIES
 BURN CARE: UNDERSTANDING THE ENVIRONMENT
Resuscitation decisions for burns in an austere environment are influ-
enced by the availability of medical supplies and the time from definitive
care. Underresuscitation may result in shock and progression into the
lethal triad (hypothermia, acidosis, and coagulopathy). Overresuscita-
tion may result in fluid overload and respiratory collapse with little to
no equipment available to handle an airway emergency.
When optimal resources are available, the Joint Trauma System Clini-
cal Practice Guidelines recommend using fluid resuscitation software
(Burn Navigator) to determine fluid resuscitation rates.63 The device
makes isotonic fluid rate of administration recommendations based on
the patient’s urine output to keep the patient’s resuscitation in the ideal
range. This device is not recommended for electrical burn injuries that
have caused rhabdomyolysis.63
If fluid resuscitation devices are not available, a simplified rule of 10s is
used for burn management, which is clinically effective and easy to imple-
ment in a prehospital environment.64 For burns >20% total body surface
area, first estimate the total body surface area burned to the nearest 10%.
Then, for adults weighing 40 to 80 kg, give IV fluid as follows: 10 mL
× % total body surface area burn per hour. For every 10 kg of patient
weight above 80 kg, add another 100 mL of fluid per hour (resuscitation
for hemorrhagic shock takes precedence over resuscitation for burn shock).
For example, for a 90-kg patient with 40% total body surface area
burns, the following would be given: 40% × 10 mL = 400 mL, plus 100 mL
for 10 kg above the 40 to 80 kg range, giving a total of 500 mL of IV fluid
per hour. Once the patient is at a higher level of care, the fluid rate can
be adjusted based on clinical status and urinary output.
 BLAST INJURIES
Injuries from explosions are exceedingly common in combat and fre-
quently cause overpressurization injuries. Tympanic membrane per-
forations and hypopharyngeal petechiae are common findings in blast
casualties and are easily missed without a thorough exam. After the 2013
Boston Marathon bombings, only 15 of 127 patients evaluated on the day
of the bombing (11.8%) were diagnosed with tympanic membrane inju-
ries.65 More than 100 patients who were hospitalized after the event were
prospectively followed, and 90% were found to have sustained tympanic
membrane injuries.66 There are many factors that contribute to a pattern
of injury, such as body orientation relative to the blast and confined ver-
sus open space, so be wary of relying on a particular clinical finding to
triage casualties.67 If anything, the most reliable sign may be respiratory
distress immediately after the blast. Casualties with clinically significant
lung injury typically manifest as respiratory failure within minutes of the
blast.67,68 See Chapter 7, “Bomb, Blast, and Crush Injuries,” for detailed
discussion. All casualties should be screened for traumatic brain injury.
 CERVICAL SPINE INJURY
The vast majority of penetrating injuries in the combat setting do not
require cervical spine immobilization, unless there is direct injury to the
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neck with associated neurologic deficit.69 Cervical spine immobilization
for penetrating injury in a combat casualty is not recommended because
it will impede the ability to manage the more immediate concerns of
a penetrating neck injury. Blunt head trauma should be treated with
cervical spine immobilization, situation permitting, as practiced in the
civilian sector.70
 ABDOMINAL TRAUMA
Although body armor does provide some protection to the upper abdo-
men, the lower abdomen is still relatively vulnerable. There is a groin
attachment for the issued body armor that provides some protection to
the lower abdomen and groin, but it is composed of flexible Kevlar to
allow freedom of movement, rather than the more durable rigid Kevlar
plate that is used to protect the chest and back. Use of this additional
piece of equipment has become more prevalent among combat troops.
With a significant large-vessel (aorta, inferior vena cava, iliac vessels),
liver, or splenic injury, there is not much a combat physician can do to
save a casualty. In this situation, stabilize the casualty as best as possible,
start an IV, administer antibiotics, and transport to a higher level of care
with surgical capability immediately. For management of difficult-to-
control, noncompressible massive hemorrhage, see the section on massive
hemorrhage control and REBOA.
If there is a bowel evisceration, replacing the contents will minimize
insensible fluid and heat loss and allow for easier casualty movement.
First remove any significant particulate matter or dirt; then attempt to
replace the bowel contents intra-abdominally (this might not be possible
if there is significant bowel edema and/or a small abdominal defect);
cover exposed bowel and the abdominal defect with a moist dressing;
cover with plastic wrap or other fluid-impervious dressing to minimize
insensible fluid loss; start an IV and administer IV fluids as needed; and
administer IV antibiotics in preparation for evacuation.
 PELVIC TRAUMA
The standard torso body armor does not provide any protection to the
pelvis. The groin attachment protects the genital region and some of
the perineum, but the inguinal regions are left largely unprotected. The
femoral vessels are vulnerable to penetrating injury, often resulting in
life-threatening hemorrhage.
A tourniquet or pressure dressing to a proximal femoral artery or vein
injury may be ineffective. For this type of injury, use of a hemostatic
agent is imperative. Direct pressure should be applied to gain immediate
control of the bleeding. Vessel clamping should only be attempted if an
effective tourniquet or pressure dressing cannot be applied, a hemostatic
dressing is not available, there is no device to control junctional hemor-
rhage, and there is no ability for immediate evacuation.
Pelvic fractures can result in significant hemorrhage that is difficult
to control. Determination of a pelvic fracture, if not obvious, should
be done from symptoms of pain and a clinical suspicion. The practice
of “springing” or doing a “pelvic rock” is no longer recommended
because this technique is likely more harmful than beneficial.71 Past
recommendations of improvised pelvic splinting with a sheet to
produce needed compression for hemorrhage control can be used (if
no other more effective options are available), but such splinting is
inferior to more recent commercially manufactured pelvic splints and
binders.71
 EXTREMITY AMPUTATION
About 7% of wounded soldiers in Operation Iraqi Freedom and
Operation Enduring Freedom had a major extremity amputation, and
50% of soldiers killed in action or who died of wounds had major
amputations.72 Field treatment of an amputation is focused primar-
ily on hemorrhage control and preserving as much tissue as possible.
Often the vessels of the limb have retracted proximally from the initial
force of the amputation, making it particularly difficult to identify and
control hemorrhage. It may appear that hemostasis has been achieved
with little effort; however, effective hemorrhage control may be neces-
sary in the form of a hemostatic agent, pressure dressing, or tourniquet
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because delayed bleeding often occurs as the damaged vessels relax
and dilate shortly after the patient appears stable. Constant reevalua-
tion of the patient is essential. A partial amputation where the limb is
still attached by substantial tissue or bone should be treated the same
as an open fracture with hemorrhage control, wound debridement and
irrigation, antibiotic administration, and splinting in an attempt to
salvage the limb.
MASS CASUALTY TRIAGE
Mass casualty, or MASCAL, events are generally defined as medical
contingencies in which the number and needs of the casualties exceed
available resources (personnel and supplies). MASCAL events are time-
constrained, complex operational problems that require the understand-
ing and calculation of multiple risk variables to accomplish the goal of
doing the most good for the greatest number of people.73 In addition to
medical considerations, risk variables may include mission objectives,
ongoing kinetic activity and threats, availability of casualty evacuation
platforms, time and distance to other treatment facilities, environ-
mental conditions, nonmedical manpower, and communications.74 It
is critical to have a rehearsed and validated PACE (Primary, Alternate,
Contingency, Emergency) MASCAL response plan.74 After security
considerations, the first step in any MASCAL response will involve the
consolidation and triage of casualties.
The triage process is ongoing and dynamic and should occur at
and through each level of care. Optimal triage is a key component of
managing a MASCAL (Table 302-5 provides one example of a simple
triage algorithm) that requires a system of command and control, the
funneling of casualties through a single designated triage point, a triage
algorithm, and a designated triage officer. Medical providers familiar
with triage algorithms, triage-specific training, and more relevant clinical
experience achieve better accuracy in the triage process.75,76 Multiple
triage algorithms exist. Validation of algorithms is difficult, and no
standardized criteria exist to assess algorithm efficacy.76,77 However,
evidence suggests that the SALT algorithm (Figure 302-3) best balances
sensitivity and specificity.76
 THREE-TIER PRIORITIZATION
SALT stands for sort, assess, lifesaving interventions, and treatment/
transport, which are the key activities that must be accomplished
during the triage process. SALT begins with a global sorting of
casualties, prioritizing them into three tiers for individual assessment.
The triage physician directs casualties to walk to a designated area “if
they need help.” Those who follow the command to walk are the last
priority for individual assessment, because they demonstrate an intact
airway, breathing, circulation, and mental status and are therefore
the least likely to have a life-threatening condition. The remaining
casualties should then be asked to wave or be observed for purposeful
movement. Those who remain still and do not move, as well as those
with obvious life-threatening injuries, such as massive external hem-
orrhage, are assessed first. Those who wave are individually assessed
next, followed by the ones who previously walked to a designated area.
Although this initial sorting is not perfect, it is an attempt to organize
numerous casualties.
 INDIVIDUAL CASUALTY ASSESSMENT
The second step of SALT is to perform individual assessments and apply
lifesaving interventions, such as controlling massive external hemor-
rhage or opening an airway. Lifesaving interventions must meet all of the
following criteria: can be provided quickly; can greatly improve a casu-
alty’s likelihood of survival; does not require the physician to stay with
the casualty; are within the physician’s scope of practice; and require
only immediately available equipment. After appropriate interventions
are performed, casualties are prioritized for treatment and assigned to
one of the following triage categories: immediate, delayed, minimal,
and expectant (includes the dead for the purpose of military triage),
known in the military by the acronym DIME.
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CHAPTER 302: Military Medicine    2013
TABLE 302-5 Mass Casualty Triage Algorithm
AIRWAY: Is the casualty moving air?
Yes—assess breathing
No—open airway, moving air now?
Yes—assess breathing
No—EXPECTANT
BREATHING: Respiratory rate >30 breaths/min?
Yes—IMMEDIATE, address cause
No—assess circulation
CIRCULATION: Radial pulse weak/absent or heart rate >140 beats/min?
Yes—IMMEDIATE, address cause
No—assess mental status
MENTAL STATUS: Responds to simple commands?
Yes—NOT an IMMEDIATE
No—IMMEDIATE, address cause
Colored triage tags or chemical light markers can mark casualties
based on triage category. Colored triage tags typically are red for imme-
diate, yellow for delayed, green for minimal, and black for expectant
or deceased. If chemical light sticks are employed, red is typically used
for immediate, green/yellow for delayed, and blue for expectant. Avoid
using green and yellow chemical lights for different triage categories to
mirror the markings on the triage tags, because it may be difficult to
distinguish the two colors during night operations.
The field triage score is another easy, rapidly applicable method
to identify casualties who are more seriously injured and expected to
have a higher mortality. The field triage score is based on two variables:
character of the radial pulse and the motor component of the Glasgow
Coma Scale (GCS-M), namely the ability to follow commands. A weak
or absent radial pulse, which correlates with a systolic blood pressure of
≤90 to 100 mm Hg, is assigned a score of 0, whereas normal pulse character
(systolic blood pressure >90 to 100 mm Hg) is assigned a score of 1.
Similarly, an abnormal GCS-M (<6) is assigned a score of 0, whereas the
ability to follow simple commands (GCS-M of 6) receives a score of 1.
A casualty can therefore receive an aggregate field triage score of 2, 1,
or 0. A retrospective review of 4988 casualties in Iraq and Afghanistan
from 2002 to 2008 demonstrated that those with a field triage score of
2 had a mortality of only 0.1% (5 of 4366), whereas those with a field
triage score of 1 and 0 had a mortality of 10.8% (33 of 540) and 41.4%
(34 of 82), respectively.78
Triage categories are not the same as evacuation categories. Triage
identifies the severity of a casualty’s injuries and determines a treat-
ment priority based on the likelihood of survival, whereas evacuation is
based on the urgency of transport to definitive care and the likelihood
of deterioration over time. Triage is an ongoing, dynamic process, and
triage categories may change if an intervention stabilizes a casualty or
if a casualty deteriorates clinically. For example, a delayed casualty with
second-degree burns over 30% of his body may change to the immediate
triage level if unrecognized inhalational injury leads to airway swelling
and compromise.
 CPR
Battlefield resuscitation of victims of blast or penetrating trauma who
have no pulse, respiratory effort, or other signs of life will not be suc-
cessful and should not be attempted because CPR on combat casualties
has failed to show any benefit.79,80 Therefore, CPR on the battlefield
is not currently recommended. Even in the civilian setting, very few
trauma arrest patients survive when prehospital CPR is performed.81,82
In a tactical situation, CPR should be considered only as a last effort if
the situation permits and appropriate resources are available and in the
case of nontraumatic disorders such as hypothermia, near-drowning,
and electrocution. Casualties with torso trauma or polytrauma, who are
pulseless and apneic, should receive bilateral needle decompression of
the chest to ensure they do not have a tension pneumothorax prior to
discontinuation of care.
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 2014   SECTION 26: Special Situations

Walk
assess 3rd

Step 1: Sort: Wave/purposeful movement

global sorting assess 2nd

Still/obvious life threat

assess 1st

Step 2: Assess:
individual assessment

Lifesaving
interventions:

• Control major hemorrhage No

• Open airway (if child Breathing? Dead
consider 2 rescue breaths)
• Chest decompression
Yes

• Obeys commands or makes All

purposeful movements? Yes Minor Yes
• Has peripheral pulse? injuries Minimal
• Not in respiratory distress? only?
• Major hemorrhage is controlled?
No
Any No
Delayed
Reassess:
considering Yes
patient conditions, Likely to survive
given current Immediate
resources, resources?
scene safety
No

Expectant

Step 3:
Treatment and/or Transport

FIGURE 302-3. SALT (sort, assess, lifesaving interventions, treatment/transport) triage algorithm.

REFERENCES capacity have a right to accept or refuse recommended health care, and
physicians have a concomitant duty to respect their choices. This right is
The complete reference list is available online at www.TintinalliEM.com. grounded in the moral principle of respect for patient autonomy and is
expressed in the legal doctrine of informed consent.”3

 ELEMENTS OF INFORMED CONSENT

CHAPTER Legal Issues in Emergency
Medicine
303 Jonathan E. Siff
Bryan E. Baskin
INFORMED CONSENT
Informed consent is a requirement for providers to educate patients with
the capacity enough to make medical decisions (or their surrogates)
about proposed treatments and alternatives, to gain agreement or refusal,
and to document that decision.1,2 Informed consent fosters the twin con-
cepts of patient well-being and autonomy. The American College of
Emergency Physicians Code of Ethics3 recognizes the obligations, stating:
Emergency physicians “serve the best interest of their patients by treating
or preventing disease or injury and by informing patients about their
condition.” It also states that: “Adult patients with decision-making
Most patients arriving at an ED agree to and sign a general consent for
treatment. This consent covers history taking, standard examinations,
and basic procedures such as venipuncture and blood analysis. General
consent forms do not provide consent for more detailed, risky, or inva-
sive testing or treatments.
Informed consent requires two elements: The patient must possess
decision-making capacity, and the patient can make a voluntary choice
free of undue influence. Informed consent begins with the delivery of
information to the patient by the provider, using an understandable for-
mat. The patient must then reach a decision and authorize the procedure
or treatment. Each part of the process is separate, albeit linked.
Patient Capacity Decision-making capacity (hereafter called “capac-
ity”) is the ability of the patient to make informed medical decisions;
it is the provider’s task to determine patient capacity.4 The definition of
capacity varies among jurisdictions, but in general describes an indi-
vidual’s ability to make a decision based on his or her values and com-
prehension of the likely consequences of that decision.5-7 The American
College of Physicians Ethics Manual describes decision-making capacity
as “the ability to receive and express information and to make a choice

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TABLE 303-1  Factors for Emergency Providers to Consider When Determining
Capacity
• Presence of conditions impairing mental function
• Presence of basic mental functioning (awareness, orientation, memory, attention)
• The patient understands specific treatment-related information
• Appreciation of the significance of the information for the patient’s situation
• Patient’s ability to reason about treatment alternatives in light of values and goals
• Complexity of the decision-making task
• Risks of the patient’s decision
• Patient’s ability to describe, and consistency in reporting, the basis of their decision
consonant with that information and one’s values.”5 Competence, which
is not the same as capacity, is a legal term indicating a ruling by a court
that a person is able to manage his or her own affairs.8
Capacity requires the ability to receive information; to process and
understand information; to deliberate about a decision; and to make,
articulate, and defend choices. Generally, the physician assesses the
patient abilities by taking a history from an alert patient absent barriers
to communication. If needed, remove any barriers to communication
due to language through translation, ideally by an impartial, in-person,
medically trained translator.
Patients with altered mental status may not possess ability to receive
or process information and thus lack capacity.9,10 However, not all condi-
tions that affect cognition or speech reception/use remove capacity (e.g.,
stroke, psychiatric illness, or dementia should not lead to a presumption
of incapacity). Assess whether the disorder affects the patient’s cognitive
abilities.6 Another potential trap is assuming that disagreement with a
physician’s plan indicates a lack of capacity; if the patient can defend
the decision based on his or her values and beliefs, disagreement does
not mean lack of capacity.10 A patient’s decision-making capacity may
change over time based on changes in medical condition; for example,
those recovering from intoxication, hypoglycemia, or hypoxia regain
capacity.
Capacity also depends on the complexity of the decision and con-
sequences of accepting or declining the intervention. For example, a
patient may have capacity to make a minor decision but not a major
decision at a given point in time.11,12 The more important the decision,
the more important is the assessment.5,12,13 If a patient has capacity to
make a given decision, a provider should respect and follow his or her
wishes.
Factors useful to assess capacity are in Tables 303-11 and 303-2.13
Free Choice Informed consent must be voluntary and free of coercion.
The choice must avoid manipulation or threats by providers, family, or
other outside influences, and be free of emotional or physical coercion.3
Information Necessary for Patient Decision Making The physician
must provide the patient with the appropriate information needed to
make a reasoned informed decision. Generally, the provider perform-
ing the intervention or creating a care path or plan obtains consent. A
delegate such as a resident or nurse practitioner may obtain consent, but
the supervisor is responsible to ensure that consent was informed.14 The
required information for decision making is the diagnosis; the nature
TABLE 303-2 Common Errors in the Assessment of Capacity
• Assuming that if the patient lacks capacity for one type of decision, he or she lacks
capacity for all decisions
• Assuming that legal competence is the same as medical decision-making capacity
• Presuming that capacity is constant over time
• Assuming that a blood alcohol level is related to competence
• Presuming that psychiatric disorders preclude adequate capacity
• Failing to ensure the patient has relevant and consistent information before making a
decision
• Assuming that capacity should only be considered for refusal of treatment
• Failure to recognize that the capacity to make decisions varies with the risks and ben-
efits inherent in the decision
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CHAPTER 303: Legal Issues in Emergency Medicine    2015
and purpose of treatment; risks and consequences of treatment; alterna-
tives and their risks and benefits; and prognosis if treatment is or is not
accepted.14
There are two standards that address disclosure for informed con-
sent.14 One requires providers to give the patient all the information a
reasonable person (not defined) would need to make the same decision
under similar circumstances.15 The alternate is the less-stringent profes-
sional standard for informed consent, which requires disclosure to be
the same as any reasonably prudent, similarly trained physician would
provide in a similar circumstance.14,16 Emergency providers benefit from
giving more, not less, information to the patient.
Discussion and Decision Give the patient the opportunity to ask
questions while considering the decision. If needed, make the patient
aware of ED time constraints that impact a decision, but do not use
time to coerce a decision. Shared decision making may be used when
appropriate to the situation.17 A patient who is unable or unwilling to
express a preference for a particular course of action may be presumed
to lack capacity.18
 DOCUMENTATION OF CONSENT
When obtaining informed consent, the process is important.19 Some
states have specific requirements regarding written consent.14 Where
specific requirements regarding written consent are not present, oral
consent is acceptable, although written documentation signed by the
patient aids the provider if consent challenges arise later.14 At a mini-
mum, the chart or consent form should reflect who obtained consent;
the provider(s) authorized to perform the treatment; that information
on risks, benefits, and alternatives was disclosed; and that the patient
had the opportunity to ask questions.14,15,20,21 Ideally, the chart will con-
tain both a signed consent form and a documented recap of the consent
process.22
 EXCEPTIONS TO INFORMED CONSENT
There are several exceptions to the right to informed consent in specific
healthcare situations. These exceptions include emergencies; therapeu-
tic privilege; public health imperatives, such as the treatment of certain
diseases; patient waiver of consent; and, rarely, emergency research.14,23
Of these, emergencies and public health imperatives are applicable to
clinicians working daily in the ED.
Providers should render needed emergency treatment when con-
sent cannot be obtained or capacity ascertained in a timely fashion
due to the nature of the illness. Implied consent is the basis of this
exception, positing that a reasonable person would give consent to
emergency or lifesaving treatment.14,24 If treatment can be delayed with-
out harm, obtain consent first. Should the initial care aid and conditions
permit consenting, do the latter before further treatment.
Public Health Imperatives Public health imperatives are situations
where the larger good may limit individual patient autonomy. Patients
with high-risk communicable diseases,25 such as severe acute respiratory
syndrome and tuberculosis, or patients with mental illness who pose an
immediate danger to themselves or others are examples where the public
harm outweighs individual autonomy. When patients meet criteria for
health department–mandated treatment and quarantine yet do not give
consent, consult hospital infectious disease staff, legal staff, and local
health officials.
 WHEN INFORMED CONSENT CANNOT BE OBTAINED
If a patient lacks capacity to give informed consent for a condition
where no exception exists, or once an emergently ill patient is stabi-
lized and further nonemergent decisions need to be made, identify a
surrogate decision maker or an existing directive when possible.3,10
Advance directives or healthcare powers of attorney provide guidance
or specify a decision maker (see Chapter 301, “Death Notification and
Advance Directives”). In the absence of a power of attorney, state law
determines the patient’s decision maker. A typical decision-making
progression is as follows (in order): spouse, adult children, parents,
adult siblings, and the nearest relative not previously described.26
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 2016   SECTION 26: Special Situations
Surrogates help providers determine what the patient would want in
a particular situation and should not substitute their values for the
patient’s. In the absence of a directive or surrogate, proceed with your
judgment of the patient’s best interest in mind and involve hospital
counsel to begin a guardianship process if the lack of capacity is likely
to be of significant duration.11
 INFORMED REFUSAL
Patients may refuse part of a treatment plan, refuse any or all care, or
wish to leave before the completion of the planned evaluation. In these
situations, ensure there are no miscommunications or misunderstand-
ings at the root of the refusal.11 Often, when issues are clarified, an
agreement is possible that defuses the situation. Some solutions are
simple, but aid an open, noncontentious discussion by, for example,
giving a blanket, calling the patient’s personal physician, or relieving
pain.11,27 If needed, develop an alternative to the original plan that does
not enhance risk, or at least minimizes any added risk (with that being
clearly shared); do not fall prey to the even greater risk setting of believ-
ing, “If my top plan is refused, I cannot offer any care.” For instance, a
patient may not want a certain procedure but would be willing to accept
admission for further evaluation.11
ED DEPARTURE AGAINST MEDICAL ADVICE AND
ED ELOPEMENT
Approximately 1.1 million patients left hospital EDs against medical
advice in 2014, representing 1% of patients,28 often with poorer out-
comes than the general ED population.29,30 Characteristics of patients
who leave against medical advice include lack of insurance, male sex,
younger age, alcohol or drug dependency, psychiatric illness, and low
income.29,30 Patients often have serious complaints such as chest pain,
abdominal pain, or trauma. Patients give many reasons for their desire
to leave, including outside obligations such as family or pets; the wish
for treatment at another hospital; concerns for cost of treatment; fear
of recommended treatment; a desire for tobacco, drugs, or alcohol;
narcotic requests; or improvement in the condition that prompted the
ED visit.31-33
Start by assessing the patient’s capacity, with special attention to bar-
riers limiting capacity. Alcohol use and psychiatric diagnoses are not
always absolute barriers to discharge against medical advice, except for
suicidal and homicidal patients; if allowing departure against medi-
cal advice with these conditions, document the patient’s behavior and
features of intact capacity. Educate the patient about the risks associated
with refusing to complete evaluation and/or treatment. Discuss the
patient’s reasons for leaving, as these present opportunities for negotia-
tion and convincing the patient to continue care.10 Use plain language
and avoid medical terms, sharing the real medical and other risks of
leaving before completing care. While it is key to invest effort to assess
understanding and to convince the patient to remain, do not use any
threats.34 Statements such as, “Insurance will not pay for this visit if
you leave against medical advice” are inaccurate and may damage the
patient–provider relationship; in addition, they often discourage the
patient from returning, adding to risk.35,36
Documentation of an against-medical-advice disposition ideally con-
tains the following27,37:
•• Clear description of capacity (with examples)
•• Discussion of the risks reviewed including diagnoses considered
•• Notation of the treatments, procedures, and courses of actions that
were refused
•• Statement of alternative treatments or courses of action that were
offered
•• Description of efforts to involve family, friends, or clergy in the
decision
•• Explanation of any potentially problematic entries in the chart such
as nursing notes or abnormal laboratory values—for example, if
the patient has an elevated serum alcohol level, document capacity
evaluation
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•• A signature by the patient on the against-medical-advice form, and if
patient refused to sign, documentation of the refusal
•• Details of the treatment and follow-up recommended and provided
•• Notation that the patient was advised that he or she is welcome to
return at any time
While the most important part of documenting an against-medical-
advice discharge is the discussion with the patient addressing the items
listed earlier, having the patient sign an actual against-medical-advice
form may help provide further liability protection in three ways: “1) it
may terminate the providers legal duty to treat a patient; 2) creation of
the affirmative defense of ‘assumption of risk’; and 3) the creation of a
record of evidence of the patient’s refusal of care.”38
When a patient leaves against medical advice, provide reasonable
treatment appropriate for the medical condition and concordant with
the patient’s wishes.34 For example, provide antibiotics for infection,
aspirin for chest pain, or stabilization for fractures. Instruct the patient
on signs and symptoms to prompt a return visit to the ED should the
patient change his or her mind.10,27
It is also important to document situations when a patient leaves after
treatment has begun but without informing ED staff, commonly called
elopement. Attempt to locate the patient within the facility and then
check logical destinations. Often a phone call to the patient’s home, cell
phone, or emergency contact can provide an opportunity to encourage
the patient to return to the ED. Document communication attempts and
their outcome.
ISSUES IN THE ED CARE OF MINORS
A minor is generally considered to be anyone less than 18 years of age,
and parental consent is usually required for the nonemergency treat-
ment of minors. In some circumstances, older children may be able to
make many medical decisions independent of their parents.39 Exceptions
to parental consent for minors include emergencies, the treatment of
certain diseases and conditions that are in the best interest of the minor
or society, minors emancipated under law, and circumstances in which
the best interests of the child are not being addressed by parents. State
laws regarding minor care vary widely; providers caring for minors
should review local regulations and call on legal counsel as needed.
 TREATMENT OF MINORS IN EMERGENCIES
Minors often present to the ED without a parent or legal guardian, alone
or in the care of an alternate caretaker such as a grandparent, school
teacher, babysitter, camp counselor, or social worker. In the United
States, under the Emergency Medical Treatment and Active Labor Act
(EMTALA), EDs must evaluate all patients presenting with a medical
condition and stabilize any emergency condition absent any require-
ment for consent.40,41 Providers have latitude in defining an emergency
medical condition, especially if there is a delay in obtaining consent. Try
to find parents or legal guardians and document efforts while emergency
care is being provided. Once stabilizing any emergency condition, the
need for appropriate parental informed consent applies.
When an adult family member, such as a grandparent or adult sibling,
brings the minor to the ED and grants consent, give care but continue
efforts to contact the parent or guardian. In the case of preplanned
parental absence, not all U.S. states require a signed note from the par-
ent authorizing treatment. In some U.S. states, laws authorize relatives
to consent to medical treatment for minors under their care. However,
if the treatment proposed carries a substantial risk and is not emergent,
contact the parents or guardian before proceeding. Providers may obtain
parental consent by telephone and should document the details in the
record (who gave consent, when, and for what).
 EMANCIPATED MINORS
Minors who have become independent from the care and control of
their parent or guardian are considered emancipated and may pro-
vide consent as adults. The definition of emancipation varies, and some
states do not have specific emancipation statutes.42 Common situations
in which minors may be considered emancipated include minors who
8/1/19 1:34 PM

are married, enlisted in the U.S. armed services, pregnant or parents
themselves, declared emancipated by a court, or self-supporting and not
living at home.
Mature Minor Exception If a minor is sufficiently mature to under-
stand the nature and consequences of a proposed medical treatment, the
minor should be able to consent to or refuse treatment without parental
involvement. The mature minor exception is accepted under common
law and in some states under specific legislation. Requirements for the
mature minor exception are as follows: the child should generally be at
least 14 or 15 years old; the treatment should be beneficial, not elective,
and of low risk; and the minor must meet the requirements of informed
consent. Given the subjectiveness of this standard, consider each indi-
vidual case before treating a minor under the mature minor doctrine.43 If
a minor is capable of providing informed consent for a given issue, then
he or she is equally capable of refusing that same treatment.
Sexually Transmitted Diseases Exception All states allow minors to
access testing and treatment for sexually transmitted diseases without
parental consent. In most states, the minor must be at least 12 years old,
but some areas have a higher age requirement.44,45 In some states, test-
ing and/or treatment for human immunodeficiency virus may not be
included in the exception.
Prenatal and Pregnancy Care Exemption Many states allow minors
to consent to prenatal care and pregnancy-related care. In states lacking
such statutes, minors are often provided prenatal care under the mature
minor doctrine, particularly if the state allows minors to consent to
other reproductive services.44,45 Thirty states have laws allowing a minor
to consent to treatment for their own child.46
Alcohol or Substance Abuse and Mental Health Treatment
Exemption Nearly all states allow minors to access treatment for alco-
hol or substance abuse. Most states have specific laws regarding access
of mental health services, and of those that do, the range of services that
can be accessed without parental involvement varies.47
Sexual or Physical Abuse Treatment Exemption The evaluation
and treatment of sexual or physical abuse without parental consent is
generally permitted. In many instances, these patients may be treated
under the emergency exemption, because minors who have suffered
physical or sexual abuse require prompt treatment. However, if the
parents are not the alleged perpetrators, seek parental involvement
early.
 PRACTICAL IMPLICATIONS OF TREATING MINORS UNDER
STATUTORY EXCEPTIONS OR AS MATURE MINORS
The minor consenting to the treatment is generally responsible for the
cost of treatment. Once a minor is treated under one of these statutes,
the minor should be afforded the same confidentiality as an adult.
In some states, certain exceptions exist if the provider feels that it is
in the minor’s best interest to have the parent notified. The Health
Information Portability and Accountability Act of 1996 (HIPAA)
Privacy Rule generally defers to state law or other applicable laws that
expressly address a parent’s ability to obtain health information about
a minor including when a parent agrees to a confidential relationship
between the physician and the minor.48 The hospital bill may pose a
potential risk for breach of confidentiality if sent to a parent or par-
ent insurer.
Assent and Refusal by the Older Minor Providers should seek the
assent and cooperation of older or “mature” minors even when parents
are granting permission for treatment. If the proposed treatment is non-
emergent and the older minor refuses to give assent, respect the minor’s
decision initially and seek legal input to assess the best option.
 WHEN THE MINOR’S INTERESTS ARE NOT BEING PROTECTED
In almost all cases, parents make decisions they believe to be in their
child’s best interests. However, situations arise when the physician
wishes to override or delay the decision making of the parent. For
example, if the parent is intoxicated or lacks capacity to give informed
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CHAPTER 303: Legal Issues in Emergency Medicine    2017
consent or refuse care for a minor child, do not accept that consent or
refusal. If parents disagree with a treatment plan based on religious or
moral reasons, the court or child protective agencies may intervene if the
disputed intervention is lifesaving. The American Academy of Pediatrics
recommends giving care to children who need medical care to prevent
substantial harm or suffering, seeking legal aid to help adjudicate, espe-
cially if religious opposition exists.49
PRIVACY, CONFIDENTIALITY, AND REPORTING
The ideas of privacy and confidentiality are important elements of eth-
ics, religion, and law because they affirm the dignity and value of the
individual.50 The Hippocratic Oath reads, “All that may come to my
knowledge in the exercise of my profession. . . . I will keep secret and will
never reveal.” The American College of Emergency Physicians Code of
Ethics states that emergency physicians should “Respect patient privacy
and disclose confidential information only with consent of the patient or
when required by an overriding duty such as the duty to protect others
or to obey the law.”51 All states and the federal government have laws that
govern privacy and confidentiality, including mandatory or voluntary
reporting requirements that may override considerations of individual
patient privacy and confidentiality.
 BARRIERS TO PRIVACY AND CONFIDENTIALITY IN THE ED
ED barriers to privacy and confidentiality include physical design;
operational issues; the presence of visitors, students, and other individu-
als; and video technology.
Design and operational issues that impact privacy and confidentiality
include the triage area, frequent movement of patients between beds, open
ED areas for documentation and work, and patient placement for close
observation to minimize risk from falls or self-harm.50,52 In addition, ED
crowding and boarding lead to the use of nontraditional bed spaces such
as hallways, which reduce the ability of staff to provide optimum privacy to
patients.53 ED staff should be vigilant when conducting interviews, teach-
ing, or communicating to maximize patient privacy and confidentiality.
Students of various disciplines, law enforcement, and visitors should
respect patient privacy and confidentiality.54,55 Requests from patients to
exclude healthcare students from observation or care are usually honored,
with some exceptions.50,54 Obtain verbal consent from patients for the
presence of students who do not participate in care, and accept refusals.
Ask patients for permission to discuss personal information in front
of any visitor, including family. Visitors should generally be allowed (as
space permits) with consent from the patient.50 Disclosure of certain
diseases, such as human immunodeficiency virus infection, to a third
party requires a written consent.56 Providers should always consider
the nature and gravity of the information being related to a patient and
try to give serious or very personal results in private, even if previously
given permission to discuss in front of a visitor.
Patients brought to the ED in the custody of law enforcement officials
pose unique challenges. The biggest issue is balancing the safety of staff
and patient(s) with the privacy and confidentiality rights of the indi-
vidual. The American College of Emergency Physicians recommends
providing unbiased, attentive, and complete care to these patients and
communicating instructions appropriate to the medical condition to
correctional or law enforcement staff while maximizing patient privacy.57
Law enforcement officials may engage in the collection of evidence and
interviewing in the ED. Except where required by law, allow patients the
option of whether or not to speak with law enforcement; patient infor-
mation releases that are not expressly required by law require consent.55
Photography and video for evidence collection, quality assurance,
and documentation are generally acceptable and governed by clear
policy, but patients should give consent except where not required
under the law.58 Photography and filming for educational and publi-
cation purposes always require patient consent. Images recorded for
nonmedical or educational purposes without consent (especially with
cell phones) are generally prohibited.59,60 Obtain any necessary permis-
sions from hospital administration and learn and follow all applicable
policies and state laws surrounding filming and photography of patients
in all circumstances. Cell phones, tablets, and laptop computers with
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 2018   SECTION 26: Special Situations
identifiable patient information must be physically secured and with
viewing/use protection, and images should never be sent via unen-
crypted email.
 THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
AND PROTECTED HEALTH INFORMATION
Definitions HIPAA protects the healthcare privacy and confidential-
ity of individuals. This legislation required standards for the security,
exchange, and integrity of electronic health information, and set rules
for basic national privacy standards and fair information practices for
health care.
The U.S. Department of Health and Human Services produced the
“Standards for Privacy of Individually Identifiable Health Informa-
tion,” also called the Privacy Rule, in 2000. The rule has been amended
several times with a major revision in January of 2013, referred to
as the Omnibus Final Rule.61 Covered entities include “health plans,
health care clearinghouses, and health care providers (broadly defined
to include anyone who furnishes, bills, or is paid for health care in the
normal course of business) and business associates of these entities, who
transmit health information in electronic form when dealing with an
individual’s health information.”62 Only those parts of the privacy rule
most applicable to emergency providers will be covered here.
Under HIPAA, key health information (often referred to as protected
health information [PHI]) is “any information, including genetic infor-
mation, whether oral or recorded in any form or medium that (1) is
created or received by a health care provider, health plan, public health
authority, employer, life insurer, school or university, or health care
clearinghouse; and (2) relates to the past, present, or future physical or
mental health or condition of an individual; the provision of health care
to an individual; or the past, present, or future payment for the provision
of health care to an individual.”62 HIPAA applies when PHI is transmit-
ted or maintained by a covered entity. The rule also discusses individu-
ally identifiable health information, including demographic data such as
name, Social Security number, date of birth, and other identifiers that
“identify the individual or for which there is a reasonable basis to believe
can be used to identify the individual.”62
Disclosure of Protected Health Information PHI should be shared
with the clear understanding that only the minimum amount of infor-
mation required to accomplish the purpose of the disclosure will be
released. These “minimum” necessary standards do not apply to infor-
mation that is given to patients directly, used for treatment, or required
by law.63 Covered entities should have procedures, including limitations
on access to electronic medical records, to ensure that users know and
obtain only that information necessary to their job or business purpose.
HIPAA allows covered entities to use PHI without authorization for
purposes of treatment, payment, and operations. Treatment is the provi-
sion, management, and coordination of health care and related services,
including consultations and referrals.64 The payment exclusion allows
a healthcare provider to use PHI to obtain payment or be reimbursed
for the care provided to an individual.64 Operations include a number
of activities, including quality improvement, employee evaluation and
credentialing, auditing programs, and business activity such as planning,
development, management, and administration.64 An exception to this
rule is that psychotherapy notes often require written consent for their
use outside treatment, certain legal matters, and the protection of the
public from a serious threat.65
HIPAA allows providers to disclose information without consent
in emergency or dangerous situations if in the patient’s best interests,
although this is often limited by more restrictive state law.66-68 There are
12 national priorities, as shown in Table 303-3,69,70 in addition to treat-
ment, payment, and operations usage, for which covered entities can
disclose PHI without authorization. These allowable disclosures have
specific conditions or limitations to balance the privacy of the individual
and the public interest for the information.69
Under the privacy rule, the risk of every possible incidental use or
disclosure of PHI does not have to be eliminated69; the covered entity
should have reasonable safeguards (as defined in the rule) and applied
the minimum necessary standards. If achieving these conditions, any
accidental event is likely to not be judged a violation of the rule.71
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TABLE 303-3  The 12 National Priorities for Which Protected Health Information
May Be Disclosed or Used Without Written Authorization
• As required by law (statute, regulation, or court order)
• For public health reporting (e.g., vital statistics, disease, adverse event reporting)
• For reporting abuse, neglect, or domestic violence
• For health oversight activities (e.g., inspections, audits)
• For judicial and administrative proceedings
• For law enforcement purposes (e.g., criminal investigations) under certain
circumstances
• For disclosures about deceased persons to medical examiners, coroners, and funeral
directors
• For organ, eye, and tissue donation purposes
• For some types of research (e.g., in cases where an institutional review board has
waived the authorization requirement)
• To avert a serious threat to the health or safety of the public
• For specialized government functions, such as military missions or correctional
activities
• For workers’ compensation claims
Patient Rights to Protected Health Information The HIPAA regula-
tions also require that a notice of privacy practices be given to all patients,
informing them of their rights regarding their health information.72
Patients are asked to sign these documents and receive a copy of the notice.
These rights to PHI include access to records in the patient’s preferred
format, request for amendments, request for additional restrictions,
notice of PHI use, and an accounting of disclosures made from their
PHI.73-76 In general, most of these functions are handled by support or
records staff, but requests to amend records must be addressed by the
provider promptly (60 days). If the provider denies a request to amend a
record, the patient has the right to place a written statement in the medi-
cal record disagreeing with the denial.73
Law Enforcement Rights to Protected Health Informa-
tion HIPAA allows the limited release of PHI for certain law enforce-
ment purposes. Release is permitted to respond to a judicially issued
warrant, subpoena, court order, or grand jury subpoena. Release is
allowed to assist law enforcement in identifying or locating a suspect,
fugitive, material witness, or missing person by releasing only the
following information: “name and address, date and place of birth,
Social Security number, ABO blood type and Rh factor, type of injury,
date and time of treatment, date and time of death, if applicable, and
a description of distinguishing physical characteristics, including
height, weight, gender, race, hair and eye color, presence or absence of
facial hair (beard or moustache), scars, and tattoos.”77 Providers may
notify authorities of a person’s death if a possible criminal activity was
the cause of the death. With patient consent, PHI may be released in
response to law enforcement requests for information about a victim
or suspected victim of crime. When a patient is a victim of a crime
and unable to consent, the provider may release information to law
enforcement if they believe the release is in the patient’s best interests
and that the information is not intended to be used against the patient
by law enforcement.62
Impact of Protected Health Information on Emergency Physicians
HIPAA allows for open discussions with primary providers, consul-
tants, and other persons involved in the care of an individual. Primary
providers can discuss or share information and records for a patient
with other providers engaged in care without first obtaining the
patient’s consent. Providers are cautioned about releasing additional
information over the phone unless they can reasonably confirm the
identity of the caller and have the patient’s permission to release addi-
tional health information.
Do not access records for which you are not the treating provider,
unless such information is needed for operations, for law enforcement,
or for another legitimate reason. Document the reason for access to any
chart where you are not the treating provider. Failure to comply with
these regulations can lead to significant monetary and even criminal
penalties for providers. See Table 303-4 for HIPAA do’s and don’ts.
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TABLE 303-4  Health Insurance Portability and Accountability Act (HIPAA) Do’s
and Don’ts
HIPAA Do’s
• Talk openly with patient’s primary physician.
• Discuss protected health information with consultants and other members of the
patient’s healthcare team.
• Use protected health information for reimbursement and operational issues.
• Release records to the patient or an authorized representative.*
• Discuss patient protected health information with family or friends if the patient is in
an emergency situation, unable to consent, and the information would be beneficial to
the patient.
HIPPA Don’ts
• Discuss patients or protected health information in public or unsecured areas.
• Leave computers with access to protected health information logged on and
unattended.
• Discuss protected health information in front of others without permission.
• Speak loudly when discussing protected health information, particularly in
public areas.
• Look at records for which you have no legitimate purpose as a provider.
*
May require the patient to sign an authorization form.
© Jonathan E. Siff.
Need to Report Protected Health Information Privacy and con-
fidentiality are not absolute rights. Ethicists, courts, and legislators
recognize the rights of the individual are overridden by the needs of the
public in select settings. In many cases, this takes the form of permitted
or mandatory reporting of certain diseases, pathogens, forms of abuse,
and other medical conditions or situations.
Abuse All states require the reporting of suspected child abuse or neglect
and generally give providers legal protection if reports are made in good
faith.52 Most states have similar reporting requirements for elder abuse.
Some of these laws only pertain to those elderly patients who are incapaci-
tated or in care facilities, whereas other states include all persons above
a certain age.78 Mandatory reporting laws for domestic partner violence
exist in some states.79-82 Regardless of the reporting mandate, it is best for
the provider to discuss potential abuse cases with the affected patient.80,82
Injury by Deadly Weapon or due to a Criminal Act Most states man-
date the reporting of injuries from deadly weapons, including stab and
gunshot wounds.80,81 Several states also require reporting of injuries that
occur as a result of a criminal act, but do not require reporting of so-
called “victimless” crimes such as drug abuse.52
Driving Impairment Many patients have medical conditions that may
impair their ability to safely operate motor vehicles; a wide variety of
conditions may meet this concern, such as seizure disorders, dementia,
vision impairment, Parkinson’s disease, and other degenerative condi-
tions, and certain medications may also impair abilities to safely oper-
ate a vehicle.83 A majority of states provide physicians with immunity
when reporting impaired drivers, and many require specific conditions
be reported (commonly epilepsy, but others may exist). In other states,
immunity is not provided, and providers could be found liable for dam-
ages resulting from reporting or nonreporting.80 The American Acad-
emy of Neurology supports optional reporting of medically impaired or
potentially impaired drivers.83 Despite the requirements, many physician
do not report these conditions; one study found very low reporting rates
in compliance with a state law requiring physicians to report all patients
with lapses of consciousness.84 In addition, some states require that pro-
viders report drivers who are in accidents while intoxicated.80
Infectious Disease Reporting The U.S. federal government requires
the reporting of contagious diseases for surveillance purposes.50 The
annual lists of diseases and conditions under national surveillance are
on the Centers for Disease Control and Prevention website.85 Other
pathogens, such as methicillin-resistant Staphylococcus aureus, may
be reportable to other databases or to state health departments. The
diseases under surveillance change over time, so frequent reeducation
is important.
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CHAPTER 303: Legal Issues in Emergency Medicine    2019
Reporting of Medical Errors Several states and organizations have
mandatory and voluntary reporting systems in an attempt to improve
healthcare processes and reduce patient morbidity and mortality due to
hospital errors and adverse events.86 Providers should comply with these
systems to improve overall care.
Reporting of Breaches and Penalties Under HIPAA Under HIPAA,
any disclosure, access, or use of PHI in a manner not permitted under
the law is a breach.87 If a breach is found, required notification includes
to the party whose information was compromised, the secretary of the
Department of Health and Human Services, and (in the case of large
breaches) the public at large.88-90 Penalties for violation of HIPAA range
from $100 per violation if the covered entity was unaware of the violation
and should not reasonably have been aware, to $1.5 million per violation
if the breach was due to willful neglect and not adequately addressed in
the required time frame.88 Federal law also provides for criminal penal-
ties of up to 10 years in jail and $250,000 in fines for HIPAA violations.91
Providers should promptly discuss any breach potential with their hos-
pital privacy officer or any potential HIPAA violation with hospital legal
counsel to optimally manage the event and follow-up.
EMERGENCY MEDICAL TREATMENT AND
ACTIVE LABOR ACT
Enacted initially in 1985, EMTALA imposes obligations on hospitals
operating EDs. These include the provision of a medical screening exam
performed by qualified medical personnel to look for an emergency medi-
cal condition (EMC) for all patients who come to the ED seeking care for
a medical condition. If an EMC is found, the patient must be stabilized
within the capability of the hospital or transferred if necessary to com-
plete stabilization.
“Comes to the ED” Under EMTALA a “dedicated emergency depart-
ment” is “any department or facility of the hospital, regardless of
whether it is located on or off the main hospital campus that” (1) is
licensed by the state as an emergency room or ED; (2) is held out to the
public as providing unscheduled care for EMCs on an urgent basis; or
(3) provides one-third of its outpatient visits for the treatment of EMCs
on an urgent, unscheduled basis.92 Hospital-owned urgent care centers
may meet this definition.
Hospitals must provide a screening examination to any patient who
comes to the “dedicated ED” (hereafter “ED”) and requests, or has a
request made by another, for evaluation or treatment of a medical condi-
tion. If a prudent layperson observer would believe the person needed
evaluation or treatment for a medical condition, the obligation under
EMTALA starts.92 Note that the language says for a “medical condition,”
not an “emergency medical condition.” Other hospital locations, such as
labor and delivery, psychiatric intake areas, and urgent care areas, which
meet the above definition, are subject to EMTALA obligations.93 An
infant born alive is an individual under the law and EMTALA obliga-
tions apply, including when the infant was born in the ED.40
Emergency Medical Condition An EMC is a “medical condition
manifesting itself by acute symptoms of sufficient severity (including
severe pain, psychiatric disturbances and/or symptoms of substance
abuse) such that the absence of immediate medical attention could rea-
sonably be expected to result in: 1) Placing the health of the individual
(or, with respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy; 2) Serious impairment to bodily
functions; or 3) Serious dysfunction of any bodily organ or part; or with
respect to a pregnant woman who is having contractions: 1) That there is
inadequate time to effect a safe transfer to another hospital before deliv-
ery; or 2) That transfer may pose a threat to the health or safety of the
woman or the unborn child.”92 For pregnant women with contractions,
an EMC exists if there is insufficient time to transfer the patient before
delivery or the transfer may pose a risk to mother or child.92
If it is determined that no EMCs exists, then EMTALA no longer
applies to that patient. It is good practice to note the time of that decision.
The courts have generally ruled that the physician must be aware an EMC
exists before he or she is liable under EMTALA.93 The EMTALA obliga-
tion does not suggest that any particular symptom, including severe pain,
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 2020   SECTION 26: Special Situations
is in and of itself an EMC, only that the presence of such symptoms man-
dates a screening to determine if the patient has an EMC.94
Medical Screening Examination A medical screening examination
is the process required to reach, with reasonable clinical confidence and
based on the patient’s presenting signs and symptoms, the point at which
it can be determined whether an EMC does or does not exist.40 This may
involve a brief history and physical examination or a more complex pro-
cess involving ancillary studies, consultants, and procedures.40
The initial screening must be the same for every patient presenting
with similar symptoms or complaints to be EMTALA compliant.93
This is true even in cases of misdiagnosis. Case law notes that misdi-
agnosis and the adequacy of screening are issues of negligence and are
better addressed under state malpractice statutes. Nurse triage alone
does not meet the hospital obligation to provide a medical screening
examination.93
EMTALA dictates that a hospital may not delay the screening
examination and stabilizing treatment to assess method of payment or
insurance status.95 Hospitals may follow reasonable registration proce-
dures, including inquiring about insurance, provided that it does not
delay the medical screening examination or discourage patients from
remaining for evaluation.95,96 Ideally, defer requests for any payments or
authorizations until after the screening examination and any indicated
stabilization to avoid triggering this concern.93 Providers may contact
another caring physician for information regarding the patient’s his-
tory, treatment, and evaluation (but not to obtain prior authorization).97
Policies by payors that attempt to restrict the number of ED visits or
consults a patient may have, that deny payment based on ED visit diag-
nosis codes, or that attempt to require insurer input into admission or
transfer decisions do not change the EMTALA obligations of hospitals
or physicians.96
Qualified Medical Personnel The statute states that, “The examina-
tion must be conducted by an individual(s) who is determined qualified
by hospital bylaws or rules and regulations.”98 These individuals must
be recognized by the hospital governing body as qualified to perform
this type of examination.98 Although the regulations do not specify
what type of provider (e.g., registered nurse, medical doctor, physi-
cian’s assistant) should perform the medical screening examination,
the qualifications of the provider may be retrospectively reviewed and
found inadequate.93
Stabilized To have a duty to stabilize, the treating providers must be
aware of the presence of an EMC. Under EMTALA, stabilize means to
provide “treatment as necessary to assure, within reasonable medical
probability, that no material deterioration of the condition is likely to
result from or occur during the transfer of an individual from a facility
or that . . . the woman has delivered the child and placenta.”92 Stabi-
lization does not require that the underlying medical condition be
resolved. For example, a patient with difficulty breathing and a history
of asthma may be stable once provided with medication and oxygen,
even though the underlying condition of asthma is still present.99
The decision regarding whether or not the patient is stable rests with
the qualified medical provider treating the patient.100,101 This decision is
subjective, not defined otherwise, and in an investigation, the burden of
proof for stability rests with the transferring hospital.
After stabilization, EMTALA no longer applies, and patients may be
discharged or admitted for further care. Once a patient is admitted, the
hospital EMTALA duty is met.102
Transfers in accordance with local protocols, including for trauma,
acute myocardial infarction, or stroke, generally meet the stabilization
requirement if the transferring hospital stabilizes within its means first.40
If a hospital is unable to stabilize the patient, then transfer to a higher
level of care is appropriate, with efforts made to stabilize before transfer
documented in the patient chart.40
The U.S. Supreme Court has ruled that the hospital or physician does
not need to have an improper motive for a transfer to be successfully
sued for failure to stabilize under EMTALA.103
Stable for Discharge According to EMTALA, “An individual is consid-
ered stable and ready for discharge when, within reasonable clinical con-
fidence, it is determined that the individual has reached the point where
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his/her continued care, including diagnostic work-up and/or treatment,
could be reasonably performed as an outpatient or later as an inpatient,
provided the individual is given a plan for appropriate follow-up care as
part of the discharge instructions. The EMC that caused the individual to
present to the dedicated ED must be resolved, but the underlying medi-
cal condition may persist. Hospitals are expected within reason to assist/
provide discharged individuals the necessary information to secure the
necessary follow-up care to prevent relapse or worsening of the medical
condition upon release from the hospital.”99
The availability of follow-up and content of discharge instructions
may be reviewed and could a trigger an investigation. One area where
this is problematic is follow-up for uninsured patients if the emergency
physician knew or should know that follow-up was or is unlikely to
occur (e.g., if a patient is referred for needed follow-up care, such as
fracture reduction, and is subsequently refused care). If there is any
question about the patient’s ability to obtain the needed intervention, ask
the specialist to see the patient in the ED.100 All discharge instructions
should educate patients to return to the ED if they have any problem
accessing follow-up care as recommended.
Psychiatric Patients EMTALA states, “Psychiatric patients are con-
sidered stable when they are protected and prevented from injuring
or harming him/herself or others. The administration of chemical or
physical restraints for purposes of transferring an individual from one
facility to another may stabilize a psychiatric patient for a period of time
and remove the immediate EMC, but the underlying medical condition
may persist, and if not treated for longevity the patient may experience
exacerbation of the EMC. Practitioners should use great care when
determining if the medical condition is in fact stable after administering
chemical or physical restraints.”99 In 2017, a single hospital settled the
largest-ever EMTALA case for nearly $1.3 million over violations stem-
ming from the practice of boarding psychiatric patients in the ED, often
for many days. The settlement noted the failure of the hospital to have
the patients evaluated by a psychiatrist and the failure of the organiza-
tion to admit these patients to open beds in their own psychiatric unit
rather than waiting for open beds at the state facility.104-107 Psychiatric
patients remain one of the greatest challenges under EMTALA due to
the difficulty of determining stability and the lack of available psychiat-
ric resources in most communities, and all organizations should review
their policies and practices considering this settlement.
Transfers Under EMTALA, transfer is “the movement (including
discharge) of an individual outside a hospital’s facilities at the direc-
tion of any person” representing the hospital, regardless of that person’s
employment status with the hospital.92
Hospitals can transfer patients if they do not possess either the
capability or capacity to care for the patient. Capability includes the
availability of technology, specialists with the needed skills to care for a
patient, and equipment or supplies required by the patient’s condition.
Capacity looks at numbers and availability of qualified staff, beds, and
equipment and what the hospital “customarily does to accommodate
patients in excess of its occupancy limits.”92 If a hospital routinely opens
extra beds to accommodate patients, they must do so if necessary to
avoid the transfer of a patient for whom they could otherwise provide
care.
Hospitals may not transfer a patient who has not been stabilized
unless an appropriate transfer is performed and either (1) the patient
requests the transfer and the request is documented in writing, includ-
ing the patient’s awareness of the risks and benefits of the transfer; or (2)
a physician documents that the medical benefits of transfer to a hospital
with greater resources reasonably outweigh the increased risk to the
patient, pregnant woman, or unborn child.108 An “appropriate transfer”
is defined in the EMTALA regulations. The following four elements are
required for an appropriate transfer.108
1. The transferring hospital stabilized the patient (or the unborn child)
to the best of its ability, minimizing the risks of the transfer to the
patient or, in the case of a woman in labor, her unborn child.
2. The receiving (accepting) hospital has the capability and capacity to
care for the patient and agrees to accept the individual and provide
appropriate medical treatment.
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3. The transferring facility sends all pertinent medical records, includ-
ing test and study results, treatment provided, and the written con-
sent for the transfer. Information not available at the time of transfer
must be sent as soon as possible. If the transfer is necessary due to the
failure of an on-call physician to appear, that physician’s name and
address must be provided to the accepting hospital.
4. The transfer must be performed through qualified personnel and
transportation as determined by the transferring physician. The
accepting facility may not condition its acceptance on the use of a
specific transport service or method.101,109
If a hospital attempts to transfer a patient to meet its EMTALA obli-
gation and the patient, or person acting on the patient’s behalf, refuses
the transfer, the first hospital’s EMTALA obligation is met. The hospital
should attempt to obtain written informed refusal with a discussion
of the risks and benefits of the refusal of transfer and describe both
the facts of the transfer that was proposed and the stated reasons for
refusal.110 A patient “stable for transfer” does not mean that the patient is
stable under EMTALA, and therefore, any EMTALA obligation does not
automatically end with the decision to transfer a patient.96 Hospitals may
not penalize a provider who refuses to authorize the transfer of a patient
with an unstabilized EMC or take negative action against any employee
who reports a violation of EMTALA.108
Duties of Receiving Hospitals A U.S. hospital with specialized capa-
bilities or facilities such as (but not limited to) burn units, trauma units,
designated disease treatment centers, or regional referral centers may
not refuse to accept a transfer from a referring hospital when the patient
in question requires the specialized capabilities and the receiving hospi-
tal has the capacity to treat the patient.111,112 The failure of centers with
specialized capabilities to appropriately accept patients requiring their
services is sometimes called “reverse dumping” and applies even if the
receiving hospital does not have its own dedicated ED.111
Due to the risk of a citation, some authors suggest that all transfers
be accepted by hospitals with specialized capabilities without inquiry
into the patient’s insurance status.100 Should the accepting hospital
find that the transfer was not appropriate or improperly motivated, it is
its duty to report the transferring hospital for a potential violation of
EMTALA.100,113 Delays in accepting a patient in transfer who has an
unstabilized EMC to receive or confirm financial information may be
an EMTALA violation by the receiving hospital.114 Failure to report an
EMTALA violation is a violation.
On-Call Responsibilities Hospitals must maintain an on-call list of
physicians “who are on the hospital’s medical staff or who have privi-
leges at the hospital, or who are on the staff or have privileges at another
hospital participating in a formal community call plan in accordance
with the resources available to the hospital.”115 The call list must specifi-
cally name an individual physician with accurate contact information,
not solely the name of a group or specialty.116 The stipulation that the
hospital provide these services “in accordance with the resources avail-
able to the hospital” leaves considerable leeway for hospitals to decide
what services to offer. Physicians who are formally on call must assist
when requested to determine if an EMC exists, to help stabilize patients,
and to accept appropriate transfers. They must do this in a reasonable
amount of time (not specified by EMTALA, but best set by each site).40
Although regulations allow for physicians to be on call at multiple hos-
pitals and to perform elective surgery while on call, a clear plan must exist
to provide adequate care in these situations.117 The emergency physician
determines if the on-call provider needs to appear in person to the ED to
see a patient. In general, EMTALA does not allow patients to be sent to
private physician offices for examination or stabilization, except where the
office is part of the hospital-owned facility and on the hospital campus.
Hospitals that allow physicians to selectively take call only for their
own established patients who present to the ED must ensure the avail-
ability of adequate on-call services to all ED patients requiring similar
care.116 If the on-call doctor will not come after substantial, well-doc-
umented efforts, including engaging hospital administration and legal
service when available, from the emergency provider, a site may transfer
the patient to receive necessary care. The emergency provider must
inform the accepting hospital that that is why the patient is being sent
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CHAPTER 303: Legal Issues in Emergency Medicine    2021
TABLE 303-5 EMTALA Do’s and Don’ts
EMTALA Do’s
• Treat all patients in the same way.
• Provide a medical screening examination appropriate to the patient’s complaints.
• Appropriately transfer patients you cannot stabilize.
• Accept transfers who require specialized services your hospital offers, as long as the
specialized services have the capacity for care.
• Involve on-call specialists when needed to diagnose or stabilize an EMC.
• Educate ED, hospital staff, and faculty on the EMTALA rules.
• See patients quickly and efficiently.
• Document the completion of the MSE and if an EMC was identified or not during the visit.
EMTALA Don’ts
• Substitute triage for an MSE.
• Discourage or coerce patients away from receiving their screening exams and
stabilization.
• Allow yourself to be convinced that a specialist does not need to come to the ED.
• Fail to stabilize within your capabilities.
• Delay the MSE for preauthorization or registration.
• Fail to follow your own rules, policies, and procedures.
Abbreviations: EMC = emergency medical condition; EMTALA = Emergency Medical Treatment and
Active Labor Act; MSE = medical screening exam.
© Jonathan E. Siff.
and provide them with the on-call doctor’s name and address (failure to
do so is an EMTALA violation).
The widespread adoption of communications technology makes
consults by a variety of electronic methods increasingly common.
There is no restriction to the use of any means of communication with
consultants.116
Table 303-5 outlines some EMTALA do’s and don’ts.
 ENFORCEMENT OF EMTALA
The U.S. Department of Health and Human Services enforces EMTALA.
A complaint initiates an investigation of a hospital for an EMTALA
violation and may start from a patient, hospital, hospital employee,
or anyone who thinks care has been denied someone inappropriately.
Hospitals may not penalize employees who report violations.108 An
EMTALA violation does not imply medical malpractice.
Punishments under EMTALA can be severe and may include a
hospital’s exclusion from participating in Medicare and Medicaid, in
addition to substantial fines. Providers found to violate EMTALA can
also be fined; the maximum fine per violation is now over $100,000
and is not covered by malpractice insurance, and/or the provider may
be excluded from federal programs, making them nearly unemploy-
able.106,118-120 Between 2002 and 2015, 75% of EMTALA settled violations
involved failure to screen, 42% involved failure to stabilize, and 16%
involved insurance or financial status gaps (some cases had more than
one omission).121
Physicians, particularly on-call physicians, are often unaware of their
obligations under EMTALA,122 requiring hospitals to have initial and
ongoing educational programs.102
 SPECIAL ISSUES AND CONCERNS UNDER EMTALA
Situations Where EMTALA Does Not Apply or Ceases to
Apply Once a patient is admitted, in good faith, as an inpatient to the
hospital for further care, EMTALA ceases to apply. However, EMTALA
still applies to patients in the ED and patients on observation status,
such as patients in an ED chest pain unit or in observation status within
the main hospital even if they are on a unit that also contains patients
on inpatient status.93,101,123 Inpatients who subsequently develop an EMC
are not covered by EMTALA, even if they are physically moved back to
the ED. EMTALA does not apply to outpatients who have already begun
a scheduled appointment. EMTALA may not apply during a declared
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 2022   SECTION 26: Special Situations
national emergency or pursuant to a state emergency or pandemic pre-
paredness plan following the issuance of a waiver under law.124
Ambulance “Parking” Prolonged delays in moving patients from EMS
care to hospital care, referred to as “parking,” may be considered a viola-
tion.109 This does not mean that every ambulance patient must instantly
be taken from the care of EMS, particularly in instances where the hos-
pital may lack capacity or capability to immediately care for the patient;
the key is reasonableness, often determined in hindsight.109
Patient-Initiated Transfers Any transfer not for medical reasons is a
patient-requested transfer. The chart should reflect the patient’s reason
for wanting the transfer, and the transfer should be to an appropriate
facility.
Use of the ED for Nonemergency Services If a request is made by
or for a patient presenting for treatment of a medical condition but the
“nature of the request makes it clear that the medical condition is not
of an emergency nature, the hospital is required only to perform such
screening as would be appropriate for anyone presenting in a similar
manner to determine” if an EMC exists.125
Withdrawal of Request for Screening Patients who fail to start or
complete the screening and treatment process fall into one of three
categories: patients who arrive at the ED and leave before their medi-
cal screening examination (often classified as left without being seen
or left before exam); patients who leave or “elope” without informing
staff at any point during the evaluation126; and patients who refuse
recommended treatment or admission and leave “against medical
advice.”
In each scenario, the hospital must make a clear, documented effort
to find a missing patient using the usual tools available.127 Describe in
the medical record the services offered (examination and treatment) and
refused, and try to get written refusal on a document that outlines the
risks and benefits. A hospital could violate EMTALA if waits are so long
that patients leave without being seen, particularly if the hospital does
not attempt to determine and document why individuals left and reiter-
ate to them that the hospital is prepared to provide medical screening
if they stay.127
State Law Some states impose additional duties or requirements on
emergency physicians and hospitals. Follow these laws unless they
directly conflict with the federal EMTALA rule, in which case the federal
statute takes precedence.
Requests for Testing Patients may present to the ED for testing, such
as radiographs or blood work, due to their misunderstanding or under
the order of their personal physician. Because these patients are not
requesting examination or treatment of a medical condition, EMTALA
does not apply. Note in the record that a medical screening examination
was not requested (signed by the patient), and record any interactions
with the ordering physician. Patients who independently present for
testing (e.g., pregnancy) should receive a medical screening examina-
tion before testing, and if they formally refuse the screening examina-
tion, refer them elsewhere for the requested testing and document the
refusal.93
If a patient comes with law enforcement, do an MSE (prudent layper-
son) and any other requested care.
Screen Away Programs Such programs aim to comply with EMTALA
by performing medical screening examinations and then either sending
away those patients found not to have an EMC or requesting payment
before treatment. Physicians and hospitals should consider the legal
risk and ethical and moral implications of such programs, particularly
in those cases where alternative sources of care are not provided.128, 129
Private Patients in the ED In some EDs, it is common for staff physi-
cians to send their patients to the ED, with plans to meet the patient.
Although this is acceptable, these patients should be evaluated in the
standard manner including an MSE and stabilized while waiting for the
private physician if she or he is not available immediately.
“The Guarantee” Some hospitals promise a patient will be triaged or
seen by a doctor within a specific amount of time. These guarantees may
be used as declared standards during an EMTALA investigation.
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Pain and EMTALA Although EMTALA indicates that pain may be a
symptom suggestive of an EMC, it only requires that the patient with
pain receive a medical screening exam consistent with the presenting
complaints. Once a patient has been identified as not having an EMC,
providers can make clinical determinations about the appropriateness of
opioids and other medications. The Centers for Medicare and Medicaid
Services clarified that the posting of signage that discusses restrictions
on ED prescribing or use of opioids may discourage patients from
receiving their medical screening exam and could be in violation of
EMTALA.130,131 Providers and staff should also not discuss with patients
the results of state pharmacy database queries prior to the completion of
the medical screening exam to prevent patients from feeling coerced not
to complete their exam.131 The best course in dealing with patients with
painful complaints is to provide a medical screening exam and, once an
EMC is determined not to exist, to treat the patient based on the clinical
scenario, risk for pharmaceutical abuse, and applicable state law.130
RISK MANAGEMENT
The ED presents a unique setting in health care where numerous factors
interact to create the potential for error.132,133 These errors can create
adverse outcomes for patients and increased medical-legal risks for ED
providers. Risk management identifies and mitigates factors that may be
a source of error.
Certain presenting complaints and conditions are associated with
poor outcomes leading to legal action (Table 303-6).132-136
The error types most commonly reported in emergency medicine
include diagnostic error or delay, treatment error or delay, improper
performance of procedure or treatment, misinterpretation of tests, fail-
ure to supervise or monitor a case, and a failure or delay to consult or
refer.132,134 Diagnostic error, which includes failure to diagnose, delay in
diagnosis, and wrong diagnosis, is consistently the most frequent and
costly in terms of malpractice claims paid, both in emergency medicine
and across all specialties.132,133,136-138 Diagnostic error is judgment that
is “missed, wrong, or delayed.”139 These lead to permanent injury or
death in almost half of filed ED malpractice cases related to diagnostic
error.133,136,138
One study evaluated the sources of these diagnostic errors in the
ED,135 finding that cognitive errors in judgment, knowledge, and vigi-
lance or memory contributed to 96% of claims with identified errors.
Communication errors, particularly as they relate to patient handoffs,
were involved in 35% of diagnostic errors. System errors, including
issues with supervision, workload, and fatigue, occurred in 37% of
TABLE 303-6  Complaints and Diagnoses Associated With High Risk of
Diagnostic Error
• Chest pain/missed acute myocardial infarction (AMI)*
• Wounds (retained foreign body, nerve or tendon damage, poor healing)
• Fractures (vertebral, forearm, leg)
• Symptom involving the abdomen and pelvis (including appendicitis and abdominal
aneurysm)
• Pediatric fever
• Meningitis
• CNS bleed
• Stroke
• Embolism
• Trauma related
• Spinal cord injuries
• Ectopic pregnancy
• Spinal cord abscess
• Headache/subarachnoid hemorrhage
• Aortic dissection
• Torsion—testicular or ovarian
*
Missed AMI is the most frequently alleged missed diagnosis.
© Jonathan E. Siff.
8/1/19 1:34 PM

TABLE 303-7 Provider Interpersonal Behaviors That Can Reduce Risk
• Introduce yourself to the patient and family.
• Dress neatly and professionally.
• Address patients respectfully.
• Sit down at the bedside.
• Discuss with patients their expectations of care.
• Speak in clear, simple language, avoiding medical terms.
• Provide emotional support and show empathy.
• Meet each signed-out patient.
• Personally provide discharge instructions and answer questions prior to patient
departure.
© Jonathan E. Siff.
cases; these errors were more prevalent where students or residents were
involved. Patient-related factors were involved in an additional 34% of
cases. Of note, two thirds of the errors involved cases in which more
than one provider participated in the care, further underscoring the
importance of communication-related factors.
 REDUCING RISK
Improving patient safety and reducing risk in emergency medicine
require a broad focus involving multiple disciplines and addressing
numerous issues including medication administration; electronic health
records; ED staffing, flow, and culture; interruptions; and available
equipment and resources.132,133,140 Although these systemic changes are
often beyond the ability of the individual physician to influence, there
are a number of steps each physician can take to reduce the risk of error
and of being named in a malpractice suit.
Establish a good patient and family interaction (Table 303-7).141 This
relationship is key to facilitating good communications and reducing
risk. Introductions are simple and important; start with telling each
patient your name and your place on the healthcare team (e.g., attending
or supervising doctor, resident physician, student). Engage any family or
friends when appropriate and permitted by the patient. Ensure that the
patient and others understand the diagnosis and discharge instructions,
particularly those related to follow-up, treatment, and when to return to
the ED. The physician should provide the opportunity for patients and
caregivers to ask questions prior to discharge to ensure comprehension.
Providers can modify other practice behaviors that may perpetuate or
lead to error and risk. Patient handoffs are an area of risk; these cannot
be eliminated, but try to lessen these or avoid using rushed patient hand-
offs to reduce the risk associated with shift change and multiple provid-
ers on the care team. Providers may fail to consider all the diagnostic
possibilities in a transferred or signed-out patient because they receive
the patient with a preexisting plan and diagnosis. It is a good practice for
new providers to meet each patient signed out to them and to evaluate
them at least once before discharge.142
Errors around procedures were the second highest category of error in
one ED study.132 Provide adequate supervision of residents and students
performing procedures, provide informed consent for every procedure
when possible, and follow established best practices and guidelines.
Another opportunity to reduce risk lies in reducing interruptions.
Although common in the ED, defer interruptions when possible to allow
accurate completion of the current task.140 Avoid criticizing the care
provided by other providers, and never make guarantees about patient
outcomes.
 SPECIFIC HIGH-RISK DIAGNOSES AND TREATMENTS
Certain diagnoses have a higher risk of poorer outcome, error, or a mal-
practice filing, noted in Table 303-6. Be aware of these diagnoses and
their atypical presentations and consider the possibility of a high-risk
problem in every patient.
The optimal treatment of many diseases is unclear, and a single ideal
care path or set of ideal care paths is not always defined. Providers
should have careful and well-documented discussions about what treat-
ments are or are not being given and why.
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CHAPTER 303: Legal Issues in Emergency Medicine    2023
NEWBORNS LEFT AT THE ED
All U.S. states, the District of Columbia, and Puerto Rico have laws
allowing a mother or others to leave a newborn at a “safe haven” to
reduce the numbers of deaths and abandonments in unsafe places.143
These laws vary with respect to who may leave the infant, how long after
birth the child may be left, whom the child may be entrusted to, and
the amount of legal protection and anonymity due the person leaving
the child.143 In most states, a healthcare provider or emergency services
provider is authorized to accept the child.143 Providers should be aware
of the laws in their state, and every ED should have a policy to deal with
this situation.
DUTY TO THIRD PARTIES
The Tarasoff ruling set the precedent that a physician owes a duty to
a foreseeable third party when the physician is aware of a reasonable
risk to that individual.144 Over the years, courts have extended that duty
to include an obligation to warn or protect others against a variety of
dangers, including communicable diseases, impaired drivers, employ-
ment physicals, and medication or treatment reactions.145,146 Physicians
have varying obligations and protections under state laws for reporting
patients and warning potential victims or authorities when third parties
may be at risk.146-150
TELEPHONE ADVICE
Calls for telephone advice should be routed to an established “advice
line” operated by the hospital, an insurer, or other entity. By dispens-
ing telephone medical advice, a physician may enter a binding physi-
cian–patient relationship.151 Teach the ED staff a standard response to
unsolicited phone calls from the general public: they should state that
they are not allowed to give advice over the phone and should encourage
the patient to seek evaluation as they best judge including coming to the
ED for evaluation.152
EXTENSION OF CARE OUTSIDE OF THE ED
ENCOUNTER
Emergency providers can be exposed to liability extending outside of the
ED. Two common sources of this risk are the writing of inpatient orders
and responding to emergencies elsewhere in the hospital.153 Emergency
physician orders that cover any part of the inpatient stay create ambigu-
ity about when the transfer of care to the inpatient provider takes place.
The American College of Emergency Physicians recommends that the
emergency physician not be compelled to write orders extending outside
of the ED. In those cases where the emergency physician initiates hos-
pital orders, the medical staff policies ideally provide for timely orders
for and evaluation of admitted patients by the inpatient staff and require
that the time the transfer of care occurred be clearly documented.154
In some hospitals, the emergency physician is expected to address
a variety of medical issues on the inpatient floors.153 Hospitals are
responsible for the treatment of inpatients; using ED providers to treat
inpatients threatens their ability to meet their ED requirements. In cases
in which no other option is available, consider bringing these acutely
changed inpatients to the ED for evaluation and treatment.155
NEGLIGENCE STANDARDS
Physicians are expected to exercise reasonable care and practice within
the accepted standard of care, the latter defined by medical opinion
and science. A failure is negligent and often the foundation in a medical
malpractice lawsuit. Efforts to protect the healthcare safety net provided
by EDs and specialists treating ED patients led some states to enact a
more rigorous standard of negligence for emergency care. This higher
standard is often referred to as gross negligence. Gross negligence has
various definitions across jurisdictions that include “conduct so reckless
as to demonstrate a substantial lack of concern for whether an injury
results” and a “failure to exercise slight care or diligence.”156,157 The term
8/1/19 1:34 PM
 2024   SECTION 26: Special Situations
TABLE 303-8 Other Legal Issues of Concern to Emergency Providers
• Peer review
• Business arrangements (anti-kickback Stark laws)
• Credentialing
• Recommendation writing
• Emergency situations arising outside of the hospital
• Compliance
• Medical malpractice
• Translation services for patients
• Acting as an expert witness
• Signing death certificates
reckless is sometimes used to describe a standard of negligence and often
is equivalent to gross negligence.156 A third standard, willful or wanton
misconduct, is often found in “Good Samaritan” laws.156 Willful or wan-
ton misconduct is behavior “where someone knew that an injury was
likely to result from an action and, despite this knowledge, acted with a
conscious disregard for the safety of another person.”156 The willful and
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wanton standard requires the provider to know that what he or she was
doing was almost certain to lead to injury.156
OTHER LEGAL ISSUES OF CONCERN
Other areas of ED practice with legal implications are listed in
Table 303-8. The legal risk varies across states.
DISCLAIMER
This chapter does not address state-specific issues or replace the
advice of the hospital attorney in a given situation. The information
provided in this chapter is not intended to be legal advice. Laws and
regulations are always changing, and this chapter does not replace
a timely consultation with an attorney specialized in healthcare
issues.
REFERENCES
The complete reference list is available online at www.TintinalliEM.com.
8/1/19 1:34 PM
 Index

Page numbers followed by an f indicate figures; page numbers followed by a t indicate tables. Bold indicates page range of the main discussion.

A risk factors, 473–474 clinical features of, 607

Abacavir, 1042t in sickle cell disease, 945 disposition and follow-up in, 611
Abciximab, 347, 1510 symptoms, 476t historical elements in, 609t
in NSTEMI, 345t in urinary retention, 481 history in, 607
in STEMI, 344t visceral, 473, 474t hypothyroidism in, 611
Abdominal aortic aneurysm, 416–418, 479t in women, 477 illness in, 612
clinical features of, 416 Abdominal pump theory on chest imaging in, 610
diagnosis of, 416 compressions, 143 inherited bleeding disorders in,
imaging in, 416, 417f–418f Abdominal trauma, 1675, 1751–1755, 611–612
treatment of, 417–418 2012 laboratory testing in, 610
Abdominal catastrophe, 735 abdominal wall injuries in, 1752 leiomyomas in, 608–609
Abdominal compartment syndrome, blunt injuries in, 1752, 1754 malignancy in, 609t
177, 481 bomb and blast injuries in, 31–32 massive uterine bleeding, 611
Abdominal pain, 262t, 473–481. See also in children, 697–698 menstrual cycle in, 607, 608f
Gastrointestinal disorders blunt, 697 ovulatory dysfunction in, 609, 609t
antibiotics in, 477, 480t hollow viscous injury, 697–698 physical examination in, 607
in bariatric surgery patients, 477–480, liver and spleen injuries, 697 in polycystic ovary syndrome, 612
480t pancreatic injury, 697 polyps in, 607
in children, 857–864 physical abuse in, 992 rapid weight change in, 612
by age group, 857–858 renal injury, 697 stress in, 612
appendicitis, 859–861 clinical features of, 1752 treatment of, 610t, 611
causes of, 857t diagnosis of, 1752–1753 Abortion
cholecystitis, 863 diaphragmatic injuries in, 1752 induced, 666, 666t
colic in, 863 duodenal injuries in, 1752 septic, 621
constipation in, 863–864 in elderly, 1678–1679 spontaneous, 620–621
Henoch-Schönlein purpura in, FAST examination in, 1753, 1753f terminology in, 620t
861–862 hollow viscous injuries, 1752 Abruptio placentae, 633–634, 633f
imaging in, 857 laparotomy in, 1754, 1754t Abscess
inguinal hernia in, 862 mesenteric injuries, 1752 anorectal, 543, 545f
intussusception, 859, 860f pancreatic injuries in, 1752 brain, 1176–1177
malrotation, 858–859 penetrating injuries in, 1752 breast, 660, 661t
necrotizing enterocolitis in, 858 peritoneal lavage in, 1753–1754, 1754f in breast disorders, 660, 661t
pancreatitis in, 863 physical examination in, 1752 cutaneous, 1007t, 1008–1010
physical examination in, 857 retroperitoneal injuries in, 1752 epidural, 1177–1179
pneumonia in, 863 solid organ injuries, 1752 gingival abscess, 1583
renal stones in, 862–863 spinal cord injury, 698 intersphincteric, 543
Streptococcus pharyngitis in, 863 treatment of, 1754–1755 intra-abdominal, 559
volvulus, 858–859 Abdominal wall hernias, 578 ischiorectal, 543, 545f
chronic, 260–263, 264t Abduction relief sign, 1881 in lungs, 450–451
diagnosis of, 478t–479t Aberrant drug-related behavior, 265–266 pelvic, 665
differential diagnosis of, 475t clinical features of, 265 perianal, 543, 545f
disposition and follow-up in, 477 diagnosis of, 266 peritonsillar, 797, 797f, 1596
in elderly patients, 477 fraudulent techniques used by patients with, in puncture wounds, 319
epidemiology of, 473 265t retropharyngeal, 796–797, 796f,
gynecologic causes of, 480t legal issues in, 266 1597–1598, 1597f
imaging in, 476–477 treatment and disposition of, 266 scrotal, 592
inspection of, 474 Ablation, endometrial, 666 in skin lesions, 1610f, 1610t
laboratory testing in, 475–476, 476t, 857 Abnormal uterine bleeding, 607–612 spinal epidural, 1888
in non-pregnant female, 612–615 adenomyosis in, 608 supralevator, 543
opioids in, 236 anticoagulants in, 611 tubo-ovarian, 657
palpation in, 474 causes of tubo-ovarian abscess, 479t
parietal, 473 by age group, 609t Absence seizures, 889, 1154
patient acuity in, 473 endometrial, 609–610 Absorbable sutures, 273, 274t
physical examination, 474 iatrogenic, 610 Abuse and assault
in postoperative patients, 480–481 nonstructural, 609–610 of elderly, 1677, 1974–1978
referred, 473 in perimenopausal women, 609t of intimate partners, 1971–1974
in resuscitation, 473 structural, 607–609 sexual, 1967–1971

2025
FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2025 8/2/19 6:02 PM

 2026   Index
Abusive head trauma, 992. See also Head
trauma
Acamprosate, 1962
Acarbose, 1430
“Accidental Death and Disability—The
Neglected Disease of Modern Society”
(1996 report), 1
Acclimation, 1346
Acclimatization. See also High-altitude
disorders
blood in, 1377
cardiovascular system in, 1377
exercise capacity in, 1378
fluids in, 1377
limitations to, 1378
sleep at high altitude in, 1378
ventilation in, 1377
Acetabular fractures, 1839–1840
Acetaminophen, 233, 1252–1258
in acute pediatric pain, 725
in back pain, 1886
dosing and administration, 234t
for headache in children, 901
IV formulation of, 1253
in liver failure, 518
metabolism of, 1253–1254, 1253f
oral, 1252–1253
overdose and toxicity of, 1254–1258
acetylcysteine in, 1255–1256, 1256t
clinical features of, 1254
diagnosis of, 1254–1255
extended-release ingestions in,
1258
extracorporeal elimination in, 1257
gastrointestinal decontamination in,
1255
hepatic failure in, 1258
IV acetaminophen overdose, 1258
multiple-dose ingestion in, 1258
Rumack-Matthew nomogram of,
1254–1255, 1255f
stages of, 1254, 1254t
treatment of, 1255–1258, 1257f
pharmacology of, 1252–1254
Acetazolamide, 1277
in high-altitude disorders, 1380t
Acetic acid, 1392
Acetylcholine, 1301
Acetylcholinesterase, 40, 1301
Acetylcysteine, 1255–1256, 1256t
Achilles tendon, 1864
injuries of, 1875
lacerations of, 301
rupture of, 1861–1862, 1866, 1866f,
1931
Acid burns, 1392–1394
in caustic ingestions, 1297, 1298f
in chemical ocular injury, 1552–1553
Acid-base disorders, 73–81
acidosis in
metabolic, 74–77
respiratory, 77–78
alkalosis in
metabolic, 77
respiratory, 78
anion gap in, 73–74
clinical approach to, 75
in diabetic ketoacidosis, 1436
parameters for evaluation, 74
pathophysiology of, 73–74
Tintinalli_Index_p2025-2116.indd 2026
Acidemia, 73, 75
Acid-fast bacilli, 454
Acidosis, 73
anion gap, 76
bicarbonate therapy in, 76–77, 77t
in cardiac arrest, 161–162
causes of, 76
differential diagnosis of, 76
lactic, 216
with large-volume normal saline
resuscitation, 76
metabolic, 74–77
in methanol or ethylene glycol poisoning,
1231
osmolal gap, 76
respiratory, 75, 77–78
treatment of, 76–77
wide AG, 76
Ackee fruit, 1413
Acne
keloidalis nuchae, 1647f
neonatal, 939, 940f
nodulocystic, 1647f
Aconite, 1411
Acquired constriction ring syndrome, 306
Acquired immunodeficiency syndrome
(AIDS). See also Human
immunodeficiency virus (HIV)
infection
anorectal-acquired infections, 543, 548t
chronic pain in, 260, 264t
proctitis in, 543
urinary tract infection in, 583
Acral lentiginous melanoma, 1659t
Acral nevi, 1659t
Acromioclavicular joint injuries,
1824–1825
anatomy in, 1824
classification of, 1825t–1826t
clinical features of, 1824–1825
diagnosis of, 1824–1825
Actifoam, 270
Activated charcoal, 1506
in barbiturate overdose, 1215
in calcium channel blocker toxicity,
1277
in decontamination, 1192
multidose, 1192
Activated protein C, 1002
Activated protein C resistance, 1475–1476
Activated PTT, 949
Acute bilateral lymphadenopathy, 785
Acute bronchitis, 436–439. See also
Pulmonary emergencies; Respiratory
disorders
clinical features of, 436
diagnosis of, 436–437
epidemiology of, 436
pathophysiology of, 436
treatment of, 437
Acute chest syndrome, in sickle cell anemia,
1484–1485, 1485f, 1486t
Acute coronary syndromes, 334–352. See also
Cardiovascular disorders
amphetamine-induced, 352
anatomy in, 334, 335f
antithrombins in, 347–348
associated medical disorders in, 352
clinical features of, 336
cocaine-induced, 352
FB:Cardiologia Siglo XXI
complications of, 348–352
conduction disturbances in, 349–350
dysrhythmias in, 349–350, 349t
heart failure in, 350
mechanical, 350–351
pericarditis in, 350–351
recurrent or refractory ischemia,
351–352
right ventricular infarction in, 351
diagnosis of, 336
electrocardiography in, 336–342, 337t,
338f–340f
serum markers of myocardial injury in,
342–343
epidemiology of, 334
history in, 336
after hours and weekend presentations in,
352
in hypertension, 400t
limiting infarct size in, 348
angiotensin-converting enzyme
inhibitors in, 348
beta-blockers, 348
calcium channel blockers, 348
magnesium, 348
nitrates in, 348
low-probability, 357–362
pathophysiology of, 334–336
physical examination in, 336
postprocedure chest pain in, 352
in pregnancy, 624
signs and symptoms of, 335t, 336, 400t
in systemic rheumatic diseases,
1908–1909
treatment of, 343–348, 343f
antiplatelet therapy, 346–348
drugs use, 339t
fibrinolytics in, 345–346, 346t
general, 343
NSTEMI, 344
percutaneous coronary intervention in,
344–345
STEMI, 343–344
unstable angina in, 334t
Acute heart failure. See Heart failure
Acute interstitial pneumonitis, in pulmonary
infiltrates, 448t
Acute kidney injury (AKI), 563–570. See also
Renal disorders
AKIN criteria, 564t
angiotensin-converting enzyme inhibitors
in, 564
cardiorenal syndrome in, 569–570
causes of, 563, 566t
in children, 881–882
clinical features of, 563–564, 881
community-acquired, 563
comorbidities in, 563–564
crystal-induced nephropathy, 564
diagnosis of, 564–568, 881–882
dialysis/renal replacement therapy in,
569, 569t
disposition and follow-up in, 569, 882
drug-induced, 566t
electrolyte disorders in, 569
epidemiology of, 563
fluid overload in, 568–569
glomerulonephritis in, 569
history in, 563–564, 881
hospital-acquired, 563
8/2/19 6:02 PM

in hypertension, 400t, 401, 403t, 569
imaging in, 882
intrinsic, 563, 566t
laboratory evaluation in, 881–882
metabolic acidosis in, 569
metformin in, 570
nonsteroidal anti-inflammatory drugs for,
564–566
pathophysiology of, 563, 881
physical examination in, 563–564, 881
pigments in, 566
postobstructive, 563
postoperative, 556–557
postrenal, 563–564
prerenal, 563–564, 566t
prevention of, 568
relief of urine flow obstruction in, 568
RIFLE criteria, 564t
risk factors for, 566t
signs and symptoms of, 400t
treatment of, 568–569, 854t, 882
volume depletion in, 568
Acute lymphoblastic leukemia, 956
Acute myelogenous leukemia, 956
Acute myocardial infarction
chest pain in, 330
likelihood ratios, 330
signs and symptoms of, 330
symptoms not associated with, 330t
syncope and, 363
Acute pericarditis, chest pain in, 332
Acute radiation syndrome, 49, 49t, 50–51
Acute respiratory distress syndrome
in diabetic ketoacidosis, 1439
mechanical ventilation in, 192, 193f
in pulmonary infiltrates, 448t
in sepsis, 998–999
Acute retroviral syndrome, 1047
Acute stress disorder, 1951–1952
Acute tubular necrosis, 563
Acute unilateral lymphadenopathy,
785–786
Acute urinary retention, 586–590
causes of, 586t
clinical features, 586–587
clot retention in, 589
diagnosis of, 587
epidemiology of, 586
in females, 589
gross hematuria in, 589
pathophysiology of, 586
pharmacologic agents in, 587t
postcatheterization care in, 589
postoperative, 589
treatment of, 587–589, 587t
urethral catheterization in, 587, 588f
Acyclovir, 1016t, 1020–1021, 1036t–1037t,
1542, 1631t, 1915t
ADAMTS-13, 1492–1493
Adenocarcinoma, disseminated intravascular
coagulation in, 1472t
Adenomyosis, 608, 614
Adenosine, 131
actions of, 131
adverse effects of, 131
in atrioventricular blocks, 101t
dosing and administration, 132t
indications for, 131
pharmacokinetics of, 131t
in pregnancy, 168t
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2027
in resuscitation of children, 683t
in tachycardia, 102
Adenosine diphosphate receptor agents.
See also Antiplatelets
in acute coronary syndrome, 346–347
in antithrombotic therapy, 1509–1510
in intracerebral hemorrhage, 1118t
Adhesive capsulitis, 1892
Adhesive pads, 150
Adhesive tapes, 272t
laceration repair with, 282f–284f
Adnexa, 1527–1528
Adolescents, 669
anovulatory uterine bleeding in, 609
compression and ventilation in, 682
ovarian torsion in, 614–615
pain assessment in, 724
pneumonia in, 811
sexual abuse and assault of, 1971
Adrenal gland, 1457
Adrenal insufficiency, 1457–1460. See also
Endocrine disorders
in acute illness or injury, 1459
adrenal crisis in, 1458–1459, 1459t
causes of, 1458t
in children, 970–971
diagnosis of, 971
pathophysiology of, 970
physical examination in, 971
chronic corticosteroids in, 1459
clinical features of, 970–971, 1458, 1458t
disposition and follow-up in, 1459
laboratory testing in, 1459
malignancy in, 1516
in pregnancy, 1460
primary, 1457, 1458t, 1459
secondary, 1457–1458, 1458t, 1459
sepsis in, 1460
treatment of, 971, 1459
Adrenergic agents, 462–465
in asthma, 464t
in calcium channel blocker toxicity, 1278
in chronic obstructive pulmonary disease,
469
Adrenergic agonist, 133t
b-Adrenergic antagonists, 348
Adsorbents, 849, 1099, 1193t, 1194, 1393t,
1395
Adult respiratory distress syndrome
in diabetic ketoacidosis, 1438
disseminated intravascular coagulation in,
1472t
in heat emergencies, 1350
in lithium toxicity, 1212
Adult Still’s disease, 1906t
Advance health directives, 2006–2007
Advance-and-cut technique, in fishhook
removal, 317, 317f
Advanced cardiac life support, 155–159
algorithms for, 155f
asystole/pulseless electrical activity,
160–161, 161f
ventricular fibrillation/ventricular
tachycardia, 159–160, 160f
capnography in, 158
chain of survival in, 152, 153f
complications in, 158–159
differential diagnoses for cardiac arrest in,
161–162
drugs used in, 158–159
Index   2027
amiodarone, 158
atropine, 159
beta-blockers, 159
calcium, 159
epinephrine, 158
lidocaine, 158–159
lignocaine, 158–159
magnesium, 159
sodium bicarbonate, 159
vasopressin, 159
Primary ABCD Survey, 155–157, 155f
Secondary ABCD Survey, 157, 157t
vascular access, 157
Advanced life support (ALS), 5
Aedes aegypti, 1081
Aeromonas, 323, 1068, 1070t–1071t
Aerosols, 35
Afebrile pneumonitis, 812
Afferent pupillary defect, 1102
Afrezza, 1420
African sleeping sickness, 1086–1087
African tick typhus, 1084
African trypanosomiasis, 1086–1087
Africanized honeybees, 1350
Afterload, 820
Aggression, in children, 987, 987t
Agitation, 1937–1940
in antipsychotics overdose, 1210
assessment of, 1936
in children, 1940
in delirium, 1942
in elderly, 1940, 1942, 1944f
in palliative care, 2003
patient safety in, 1938
in poisoning, 1187
restraints in, 1940
show of concern to patients, 1938
treatment of, 1938–1940, 1939f
verbal de-escalation in, 1940
AIDS dementia complex, 1035
Air embolism
during hemodialysis, 577
hyperbaric oxygen therapy in, 138
systemic, 1738–1739
Air leak syndromes, 735
Air Medical Physician Association, 9
Air Medical Physician Handbook, 10
Air medical transport, 4, 9–13. See also
Emergency medical services
environmental factors of, 10–11
by fixed-wing aircraft, 12–13
by helicopter, 10–12
medical direction for, 13
in pneumothorax, 460
Airbag burns, 1396
Airborne precautions, 1098
Airway and ventilation adjuncts, 5–6
Airway devices
adjuncts, 713
complications of, 1600–1605
Airway management
in anaphylaxis, 69
in angioedema, 1282
in cardiogenic shock, 355
in cardiopulmonary resuscitation, 144–146
head tilt-chin lift maneuver, 145
jaw thrust maneuver, 145–146, 145f
suspected opioid overdose, 145
in caustic ingestions, 1299
cervical spine control in, 1669–1671
8/2/19 6:02 PM
 2028   Index
Airway management (Cont.):
in children, 714–719
congenital anomalies in, 717
difficult airway in, 716–717
difficulty factors in, 181t
endotracheal intubation in, 6
equipment and supplies, 5–6, 174–175
in facial trauma, 1718
foreign body obstruction, 146–148
chest thrust maneuver, 147, 148f
finger-sweep maneuver, 148, 148f
Heimlich maneuver, 147, 147f
obstruction airway (Heimlich)
maneuver, 147
in head trauma, 1687–1688
in hemoptysis, 434
in military medicine, 2009
nasal airway in, 6
in neck injuries, 1722–1723
in neonates, 718–719, 735
noninvasive, 173–179
in obese patients, 1996–1997, 1997f
oral airway in, oral and nasal airways, 6
oxygenation in, 174
patient positioning in, 174
in pediatric trauma, 691
in pregnancy, 167
preparation for, 174
rapid-sequence intubation in, 6
in shock, hemorrhagic, 65
in spinal injuries, 1708
supraglottic, 6, 177–179, 717
surgical, 194–200, 718
in systemic rheumatic diseases,
1906–1908
in trauma, 1669–1671
Airway obstruction
foreign bodies in, 146–148
chest thrust maneuver, 147–148, 148f
finger-sweep maneuver, 148
Heimlich maneuver, 147, 147f
obstruction airway (Heimlich)
maneuver, 147
malignant, 1513
upper, 174t
Akathisia, 1210–1211, 1954
Akinesia, 1170
Alanine aminotransferase, 510, 517
Albendazole
in creeping eruption, 1091
for pinworms, 654t
in trichomoniasis, 656t
Albumin
in anion gap, 74
in fluid therapy, 62t
in hepatic disorders, 517
Albuterol
in anaphylaxis, 70t
in asthma, 464t
dosages of, 806t
Alcohol abuse
in elderly, 1945
in pregnancy, 629
seizures in, 1157
treatment of emancipated minors, 2017
withdrawal syndromes, 1225t
Alcohol dehydrogenase, 1222
Alcohol withdrawal seizures, 1224
Alcoholic ketoacidosis, 1441. See also
Endocrine disorders
Tintinalli_Index_p2025-2116.indd 2028
Alcoholic liver disease, 519 Altitude acclimatization
Alcoholics blood in, 1377
ataxia or gait disorder in, 1145 cardiovascular system in, 1377
elderly, 1945 exercise capacity in, 1378
emancipated minors as, treatment of, fluids in, 1377
2017 limitations to, 1378
pneumonia in, 442–443 sleep at high altitude in, 1378
pregnant women, 629 ventilation in, 1377
seizures in, 1157 Aluminum acetate, 1659
Alcohols, 1222–1232 Aluminum phosphide, 1308t
chemical structures of, 1222f Alveolar cell carcinoma, in pulmonary
ethanol, 1223–1224 infiltrates, 448t
ethylene glycol, 1227–1232 Alveolar hemorrhage, 1908
isopropanol, 1225–1226 in pulmonary infiltrates, 448t
methanol, 1227–1232 Alzheimer’s disease, 1139, 1943–1944
withdrawal syndromes, 1224–1225 Amantadine, 1169, 1212
Aldosterone, 1281, 1457, 1458 Amatoxin, 1408–1409
Aldosterone antagonists, adverse effects of, Amblyopia, 764
408t Ambulances, 2, 4
Alfentanil, 252t, 255 Amebiasis, 1088
Alger brush, 1546 American Board of Emergency Medicine, 1
Alkalemia, 73, 75 American Conference of Governmental
Alkali burns, 1394–1395, 1395f Industrial Hygienists, 35
in chemical ocular injury, 1552–1553 American Society of Anesthesiologists (ASA),
Alkaline phosphatase, 517 classification system, 249t
Alkaline reserve, 1297 American trypanosomiasis, 1087
Alkaloids Amethocaine, 237t, 727
antimitotic, 1412–1413 Amides, 236, 237t
belladonna, 1309t, 1412 Amiloride, 1281
designer, 1247 Aminocaproic acid, 1480
in poisonous plants, 1411t Aminoglycosides, in acute kidney failure,
pyrrolizidine, 1326t 566
vinca, 1519t Amiodarone, 624
Alkalosis, 73 actions of, 126, 127t
causes of, 77 adverse effects of, 127, 128t
metabolic, 77 in cardiac arrest, 159
respiratory, 75, 78 dosing and administration, 127, 127t
treatment of, 77 indications for, 127t
Alkyl mercury compounds, 1396 pharmacokinetics of, 126, 127t
Allen chart, 1526 in pregnancy, 168t
Allen’s test, 292 in resuscitation of children, 683t, 685
Allergens, 1658–1659 in tachydysrhythmias, 101t
Allergic conjunctivitis, 770, 1541–1542, in thyrotoxicosis, 1457
1541f Amitraz, 1305
Allergic contact dermatitis, 1633–1634, Amitriptyline, 234t, 1195t
1634t, 1658–1659, 1658t Amlodipine, 133t, 1276t
Allergic rhinitis, 773–774 Ammonia, 39, 517, 969, 1319t, 1320
Allergies, 71–73 Amniotic fluid embolus, 646
drug reactions, 72–73 Amniotic fluid, ferning of, 635f
food, 72 Amoxapine, 1194, 1195t
Allis maneuver, 1846–1847, 1847f Amoxicillin
Alloimmune hemolytic anemia, 1492–1494 in asymptomatic bacteriuria, 626
Alloimmunization, 949 in bacterial sinusitis, 773t
Alpha particles, 47, 48t in chlamydial infections, 1014
Alpha-gal allergy, 72 in cystitis, 626
Alpha-glucosidase inhibitors, 1429t, 1430 in endocarditis, 833
Alphavirus, 43t in premature rupture of membranes, 635
arthritis from, 1926t Amoxicillin-clavulanate
Alprazolam, in nausea and vomiting, 484t in animal bites, 1915t
Alprostadil, 606 in diverticulitis, 528t
Alteplase, in STEMI, 344t in facial infections, 1568t
Altered mental status, 902–904. See also in felon/paronychia, 1915t
Mental health disorders in human bites, 323
AEIOU TIPS mnemonic, 904t in pneumonia, 444t
in children, 902–904 in postpartum endometritis, 636
clinical features of, 904 in postrepair wound care, 324, 325t
diagnosis of, 890t, 903 in urinary tract infection, 873t
pathophysiology of, 902–903 in urinary tract infections, 582t
treatment of, 903–904, 904t Amoxicillin-clavulanic acid, in puncture
Alternobaric vertigo, 1370 wounds, 319
FB:Cardiologia Siglo XXI
8/2/19 6:02 PM
 Index   2029

Amphetamines, 1238–1242 dosage and precautions, 235 dental, 1589–1594

in acute coronary syndrome, 352 in emergency delivery, 638t in foot and leg lacerations, 302–303
in body stuffers and body packers, 1242 hepatic dysfunction and, 235 general, 249
chemical names of, 1239t in impingement syndrome, 1890 for hand, 1788
chest pain in, 1241 methemoglobinemia in, 1330t intradermal, 238
drug interactions with, 1242 in myasthenia gravis, 1166t local, 236–238, 727
dysrhythmias in, 1241 nonopioid, 233 general principles, 237–238
in fever, 1979 opioid, 231 pharmacology, 236
hallucinogenic, 1245 precautions, 235 systemic toxicity of, 236
headaches and, 1108 in rapid-sequence intubation, 715t methemoglobinemia in, 1330t
hypertension in, 403t, 1241–1242 renal dysfunction and, 235 in myasthenia gravis, 1166t
pharmacokinetics of, 1239t route of administration, 234–235 in pericardiocentesis, 226–227
pharmacology of, 1238–1239 topical, 235t regional, 238–247
in pregnancy, 1240 Anaphylaxis, 68–71 digital blocks, 239–240
sedation in, 1238–1239 airway management in, 69 facial nerve blocks, 244–246
toxicity of, 1238–1242 antihistamines in, 70 foot and ankle blocks, 242–244
cardiovascular, 1239–1240 bronchodilators in, 71 hand and wrist blocks, 240–242
clinical features of, 1239–1240 causes of, 68t subdermal, 238
diagnosis of, 1240–1241, 1240t clinical criteria of, 68t topical, 238, 727, 1534t
gastrointestinal effects of, 1240 clinical features of, 68–69, 69t in wound preparation, 269
laboratory testing in, 1240–1241 corticosteroids in, 70 Aneurysms, 415–419. See also Cardiovascular
neurologic syndromes in, 1239–1240 decontamination in, 69 disorders
pulmonary effects of, 1240 defined, 68 abdominal aortic, 416–418
renal effects of, 1240 diagnosis of, 69 anastomotic, 420
treatment of, 1238–1240 discharge planning in, 72t clinical features of, 416
withdrawal from, 1242 epinephrine in, 69–70 diagnosis of, 416–417
Amphotericin, 1013, 1036t glucagon in, 71 extremity, 419
Amphotericin B, 1328 idiopathic, 68 femoral or iliac artery, 419
Ampicillin oxygenation in, 69 hepatic artery, 419
in animal bites, 1915t pathophysiology of, 68 imaging in, 417–418
in deep space infection, 1915t treatment of, 69–71, 70t infected, 415
in diverticulitis, 528t vasopressors in, 71 mycotic, 415
in endocarditis, 833 Anaplasmosis, 1073–1074 nonaortic large-artery, 419t
in flexor tenosynovitis, 1915t clinical features of, 1072t peripheral, 415–416
in pelvic inflammatory disease, 657t treatment of, 1073t popliteal, 419
in postpartum endometritis, 636t Anastomotic aneurysm, 420 pseudoaneurysms, 415, 575
in urinary tract infection, 873t Anastomotic leaks, in gastrointestinal surgery Rasmussen’s aneurysm, 433
Ampicillin-sulbactam, in facial infections, complications, 559 splenic artery, 419
1568t Ancylostoma braziliense, 1091 subclavian and innominate artery, 420
Amprenavir, 1042t Ancylostoma caninum, 1078 thoracic aortic, 419
Amputation Androgens, 1457 treatment of, 418–419, 418t
of digits, 296–297 Anemia, 1461–1463. See also Hematologic vascular access, 575
extremity, 2012–2013 disorders visceral, 415–416, 419
in foot and leg lacerations, 306 aplastic, 1464t Angel dust, 1244t, 1246
in military medicine, 2012–2013 autoimmune hemolytic, 954 Angel’s trumpet, 1248
Amygdalin, 1413 in children, 953–954 Angioedema, 71–72. See also Edema
Amylase, 509–510 of chronic disease, 1464t from ACEIs and ARBs, 1282
Amylin, 1430 classification of, 954, 1462t drug reactions, 1646
Amylin analogues, 1430 in congenital heart disease, 829 hereditary, 72
Amyloidosis, in end-stage renal disease, 575 Cooley’s, 1488 in morbilliform/urticarial eruptions,
Amyotrophic lateral sclerosis, 1165 in Crohn’s disease, 489t 1644–1645, 1644t
clinical features of, 1166 cyanocobalamin deficiency anemia, treatment of, 72t
diagnosis of, 1161 1464t Angiography
pathophysiology of, 1165 hemolytic, 1490–1494 in aortic dissection, 413–414
treatment of, 1165 in hemoptysis, 433 in pelvic fracture, 1841
Anal canal neoplasms, 547t iron deficiency, 954 of trauma to extremities, 1763–1764
Anal fissures, 540–541 iron deficiency anemia, 1464t in venous thromboembolism, 392–396,
anatomy in, 540 in leukemia, 956 394f
clinical features of, 540–541, 541f macrocytic, 1462f Angiotensin II, 136–137
treatment of, 541 microcytic, 1463f actions of, 136
Anal margin neoplasms, 546, 547t normocytic, 1463f cardiovascular effects of, 134t
Anal stenosis, 541 pathophysiology of, 1461 contraindications, 134t
Anal tags, 536–537 sickle cell, 1483–1487 dosing and administration, 134t
Anal warts, 547 in sickle cell disease, 946 indications for, 137
Analgesia sideroblastic anemia, 1464t pharmacokinetics of, 137t
in abdominal pain, 236 in systemic rheumatic diseases, 1912 Angiotensin receptor blockers, 132, 133t
levels of, 249t treatment of, 953–954, 1462–1463, 1464t adverse effects of, 408t, 1282
in trauma, 236 types of, 1464t in cough, 432
Analgesics Anesthesia in heart failure, 372
disposition, 236 defibrillation and, 151 mechanism of action, 1280t

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 2030   Index

Angiotensin-converting enzyme inhibitors, Anterior glenohumeral dislocations, trimethoprim-sulfamethoxazole, 1328

132, 133t, 348, 564 1827–1828 vancomycin, 1328
adverse effects of, 409t, 1282 Cunningham technique, 1829, 1831f Antibiotics
in cough, 432 external rotation (Kocher’s technique), in abdominal pain, 477, 480t
in heart failure, 372 1829, 1829f in acute kidney failure, 566
mechanism of action, 1280t FARES technique, 1829 in bacterial sinusitis, 773t
Anion gap, 73–74, 1229, 1230f, 1298 FARES technique in, 1831f in carbuncles, 1010
Anisatin, 1411t Milch technique in, 1829, 1830f in cellulitis, 1008t
Anisocoria, 1527 reduction technique in, 1828–1829 in chronic obstructive pulmonary disease,
Anistreplase, 1511 scapular manipulation technique in, 1829, 470
in STEMI, 344t 1829f in Crohn’s disease, 490
Ankle Stimson technique in, 1828–1829 in cutaneous abscesses, 1010
anatomy of, 1862–1863, 1863f traction-countertraction technique in diarrhea, 486t, 851
arthrocentesis of, 1924–1925, 1925f (modified Hippocratic) in, in eye disorders, 1534t–1535t
dislocations, 1867f 1828, 1828f in foot and leg lacerations, 307
fractures of, 1868–1870 types of, 1827f in frostbite, 1336
distal fibular, 920 Anterior-posterior compression, 1838 in furuncles, 1010
distal tibial, 920 Anterolateral thigh, 1897 in gastroenteritis, 849–850
injuries of, 1862–1870 Anthracenones, 1412 in hand infections, 1915t
associated and occult, 1869t Anthraquinones, 494t in hand lacerations, 293
in children, 919–921 Anthrax, 42, 1077t in marine-associated wounds, 1363t
clinical features of, 1863–1864 cutaneous, 1078 in meningitis, 755
diagnosis of, 1864 inhalation, 1076 in military medicine, 2012
history of, 1863 signs and symptoms of, 43t in myasthenia gravis, 1166t
imaging in, 1864, 1865f treatment of, 45t in otitis externa, 761
ligament in, 1866–1867 vaccine, 1076 in otitis media, 759–761
muscular, 1868 Antiandrogens, 1999 in pelvic inflammatory disease, 657
physical examination of, 1863–1864 Antiarrhythmics, 91t, 123–132 in pneumonia, 815–816
tendon in, 1864–1866 adenosine, 131 in postrepair wound care, 324–325, 325t
joint aspiration of, 1924–1925, 1925f amiodarone, 126–128 in premature rupture of membranes, 635
lacerations, 305–306 atropine, 131 pretreatment with, 756
Ankle block, 242–244 calcium channel blockers, 129–130 in puncture wounds, 319
Ankle stirrup, 1779, 1779f carvedilol, 126 in sepsis, 1003t–1004t
Ankle-brachial index, 422 Class I, 123–125 in suppurative arthritis, 923t
Ankylosing spondylitis, 1906t, 1914t. Class II, 125–126 in tetanus, 1050
See also Arthritis; Systemic rheumatic Class III, 125–129 in upper gastrointestinal bleeding, 497
diseases Class IV, 129–130 in urinary tract infection, 873–874, 873t
in Crohn’s disease, 489t clevidipine, 130 Anticholinergics, 1190t, 1309–1312
Anorectal abscesses, 543, 544f digoxin, 131–132 in asthma, 464t, 807
Anorectal disorders, 536–561 diltiazem, 129–130 in chronic obstructive pulmonary disease,
abscess, 543, 545f dofetilide, 129 469–470
anal fissures, 540–541, 541f dronedarone, 128 in eye disorders, 1534t
anatomy in, 536, 537f, 539f esmolol, 126 in heat emergencies, 1346
cryptitis, 541–542, 542f flecainide, 124–125 muscarinic and antimuscarinic effects,
fistula-in-ano, 542–543, 542f ibutilide, 129 1310t
foreign bodies, 547–548, 547f, 549f, 553f isoproterenol, 131 muscarinic receptors, 1310t
hemorrhoids, 537–540 labetalol, 126 pharmacology of, 1309–1310
hidradenitis suppurativa, 550–551, 551f lidocaine, 124 screening for, 1311
physical examination in, 536 magnesium sulfate, 131 toxicity of, 1306–1309
pilonidal sinus, 548–550 metoprolol, 126 clinical features of, 1310–1311
proctitis, 543 nicardipine, 130 diagnosis of, 1311
pruritus ani, 548, 550f in prevention of sudden cardiac death, 56 treatment of, 1311–1312, 1311t
rectal prolapse, 543–545, 546f, 561 procainamide, 124 in vertigo, 1152t
rectovaginal fistula, 551, 551t propafenone, 124–125 Anticoagulant necrosis, 1647
skin tags, 536–537, 538f propranolol, 125–126 Anticoagulant rodenticides, 1307
stenosis, 541 sodium channel blockers, 123–125 Anticoagulants, 611
tumors, 546–547, 547t sotalol, 128–129 circulating, 1474
Anorectal tumors, 546–547, 547t Vaughn-Williams classification of, 123t in deep venous thrombosis, 397t
Anorexia, 253 verapamil, 129–130 direct thrombin inhibitors, 1505
Anorexia nervosa, 1956 vernakalant, 129 factor Xa (FXa) inhibitors, 1506
criteria for, 1957t Antibacterials interaction with NSAIDs, 1260
Anoscopy, 552 beta-lactam agents, 1327 in pulmonary embolism, 397t
Anrep effect, 58 cephalosporin, 1327 in transient ischemic attack, 1135
Ant bites, 1351. See also Insect bite clindamycin, 1327–1328 warfarin, 1503–1505
and stings fluoroquinolones, 1328 Anticoagulation
Antacids, 507 ketolides, 1328 in congenital heart disease, 829
Anterior compression with associated linezolid, 1328 in head trauma, 1695
transverse fracture, 1700f macrolides, 1328 Anticonvulsants, 233–234, 1283–1289
Anterior cord syndrome, 1709 penicillin, 1327 carbamazepine, 1285–1286
Anterior cruciate ligament, 1854–1855 toxicity of, 1327–1328 in emergency delivery, 638t

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 Index   2031

eslicarbazepine acetate, 1288 metabolism/excretion, 133t cangrelor, 347

ethosuximide, 1287 onset, 133t clopidogrel, 347
ezogabine, 1288 oral, 407t dosing and administration, 1509t
felbamate, 1288 in preeclampsia and eclampsia, 633t duration of activity, 1471t
first-generation, 1287 side effects, 133t glycoprotein IIb/IIIa antagonists,
fosphenytoin, 1283–1285 sympatholytic agents, 1281–1282 1510, 1510t
gabapentin, 1288 vasodilators, 1282–1283 glycoprotein IIb/IIIa inhibitors, 347
lacosamide, 1288 Antimalarials in head trauma, 1695
lamotrigine, 1285–1286 adverse effects of, 1063t in ischemic stroke, 1129
levetiracetam, 1288 atovaquone-proguanil, 1328 in NSTEMI, 345t
methsuximide, 1287 chloroquine, 1328 phosphodiesterase inhibitors, 1510
in myasthenia gravis, 1166t contraindications, 1076t prasugrel, 346
oxcarbazepine, 1288 in hemoglobin H disease, 1489t in STEMI, 344t
pathophysiology of, 1283–1284 hydroxychloroquine, 1328 ticagrelor, 346–347
phenobarbital, 1287 mefloquine, 1328 in transient ischemic attack, 1135
phenytoin, 1283–1285 in myasthenia gravis, 1166t Antipsychotics, 1190t, 1208–1212, 1519t,
pregabalin, 1288 primaquine, 1328 1954, 1954t–1955t
primidone, 1287 quinine, 1328–1329 acute dystonia in, 1954
rufinamide, 1288 for severe malaria, 1061t adverse effects, 1954–1955
second- and third-generation, 1287–1289, toxicity of, 1328–1329 adverse effects of, 1210–1212
1287t for uncomplicated malaria, 1061t cardiovascular, 1210
in status epilepticus, 1158 Antimicrobials, 1327–1328 extrapyramidal symptoms, 1210–1211
stiripentol, 1289 antibacterials, 1327–1328 akathisia in, 1954
tiagabine, 1289 beta-lactam agents, 1327 anticholinergic effects, 1955
topiramate, 1289 cephalosporin, 1327 cardiovascular effects, 1955
valproic acid, 1286 clindamycin, 1327–1328 first-generation or typical, 1209t
in vertigo, 1152t fluoroquinolones, 1328 history of, 1208
vigabatrin, 1289 ketolides, 1328 neuroleptic malignant syndrome in,
zonisamide, 1289 linezolid, 1328 1211–1212, 1211t, 1955
Anti-D immunoglobulin, 620 macrolides, 1328 overdose and toxicity of
Antidepressants, 91t, 233–234 penicillin, 1327 clinical features of, 1210
atypical, 1199–1201, 1200t, 1948–1949 trimethoprim-sulfamethoxazole, 1328 diagnosis of, 1210
cyclic, 234, 1194–1199 vancomycin, 1328 treatment of, 1210
heterocyclic, 1949 antifungals, 1328 Parkinson’s syndrome in, 1954–1955
serotonergic, 1201–1204 amphotericin B, 1328 pathophysiology of, 1208–1210
Antidiarrheals, 487t triazoles, 1328 pharmacokinetics of, 1210
in Crohn’s disease, 490 antimalarials, 1328–1329 receptor affinity of, 1210t
in gastroenteritis, 849 atovaquone-proguanil, 1328 second-generation, 1209t, 1939–1940
Antidotes, 1187, 1188t chloroquine, 1328 third-generation, 1209t
Antiemetics, 91t, 475, 484t, 622t hydroxychloroquine, 1328 Antiretroviral therapy, 1041, 1042t–1043t
in emergency delivery, 638t mefloquine, 1328 Antirheumatics, 1166t
in gastroenteritis, 848–849 primaquine, 1328 Antisecretory agents, in gastroenteritis, 849
in vertigo, 1152t quinine, 1328–1329 Antithrombins, 347–348
Anti-factor Xa activity, 1468t antiparasitics, 1329 in acute coronary syndrome, 347
Antifibrinolytics, 612, 1512–1513 antituberculosis drugs, 1327–1328 bivalirudin, 348
Antifungal drugs, 91t ethambutol, 1329 in clotting disorders, 1475t
amphotericin B, 1328 isoniazid, 1327–1328 deficiency of, 1475
toxicity of, 1328 pyrazinamide, 1329 fondaparinux, 347–348
triazoles, 1328 rifampin, 1329 hemostasis test, 1468t
Antihistamines, 91t methemoglobinemia in, 1330t low molecular weight heparins
in anaphylaxis, 70 in skin disorders, 1622 (LMWHs), 347
avoidance of, in delirium, 1942 toxicity of, 1327–1329, 1327t in NSTEMI, 345t
in cold urticaria, 1333 Antimitotic alkaloids, 1411t, 1412–1413 in STEMI, 344t
in eye disorders, 1534t Antimotility agents, 486t Antithrombotics, 1500–1513
in nausea and vomiting, 484t Anti-MRSA drug, in pneumonia, 445t antifibrinolytics, 1511–1512
in skin disorders, 1622, 1622t Antinuclear cytoplasmic antibody antiplatelets, 1509–1511
in vertigo, 1144, 1152t (ANCA)–associated vasculitides, clinical indications for, 1501t–1503t
Antihyperglycemic agents, 1428, 1429t 448t complications of, 1508t
Antihypertensive agents, 132, 1278t, Antiparasitics, 91t, 1329 fibrinolytics, 1511–1512
1279–1283 Antiphospholipid antibodies, 1468t fondaparinux, 1508
actions of, 132 Antiphospholipid syndrome, 1477, 1477t, heparins, 1506–1508
adverse effects of, 408t 1906t hirudins, 1508
in aortic dissection, 414 Antiplatelets, 1503, 1508–1510 in ocular hemorrhage, 1550–1552
diuretics, 1279–1281 in acute coronary syndrome, 346–348 oral anticoagulants, 1503–1508, 1505t
dosing and administration, 133t adenosine diphosphate receptor agents, Antituberculosis drugs
in emergency delivery, 638t 1509–1510 ethambutol, 1329
indications for, 132 adenosine diphosphate receptor isoniazid, 1327–1328
indicators for, 407t antagonists, 346–347 pyrazinamide, 1329
interaction with NSAIDs, 1260 in arterial occlusion, 423t rifampin, 1329
intravenous, 405t–406t aspirin, 346, 1508–1510 toxicity of, 1327–1328

FB:Cardiologia Siglo XXI

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 2032   Index
Antivirals, 91t
in eye disorders, 1535t
in vertigo, 1152t
Anxiety disorders, 1951–1952
acute stress disorder, 1951–1952
in children, 988
clinical features of, 1951
diagnosis of, 1952
generalized, 1951
panic disorder, 1951
pathophysiology of, 1951
posttraumatic stress disorder, 1951–1952
symptoms of, 1951t
treatment of, 1952, 1952t
Anxiolysis, 727, 728t
Aortic dissection, 412–415. See also
Cardiovascular disorders
antihypertensives in, 415
in arterial occlusion, 420
chest pain in, 331
clinical features of, 412, 413t
diagnosis of, 413–414
disposition and follow-up in, 415
epidemiology of, 412
history in, 412
in hypertension, 400t, 402, 403t
imaging in, 413–414
physical examination in, 412–413
in pregnancy, 415
signs and symptoms of, 400t
thoracic, 421t
treatment of, 414
vasodilators in, 415
Aortic insufficiency, acute, 353
Aortic regurgitation, 377–378
clinical features of, 377–378
diagnosis of, 378
epidemiology of, 377
pathophysiology of, 377
treatment of, 378
Aortic stenosis, 377, 825, 838
clinical features of, 377
diagnosis of, 377
epidemiology of, 377
treatment of, 377
Aortic syndromes, 412–415. See also
Cardiovascular disorders
Aortoenteric fistulas, 416
Aortography, 1750–1751
Aortovenous fistulas, 416
Apgar score, 642t
Aphasia, 1102
Aphthous stomatitis, 1584, 1584f
Aphthous ulcers, 776–777, 776f
Apixaban, 1465, 1506
in deep venous thrombosis, 397t
in pulmonary embolism, 397t
Apnea, 740
central, 740
in neonates, 736
obstructive, 740
of prematurity, 740
Apneic oxygenation, 181
Apophysis, 905
Apparent life-threatening event (ALTEs),
739–744
anatomic causes of, 743
breath-holding spells in, 743
cardiac causes of, 743
child abuse in, 742–743
Tintinalli_Index_p2025-2116.indd 2032
classification of, 740
defined, 740
diagnostic testing in, 743
differential diagnosis of, 740–742, 741f,
742t
ED approach to, 743
epidemiology of, 740
gastroesophageal reflux disease in, 742
metabolic causes of, 743
oral dysphagia in, 742
pathophysiology of, 740
pertussis in, 742
poisoning in, 742–743
respiratory tract infections in, 742
risk stratification in, 743
seizures in, 742
serious bacterial infections in, 743
Appendageal torsion, 595t, 596
Appendicitis, 523–527. See also
Gastrointestinal disorders
abdominal pain in, 478t
in children, 527, 859–861
clinical features of, 523, 860
diagnosis of, 523–526, 860, 860t
differential, 524t
scoring systems in, 524
epidemiology of, 523
imaging in, 524–526, 525f–526f
imaging of, 861f
laboratory testing in, 524
pathophysiology of, 523
in pregnancy, 628
in pregnant women, 526–527
treatment of, 526, 861
in uninsured/underinsured patients, 526
Appendicular coordination, 1106
Applanation tonometer, 1530, 1530f
Apraxia, 1102
Apraxic gait, 1143
Aprepitant, 1519t
Apt test, 866
Arboviral infections, 1031–1032. See also
Viral infections
clinical features of, 1031
diagnosis of, 1031–1032
epidemiology of, 1031
in North America, 1031t
pathophysiology of, 1031
treatment of, 1032
Arcanobacterium haemolyticum infections,
780
Arcanobacterium pharyngitis, 780
Arenaviruses, 43t, 45t
Argatroban, 1509
Arginine, 970
Aripiprazole, in bipolar disorder, 1950t
Arm injuries, in lacerations, 292–299
Arm sling, 1776, 1777f
Armed spiders, 1354–1355
Arrhythmias, 99–123. See also Dysrhythmias;
Heart disorders
atrioventricular blocks in, 111–114
bradyarrhythmias in, 100, 105–106
Brugada syndrome, 122–123
conduction and repolarization
abnormalities, 119–123
ectopic beats, 103–105
in electrical injuries, 1398
instability indicators for, 100t
in poisoning, 1187
FB:Cardiologia Siglo XXI
in pregnancy, 623–624
premature atrial contractions, 104, 104f,
104t
premature ventricular contractions,
104–105, 105f
stable patients with, 101
supraventricular tachydysrhythmias,
106–111
in systemic rheumatic diseases, 1909
tachydysrhythmias in, 100–103
unstable patients with, 101
wide-complex tachydysrhythmias,
114–118
Wolff-Parkinson-White syndrome, 119–122
Arrhythmogenic right ventricular
cardiomyopathy, 53–54, 123, 838
Arsenic poisoning, 1314–1316. See also
Poisoning
chelation therapy in, 1314t
clinical features of, 1315
diagnosis of, 1315
epidemiology of, 1314–1315
pathophysiology of, 1315
pharmacology of, 1315
from rodenticides, 1308t
treatment of, 1316
Arsine, 1316
Artemether-lumefantrine, 1061t, 1063t
Arterial blood gas (ABG)
analysis of, 79–80
capnography, 80–81
in cyanosis, 430
pulse oximetry, 80
Arterial blood pressure, in shock, 60t
Arterial catheterization, 209–211
alternative sites, 209
complications in, 211t
indications for placement in, 209f
materials for, 210t
radial artery anatomy in, 209
techniques for, 210, 210t, 211f
ultrasound-guided localization of, 210
Arterial embolization, in endocarditis, 1045
Arterial gas embolism, 1372–1373
criteria for, 1372t
diagnosis of, 1372–1373
imaging in, 1373
laboratory testing in, 1373
treatment of, 1373
Arterial occlusion, 420–423. See also
Cardiovascular disorders
acute limb ischemia and, 422
aortic dissection in, 420
claudication in, 422, 422t
clinical features of, 420–421
diagnosis of, 422–423, 423t
disorders associated with, 421t
embolic vs. thrombotic, 423t
embolism in, 420
epidemiology of, 420
imaging in, 423
laboratory testing in, 423
pathophysiology of, 420
thrombosis in, 420
treatment of, 423, 423t
Arterial pressure index, 293
Arterial ulcers, 1425
Arteritis, 1907t
Takayasu’s, 1907t
temporal, 1110, 1111t, 1907t
8/2/19 6:02 PM
 Index   2033

Artesunate, 1061t epidemiology of, 461 in pregnancy, 624

Artesunate-amodiaquine, 1061t exacerbations in, 463f thyrotoxicosis in, 1457
Arthritis imaging in, 804t treatment of, 107–110, 109t–110t
alphavirus, 1926t initial assessment of, 803 in Wolff-Parkinson-White syndrome, 121f
in children, 921–922 key history points in, 462t Atrial flutter, 106–110
cricoarytenoid joint, 1906 management of, 463f ECG of, 108f, 108t
in Crohn’s disease, 489t mimickers, 462t treatment of, 107–110, 109t–110t
differential diagnosis of, 1920t near-fatal, 807 Atrial septal defect, 827
in hepatitis, 1926t noninvasive positive-pressure ventilation Atrioventricular block
hepatitis virus, 1926t in, 807 in children, 839
HIV, 1926t pathophysiology of, 461, 803 differential diagnosis of, 1276t
juvenile idiopathic, 923 patient monitoring in, 462 drugs for, 101t
in Lyme disease, 1927 in pregnancy, 626 first-degree, 111–114, 111f
osteoarthritis, 1927 severity of, 462t second-degree Mobitz type I (Wenckebach),
parvovirus, 1926t status asthmaticus, 465–466 112, 112f, 112t, 113f
poststreptococcal reactive, 925 treatment of, 462–465, 804–808, 804t, second-degree Mobitz type II, 112–113,
reactive arthritis, 1927 806t 113f, 113t
rheumatoid, 1907t, 1914t adrenergic agents, 462–465, 464t third-degree, 113–114, 113f, 113t
rheumatoid arthritis, 1927 anticholinergics, 464t, 465 Atrioventricular nodal reentrant tachycardia,
rubella, 1926t anticholinergics in, 807 110–111
septic, 921–922, 1912, 1914t, 1920t, corticosteroids, 465 Atrophic vaginitis, 653
1925–1926, 1983 corticosteroids in, 465, 806–807, 806t Atropine, 40, 131, 1407
viral, 1926 dosages of medications, 806t actions of, 131
Arthrocentesis, 1855, 1921–1925 epinephrine in, 466 adverse effects of, 131
ankle joint aspiration in, 1924–1925, 1925f heliox in, 807 in arrhythmias, 131
elbow joint aspiration in, 1922, 1922f ketamine in, 466, 807 in beta-blocker toxicity, 1274
hip joint aspiration in, 1923, 1923f magnesium in, 465, 807 in bradyarrhythmias, 101t
knee joint aspiration in, 1923–1924, 1924f mechanical ventilation, 466 in cardiac arrest, 159
shoulder joint aspiration in, 1921–1922, methylxanthines in, 807 in diarrhea, 486t
1922f short-acting b2-receptor agonists in, dosing and administration, 131, 131t
wrist joint aspiration in, 1923, 1923f 804–806 hallucinogenic properties of, 1247t, 1248
Arthropathy, 1902 steroids, 464t for nerve agent victims, 40
Articular surface fractures, 1819 ventilation in, 807, 808t in organophosphate poisoning, 1302t, 1303
Artificial urinary sphincters, complications of, in wheezing, 803–810 pharmacokinetics of, 131t
605–606, 606t Asymptomatic bacteriuria, 578 in pregnancy, 168t
Ascariasis, 1089–1090 Asymptomatic drowning, 1376 in resuscitation of children, 683t, 685
Ascites, 519, 520f Asymptomatic hypertension, 406–408 Atypical antidepressants, 1199–1201. See also
Ascitic fluid aspirate, 517 Asynchronous pacing, 217 Antidepressants
Ascorbate, 1323t, 1325 Asystole, algorithm on management of, bupropion, 1199–1200
Aspartate aminotransferase, 517 160–161, 161f mirtazapine, 1200
Aspergillosis, allergic bronchopulmonary, 448t Ataxia, 1142–1145. See also Neurologic nefazodone, 1200
Asphyxiants, 38–39 disorders pharmacology of, 1199–1200, 1200t
Aspiration, in pulmonary trauma, 1736 in alcoholic patients, 1145 trazodone, 1200–1201
Aspiration pneumonia, 446–447, 817 cerebellar, 1143 vilazodone, 1201
clinical features of, 447 in children, 1140t, 1145, 1145t vortioxetine, 1201
diagnosis of, 447 clinical features of, 1144 Auricular block, 245, 245f
disposition in, 447 diagnosis of, 1144 Auricular hematoma, 290
epidemiology of, 446 etiologies of, 1143t Auspitz sign, 1653
pathophysiology of, 447 gait disorders in, 1143 Australasian Triage Scale, 1934
risk factors for, 447t history in, 1144 Autism spectrum disorder, 980–981
treatment of, 447 motor, 1143 Autoimmune hemolytic anemia, 1490–1492
Aspirin, 233, 624, 1508–1509 pathophysiology of, 1142–1143 categories of, 1491t
dosing and administration, 234t, 1509t physical examination in, 1144 in children, 954
interaction with NSAIDs, 1260 sensory, 1143 cold antibody, 1491–1492
in intracerebral hemorrhage, 1118t Atazanavir, 1042t mixed-type, 1493
in NSTEMI, 345t Atelectasis, postoperative, 556 warm antibody, 1490–1491
in STEMI, 344t Atenolol Automated external defibrillators, 149
Assessment of Blood Consumption score, 66 in NSTEMI, 345t Autonomic dysfunction, 402
Assisted reproductive procedures, 666–667 in STEMI, 344t Autonomic neuropathy, 1426t
Assisted ventilation, in chronic obstructive Athletes, hip injuries in, 1850 Autopositive end-expiratory pressure, 799
pulmonary disease, 470, 470t Atlanto-occipital dissociation (AOD), 1704f Autopsy, 2006
Asterixis, 520 Atonic seizures, 889 Autumn crocus, 1412–1413
Asthma, 461–466, 803–810. See also Atopic dermatitis, 940, 941f, 1636t–1637t, Avalanche burial, 1345
Pulmonary emergencies; Respiratory 1640–1641, 1640f, 1658t, 1660, Avascular necrosis, 923, 942f, 944, 1902t,
disorders 1660f 1903f
airflow obstruction in, 461t Atovaquone-proguanil, 1061t, 1063t, 1328 Avulsion fracture, 1838–1839, 1839f, 1839t
checklist for discharge, 466t Atrial fibrillation, 106–110 Avulsion injuries, nail bed, 298, 298f–299f
clinical features of, 461, 803 in acute coronary syndrome, 349 Axial coordination, 1106
diagnosis of, 462, 803–804 clinical significance of, 107 Axillary artery, thrombosis of, 1894
endotracheal intubation in, 807, 807t ECG of, 107f Azathioprine, 1169

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2033 8/2/19 6:02 PM

 2034   Index
Azithromycin
in bacterial infections, 933t
in chancroid, 1015t, 1021
in chlamydial infections, 1014, 1015t
in diarrhea, 486t
in endocarditis, 833
in facial infections, 1568t
in gonorrhea, 1015t, 1017
in granuloma inguinale, 1015t–1016t
in pelvic inflammatory disease, 657
in pertussis, 439
in pneumonia, 444, 444t
for sexual infection prophylaxis, 1970t
in syphilis, 1016t
in typhoid fever, 1082
in urinary tract infections, 582t
Aztreonam
in diverticulitis, 528t
in pneumonia, 445t
B by microscopy, 581
B virus, 324
Babesiosis, 1074–1075
clinical features of, 1072t
treatment of, 1073t
Babinski response, 1105–1106
Babinski’s sign, 1105–1106
Bacillary angiomatosis, 1041
Bacillus anthracis, 41–42, 43t, 45t, 1066t,
1076
Bacillus Calmette-Guérin immunization,
452
Bacillus cereus, 1066t
Back pain, 1884–1888. See also
Musculoskeletal disorders
chronic, 1886
clinical features of, 1884–1885
diagnosis of, 1885
differential diagnosis of, 1885–1888
disk herniation in, 1886–1887
epidural compression syndrome in, 1887
historical risk factors for, 1884
imaging in, 1885
in injection drug users, 1981
location of, 1884
low, 1886
neurologic deficit in, 1884
neurologic examination for, 1884–1885,
1885f
nonspecific, 1885–1886
patient age in, 1884
physical examination in, 1884–1885,
1885f
risk factors for, 1881
sciatica in, 1886
spinal infection in, 1887–1888
spinal stenosis in, 1887
systemic complaints in, 1884
transverse myelitis in, 1887
trauma in, 1884
Baclofen, 428t
Bacteremia
in children, 747
in sickle cell disease, 943t
Bacterial meningitis, 1172–1175
chemoprophylaxis for, 1174–1175
in children, 752
clinical features of, 753, 1172
diagnosis of, 1172–1173
epidemiology of, 1168
Tintinalli_Index_p2025-2116.indd 2034
history in, 1172
laboratory testing in, 1173–1174
lumbar puncture in, 1172–1173
otitis in, 1174
pathophysiology of, 753, 1172
physical examination in, 1173
risk factors for, 1172t
signs and symptoms of, 753
sinusitis in, 1174, 1174f
treatment of, 1173–1175, 1173t
Bacterial nongonococcal septic arthritis,
1925
Bacterial pneumonia, in HIV infection,
1039
Bacterial vaginosis, 648–649
causes of, 648–649
diagnosis of, 649
sexually transmitted infections in, 649
treatment of, 649
Bacteriuria
in pregnancy, 626–627
Bag-mask ventilation, 711–712, 711f
Bag-valve mask, 175, 176f, 258, 682
Baker cyst, 1901–1902, 1902f
Balanitis, 593, 877, 1653
Balanoposthitis, 593, 877, 877f
Balloon tamponade, in upper gastrointestinal
bleeding, 498, 498f
Baloxavir, 438t, 1025
Bamboo spine, 1887
Bangungut, 55
Barb blisters, 1215
Barbiturates, 186, 256, 1214–1215
overdose and toxicity of, 1215–1217
activated charcoal for, 1215
airway assessment and stabilization in,
1215
clinical features of, 1214–1215
diagnosis of, 1215
extracorporeal elimination in, 1215
forced diuresis in, 1215
treatment of, 1215
urinary alkalinization in, 1215
pharmacology of, 1214
properties of, 1214t
in sedation, 731
withdrawal syndromes, 1215
Bariatric surgery, complications of,
559–560
Bariatric surgery patients, abdominal pain in,
477–480, 480t
Barium carbonate, 1308t
Barotitis (ear squeeze), 1369
Barotrauma, 140–141
of ascent, 1369t, 1370
of descent, 1369–1370, 1369t
inner ear, 1370
pathophysiology of, 1369
pulmonary, 1370, 1371f
sinus, 1370
Bartholin gland cyst and abscess, 653, 653f
Bartonella henselae infections, 322–323
Barton’s fracture, 1808, 1808f
Basic life support (BLS), 5
Bath salts, 1239, 1244t, 1245–1246
Bazett’s equation, 55
Beam me up (drug), 1246
Beaver fever, 1068
Bedbugs, 1357, 1649
FB:Cardiologia Siglo XXI
Bedside echocardiography, in cardiac arrest,
355
Bee stings, 1350–1351. See also Bites and
stings
anaphylaxis in, 1351
clinical features of, 1350–1351
treatment of, 1351
venom in, 1350
Beef tapeworm, 1090
Behavioral disorders
in children, 982–988
aggression in, 987, 987t
anxiety in, 988
causes of, 983t
child abuse and neglect in, 985
clinical assessment of, 983–984
depression in, 988
epidemiology of, 982–983
history in, 983
imaging in, 983
laboratory testing in, 983
non-suicidal self-injury in, 987
physical examination in, 983
psychosis in, 988, 988t
substance misuse and withdrawal in,
988
suicidal ideations and attempts in, 984t,
985–987, 985f, 985t, 986f
HEARTSMAP Structured Mental Health
Screening Tool, 984t
Behçet’s disease, 1906t
Belladonna alkaloids, 1412
Bell’s palsy
clinical features of, 1160–1161
diagnosis of, 1161
in HIV infection, 1025
treatment of, 1161
unilateral facial paralysis in, 1160–1161
Benazepril, 133t, 1282
Bending fractures, 907–908
Benign migratory glossitis, 1585
Benign neoplasms, 788–789
Benign paroxysmal positional vertigo,
1146, 1148–1149, 1150t
anterior canal, 1149
horizontal canal, 1149
posterior canal, 1148
treatment of, 1148–1149
Bennett’s fracture, 1793
Benzamide, in nausea and vomiting, 484t
Benzathine penicillin G, in syphilis,
1016t
Benzocaine, 39, 237t
Benzodiazepines, 256, 628, 1215–1218,
1216t, 1519t
antagonists, 1218
in anxiety disorders, 1952
avoidance of, in delirium, 1942
in nausea and vomiting, 484t
in opioid use disorder, 1963–1964
overdose and toxicity of, 1217–1218,
1218t
clinical features of, 1217
diagnosis of, 1217
treatment of, 1217–1218
pharmacology of, 1216–1217
in seizures, 891, 892t, 1198
in serotonin syndrome, 1204
in status epilepticus, 1158
in sympathetic crisis, 402, 403t
8/2/19 6:02 PM
 Index   2035

in vertigo, 1144, 1152t cardiac, 332–333 factors affecting, 30–31

withdrawal syndromes, 1217–1218 in heart failure, 369 forensics in, 33
Benzothiazepines, 1275, 1276t Biosyn®, 274t pathophysiology of, 30
Benzyl alcohol, 238 Bioterrorism, 41–47, 45t. See also Disaster in pregnant women, 33
Berger’s disease, 884 situations staff safety in, 33
Beriberi, 1324 agents of, 42, 43t treatment of, 33
Beta particles, 47, 48t clinical features of, 44 triage in, 33t
Beta-adrenergic agents, 462–465 ED scenarios, 42–44 types of, 30
Beta-adrenergic blockade, 1456t epidemiology in, 41–47 Bleach, 1297
Beta-blockers, 55, 125–126, 125t, 159, 348, management, 47 Bleeding
1270–1275 medical surge capacity and capability in, abnormal uterine, 607–612
adrenergic receptor agents, 1261 46–47 control, 270
adverse effects of, 408t prophylaxis, 45t diathesis, 575
in aortic regurgitation, 378 public health and, 42, 46–47 gastrointestinal, 864–870
in atrial fibrillation, 109 recognition of, 42–44 in hemodialysis, 575–576
carvedilol, 126 response to, 44–45 intrabronchial, 1736–1737
esmolol, 126 signs and symptoms in exposure to, 43t lower gastrointestinal, 498–500
in eye disorders, 1536t treatment in, 45t postconization, 665–666
in heat emergencies, 1346 vaccination in, 45t in pregnancy, 633–634
in hypertension, 402, 405t, 406 Biotin, 1325 upper gastrointestinal, 495–498
labetalol, 126 Biotoxins, 41, 41t vaginal, 880
pharmacology of, 1270t Biphasic defibrillators, 5 causes of, 607–610
profiles, 1272t Bipolar disorder, 1949–1951. See also Mental causes of, by age group, 609t
propranolol, 125 health disorders; Mood disorders coagulopathies in, 609
in tachycardia, 102 clinical features of, 1949 in emergency delivery, 640
toxicity of, 1270–1275 drugs for, 1950t in pregnancy, 633–634
atropine in, 1274 in elderly, 1945–1946 terminology for, 608t
calcium therapy for, 1274 pathophysiology of, 1966 variceal, 867, 869
clinical features of, 1271 treatment of, 1967 Bleeding disorders. See also Hematologic
diagnosis of, 1271–1272 Bipyridyl herbicides, 1305–1307 disorders
high-dose insulin therapy in, Bisacodyl, 494t acquired, 1469–1471
1273–1274, 1274t Bismuth, 1318t in coagulation disorders, 1471–1474
intravenous lipid emulsion therapy in, Bismuth subsalicylate, in diarrhea, 486t in platelet defects, 1469–1471
1274 Bisoprolol, 1454 Blepharitis, 765, 1540
phosphodiesterase inhibitors in, 1275 Bite wounds, 321–324. See also Wounds Blind nasotracheal intubation, 189
sodium bicarbonate for treatment of, from cat and dog bites, 321–322 Blind subxiphoid approach, 228, 228f
1275 exotic and wild animals, 323 Blister beetles, 1357
treatment of, 1272–1275 fish bites, 323 Blistering burns, 1403
in vertigo, 1152t human bites, 323 Blistering diseases, 1648
Betahistine, 1152t infections in, 323 Blizzards, 29
Beta-lactam, 445t, 1327 antibiotics for, 1915t Blood
Beta-lactamase, 445t livestock and large game animals, 323 in acclimatization, 1377
Beta-lactamase inhibitor, in pneumonia, 445t from mammalian bites, 321 cerebral blood flow, 1683
Beta-receptor antagonists, 804–806 rabies infections, 1052, 1052t exposure to, 1093t
Bhopal industrial accident (1984), 35 rodents, 323 hemoglobin, 39, 566
Bicarbonate, 63, 76–77, 77t Bites and stings in anemia, 1462t
in diabetic ketoacidosis, 1439 of blister beetles, 1357–1358 hemoglobin C, 1488
Bicarbonate therapy, 974 of caterpillars, 1357 hemoglobin H, 1488–1489
Biceps, 1811, 1877f of chiggers, 1356 hemoglobin O-Arab, 1488
anatomy of, 1811f on hands, 1914 in sickle cell disease, 1488
tendon rupture in, 1813–1814 of insects, 1350–1358 in vaso-occlusive crisis, 945
Biceps tendon disorder, 1892–1893 of moths, 1357 platelets, 67, 1469–1471
Bier block, 247–248 of reptiles, 1358–1362 functional disorders in, 1471, 1471t
Bigelow maneuver, 1847, 1848f of scorpions, 1355–1356, 1356t transfusion, 1496–1497
Biguanides, 1429t of spiders, 1351–1355 red blood cells of, 583
Bilevel positive airway pressure, 6, 175–177 Bitolterol, in asthma, 464t agglutination of, 1491
Bilharzia, 1087 Bivalirudin, 345t, 348, 1508 in anemia, 1461
Biliary colic, 478t, 512 Black cohosh, 519t, 1326t clinical features of, 1461
Biliary disease, 332 Bladder diagnosis of, 1461–1462
Biliary sludge, 513 injuries to, 1759–1760 laboratory testing in, 1462t
Biliary tract surgery, complications of, rupture of, 1760f normal values for adults, 1462t
560–561 Bladder outlet obstruction, 478t oxidative stress-causing drugs, 1489t
Bilirubin, 517, 945 Bladder pain syndrome, 262, 262t, 264t packed, 66, 1496
Bimalleolar fractures, 1868f Blast injuries, 30–33, 1399, 1739, 2012. See tests, in tuberculosis, 453
Binge eating disorder, 1956 also Crush injuries transfusion of, 1496–1500
criteria for, 1957t in children, 33 in trauma, 1671–1674
Biologic therapy, emergency complications of, clinical features in, 31 white blood cell count
1519–1521 diagnosis in, 32–33 in ascitic fluid, 517
Biomarkers epidemiology of, 30 in systemic rheumatic diseases, 1912
in aortic dissection, 413 external hemorrhage in, 32 in urinalysis, 581

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2035 8/2/19 6:02 PM

 2036   Index

Blood gases, 78–81 clinical features in, 31 decision tree, pediatric, 688f
alveolar gas exchange, 79 diagnosis in, 32–33 differential diagnosis of, 1276t
arterial blood gas analysis, 79–80 epidemiology of, 30 in hypothermia, 1360
capnography, 80–81 external hemorrhage in, 32 toxicologic causes of, 1272t
functional residual capacity, 78 factors affecting, 30–31 Bradydysrhythmias, 363
minute ventilation, 78 forensics in, 33 Bradypnea, in hypothermia, 1360
oxygen delivery to alveolar space, 79 pathophysiology of, 30 Brain
pulse oximetry, 80 in pregnant women, 33 abscess in, 1176–1177
respiratory physiology in, 78–79 staff safety in, 33 anterior and posterior circulation of, 1119t
tidal volume of, 78 treatment of, 33 cerebral hemisphere, 1119f–1120f
venous blood gas analysis, 80 triage in, 33t herniation, 1684
Blood loss anemia. See also Anemia, types of, 30 hypernatremia and, 86f
hyperbaric oxygen therapy in, 139 Bone marrow aspirate, 719 hyponatremia and, 86f
Blood pressure Bones, 1767 imaging of, 1126–1127
arterial, 212 carpal, 1795 Brain injury
categories of, 400t of hand, 1782f in bomb and blast injuries, 32
central venous, 213–214 metastases, 1514 in head trauma, 1683–1684
control of, 1128 NSAID overdose and, 1261 brain herniation, 1684
diastolic pressure, 212 pain in sickle cell disease, 1485 cerebral perfusion pressure management
diseases associated with elevated, 401t of shoulder, 1888, 1889f for, 1689
in head trauma, 1688 of wrist, 1782f edema in, 1684
in hypertension, 400t Bordetella pertussis infections, 436 goal-directed therapy for, 1689t
measurement of in BRUEs/ALTEs, 742 mild, 1705–1707
invasive, 212–213 in pneumonia, 811, 812t primary, 1683–1684
noninvasive, 212–213 Borrelia, 1085 secondary, 1684
noninvasive measurement of, 212–213 Boston Criteria, 749t, 750 after ROSC, 170
oscillometry in, 212 Botfly bites, 1649–1650 Brain tumor, headache in, 1110
palpation in, 212 Botulinum toxin, 41 Branchial cleft cysts, 788
sphygmomanometry in, 212 Botulism, 41, 43t, 1163 Branham sign, 576
optimal, 212 Boutonnière deformity, 295, 295f, 1791f Breast cancer, 660
in shock, 60t Bovine papular stomatitis, 1078 Breast disorders, 658–662
systolic pressure, 212 Bowditch effect, 58 abscess in, 660, 661t
Blood products Bowel obstruction, 478t, 530–532. See also cellulitis in, 660
characteristics of, 1495t Gastrointestinal disorders clinical features of, 658–659
coagulation factor VIIa (recombinant), 1498 causes of, 530t engorgement, 659
cryoprecipitate, 1497–1498 clinical features of, 530–531, 531t fibrocystic, 662
fibrinogen concentrate, 1498 complications of, 558–559 hematoma in, 662
fresh frozen plasma, 1497, 1497t diagnosis of, 531 hidradenitis suppurativa, 660, 661t
in leukemia, 956–957, 957t early post operative, 480–481 history in, 658–659
in military medicine, 2010–2011 epidemiology of, 530 implants in, 662
platelets, 1496–1497 in gastrointestinal surgery complications, inflammatory, 660
prothrombin complex concentrate, 1498 558–559 inflammatory breast cancer, 660
Blue toe syndrome, 421, 421t history in, 530–531 in lactation, 659–660
Bluebottle jellyfish, 1367 imaging in, 531, 531f mass in, 662
Blunt injuries. See also Trauma laboratory testing in, 531 mastitis in, 659–660, 660f, 661t
in abdominal trauma, 700–702, 1752, 1754 large, 530, 531f mastodynia, 660–661
in cardiac trauma, 1746–1747 pathophysiology of, 530 Mondor’s disease, 661–662
cardiac dysfunction in, 1746 physical examination in, 531 nipple discharge, 661, 662t
cardiac rupture, 1747 small, 530, 531f nipple irritation in, 659, 662
cardiac valves, 1746–1747 treatment of, 532 noninflammatory, 660–661
chordae tendineae, 1746–1747 Bowel sounds, auscultation of, 474 pathophysiology of, 658
commotio cordis in, 1746 Bowing fractures, 907–908, 915 physical examination of, 659
coronary vessels, 1747 Box jellyfish, 1367–1368, 1368f wound infections, 662
myocardial infarction, 1747 Boxer’s fracture, 1793 Breast implants, 662
papillary muscles, 1746–1747 Boyle’s law, 1368–1369 Breast surgery, complications of, 558
pericardial inflammation syndrome, 1747 Brachial plexopathy, 1162–1163 Breath-holding spells, 743, 837–838
physical examination in, 1747 Brachial plexus, 1162f Breathing
septum, 1746–1747 anatomy of, 1834, 1835f in head trauma, 1687–1688
thoracic great vessels in, 1747 injuries of, 1834 in neck injuries, 1723
in chest wall trauma, 177 clinical features of, 1834 in pediatric trauma, 692
of eye, 1548–1552 diagnosis of, 1834 periodic, 736, 740
hyphema, 1548 sensory distribution of, 1835f in trauma, 1671
orbital blow-out fractures, 1548–1549, Brachial plexus neuritis, 1894 Breech presentation, 644, 645f. See also Labor
1549f Bradyarrhythmias, 100, 105–106 and delivery
orbital hemorrhage, 1550–1552 drugs for, 101t Brief Confusion Assessment Method, 1137f
ruptured globe, 1549–1550, 1550f idioventricular rhythms in, 106, 106f Briefly resolved unexplained events (BRUEs),
in neck trauma, 1726–1727 junctional rhythm in, 105–106, 105f, 106t 739–744
Boerhaave’s syndrome, 331, 502 Bradyasystole, 56, 57t anatomic causes of, 743
Bomb and blast injuries, 30–33 Bradyasystolic arrest, 56–57 breath-holding spells in, 743
in children, 33 Bradycardia cardiac causes of, 743

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 Index   2037

child abuse in, 742–743 syncope and, 363 ischial, 1898

classification of, 740 treatment of, 121–122 ischiogluteal, 1898
defined, 740 Brugia malayi, 1091 nonseptic, 1928–1929
diagnostic testing in, 743 Brugia timori, 1091 olecranon, 1929
differential diagnosis of, 740–742, 741f, 742t Bruises, in child abuse, 990, 990f–991f prepatellar, 1928t, 1929
ED approach to, 743 B-type natriuretic peptide, 354, 426 septic, 1928t, 1929
epidemiology of, 740 Buckthorn, 1412 treatment of, 1899
gastroesophageal reflux disease in, 742 Budd-Chiari syndrome, 521 trochanteric, 1897–1898
metabolic causes of, 743 Budesonide, 793t Burst fracture, 1701f, 1713
oral dysphagia in, 742 Buerger’s disease, 421t Burst lung syndrome, 1370
pathophysiology of, 740 Bufotoxins, 1247t Buruli ulcers, 1657, 1657f
pertussis in, 742 Bulbar conjunctiva, 1523 Buspirone, 1219, 1220t
poisoning in, 742–743 Bulimia nervosa, 1956 Butoconazole, in Candida vaginitis, 650t
respiratory tract infections in, 742 criteria for, 1957t Butorphanol, 233t, 1235
risk stratification in, 743 Bulla, 1613f, 1613t Buttocks, trauma to, 1755–1757
seizures in, 742 diagnosis of, 1617f, 1617t Butyl-cyanoacrylate, 282, 283t
serious bacterial infections in, 743 Bullous impetigo, 933–934, 934f Butyrophenones, in nausea and vomiting,
Bristleworms, 1367 Bullous myringitis, 1564 484t
British anti-Lewisite, 1314 Bullous pemphigoid, 1649, 1649f
Broca’s aphasia, 1102 Bumetanide, 1281 C
Bromo-benzodifuranyl-isopropylamine, in heart failure, 372t Ca2+-sensing receptor, 96
1244t, 1247 BUN-to-creatinine ratio, 567 Cadmium, 1318t
Bromocriptine, 1212 Bupivacaine, 236 Caffeine, 1262–1263
Bromo-DragonFLY, 1244t, 1247 dosing and administration, 237t content in various products, 1263t
Bronchiolitis, 801–803 Buprenorphine, 233t, 1235 pharmacology of, 1263
bronchodilators in, 802 in opioid use disorder, 1963, 1965f toxicity of, 1264
causes of, 801 transdermal, 231 Calcaneus fractures, 1870–1872
clinical features of, 801 Bupropion, 1948–1949 Calcific tendinitis, 1891–1892
corticosteroids in, 803 pharmacokinetics of, 1199 Calcifications, 1905
diagnosis of, 801 toxicity of Calcitonin, 96
disposition and follow-up in, 803 clinical features of, 1199–1200 Calcium, 67, 95–98
in neonates, 734 treatment of, 1200, 1200t in beta-blocker toxicity, 1274
oxygenation in, 801 Burch and Wartofsky Point Scale (BWPS), in cardiac arrest, 159
pathophysiology of, 801 1452, 1453t in circulatory shock, 67
in pneumonia, 811 Buried dermal sutures, 275t, 276, 278f disorders of, 856
risk factors for, 801t Burkholderia mallei, 43t hypercalcemia, 97–98, 856
treatment of, 801–802, 802f Burns, 1384–1391. See also Environmental hypocalcemia, 95–97, 856
ventilation in, 803 injuries homeostasis of, 95
in wheezing, 801–803 chemical, 1391–1396 pathophysiology of, 95
Bronchiolitis obliterans organizing in children, 991 in resuscitation of children, 683t, 686
pneumonia, 448t classification of, 1386t Calcium antagonists, in vertigo, 1152t
Bronchitis. See also Respiratory disorders clinical features of, 1385–1388 Calcium channel blockers, 129–130, 132, 133t,
acute, 436–439 cutaneous, 1398 1275–1279
clinical features of, 436 depth of, 1385–1386, 1386t, 1387f in acute coronary syndrome, 348
diagnosis of, 436–437 in elderly, 1677 adverse effects of, 408t
epidemiology of, 436 electrical, 1397 in atrial fibrillation, 109
pathophysiology of, 436 epidemiology of, 1384 classes of, 1275
treatment of, 437 fluid resuscitation in, 1389, 1389t diltiazem, 129–130
in high-altitude disorders, 1383 hand, 1794 in heart failure, 371
Bronchoalveolar cell carcinoma, in pulmonary inhalation injury in, 1388 in heat emergencies, 1346
infiltrates, 448t initial assessment of, 1388–1389 in hypertension, 405t, 406
Bronchodilators in military medicine, 2012 nicardipine, 130
in anaphylaxis, 71 minor, 1390–1391 oral, 1276t
in bronchiolitis, 802 pathophysiology of, 1384–1385 pharmacology of, 1275–1276
dosages of, 806t physiologic effects of, 1385t in tachycardia, 102
Bronchorrhea, 253 prehospital care in, 1388 toxicity of, 1275–1279
Bronchoscopy, in hemoptysis, 438 size of, 1385, 1385f adrenergic agents, 1278
Broselow® resuscitation tape, 679f transfer to burn unit, 1387–1388 calcium salts in, 1277–1278
Brown-Séquard syndrome, 1710 treatment of, 1388, 1389t clinical features of, 1276
Brucella, 43t, 1066t escharotomy in, 1390f diagnosis of, 1276–1277
Brucella canis, 1071t of minor burns, 1390–1391 extracorporeal circulatory support in,
Brucellosis, 1076, 1077t wound care in, 1389–1390 1279
signs and symptoms of, 43t BURP maneuver, 182 gastrointestinal decontamination in,
treatment of, 1075t Bursae, 1895 1277
Brudzinski sign, 750, 754 Bursitis, 1927–1928. See also Musculoskeletal glucagon in, 1279
Brugada pattern, 1239 disorders insulin therapy in, 1278–1279, 1278t
Brugada syndrome, 55, 55f, 105, 120–122 differential diagnosis of, 1007t lipid emulsion in, 1279
clinical features of, 121 of foot, 1929–1930 treatment of, 1277–1279, 1277t, 1278f
electrocardiogram of, 121f, 121t iliopectineal, 1898 in urologic stone disease, 602
risk stratification in, 122t iliopsoas, 1898 verapamil, 129–130

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 2038   Index

Calcium chloride, in resuscitation of poisoned ancillary testing in, 1416 asystole/pulseless electrical activity,
patient, 1188t in burns, 1388 160–161, 161f
Calcium gluconate carboxyhemoglobin in, 1415–1416 ventricular fibrillation/ventricular
in emergency delivery, 638t in children, 1417 tachycardia, 159–160, 160f
in resuscitation of poisoned patient, 1188t clinical features of, 1415–1416 capnography in, 158
Calcium oxalate, 1230, 1411t delayed neurologic sequelae in, 1417 chain of survival in, 152, 153f
Calcium-induced calcium release, 1270 in elderly, 1417 complications in, 158–159
Calluses, 1659t, 1662–1663, 1663t encephalopathy in, 1417 differential diagnoses for cardiac arrest in,
Camper’s fascia, 591 epidemiology of, 1414–1415 158
Campylobacter infections, 1066t, 1067 history in, 1416 drugs used in, 158–159
gastroenteritis in, 846t hyperbaric oxygen therapy in, 140 amiodarone, 159
Canadian Triage Acuity Scale, 1934 imaging in, 1416 atropine, 159
Cancer. See also Tumors inflammatory and platelet effects, 1415 beta-blockers, 159
alveolar cell, 448t mitochondrial inhibition in, 1415 calcium, 159
breast, 660 pathophysiology of, 1415 epinephrine, 158
bronchioloalveolar cell, 448t physical examination in, 1416 lidocaine, 158–159
of cervical spine, 1883 in pregnancy, 1417 lignocaine, 158–159
disseminated intravascular coagulation in, signs and symptoms of, 1415t magnesium, 159
1472t sources of, 1415t sodium bicarbonate, 159
Hodgkin’s lymphoma, 957 tissue hypoxia in, 1415 vasopressin, 159
leukemia, 956–957, 1472t treatment of, 1416–1417 Primary ABCD Survey, 155–157, 155f
non-Hodgkin’s lymphoma, 958 in winter disasters, 29 Secondary ABCD Survey, 157, 157t
oral, 1585 Carbon monoxide toxicity, headache in, vascular access, 157
penile, 595 1113 Cardiac markers, in end-stage renal disease,
thyroid, 789 Carbonic anhydrase inhibitors, 1536t 574
venous thromboembolism in, 399 Carboprost, in emergency delivery, Cardiac output
Candida infections, 1652t 638t, 653t monitoring of, 214–215
drugs for, 1037t Carboxyhemoglobin, 1388 noninvasive measurement of, 215
in groin and skinfolds, 1652–1653, 1653f in carbon monoxide poisoning, 1415, 1415f optimal, 214
in HIV infection, 1037t, 1040, 1040f Carboxyhemoglobinemia, 430 pulse contour analysis, 215
treatment of, 1037t Carboxylic acids, 1411t in shock, 58
vaginitis, 649–650 Carbuncles, 1005, 1008–1010 transthoracic echocardiography, 215
Candidiasis, 1036t Carcinoma volume responsiveness in mechanically
Canes, 1781 alveolar cell, 448t ventilated patients, 214–215
Cangrelor, 347 bronchioloalveolar cell, 448t volume responsiveness in spontaneously
Canker sores, 776–777, 776f disseminated intravascular coagulation in, breathing patients, 214–215
Cannabinoid hyperemesis syndrome, 261, 1472t Cardiac pacing, 216–223
261t, 264t penile, 595 asynchronous, 217
Cannabinoids, 1246–1247 Carcinomatous meningitis, 1113 in beta-blocker toxicity, 1275
Cannabis, 1244t, 1246 Cardiac arrest, 159–160. See also Heart equipment in, 216–217, 217t
for chronic pain, 262 disorders indications for, 217t, 350t
Cantharides, 1395 algorithms for, 159–162 permanent, 218–222
Capillary glucose monitoring, 1423 asystole/pulseless electrical activity, coding system in, 221t
Capitate fracture, 1802t, 1804–1805, 1806f 160–161, 161f complications in, 220–221
Capitellum fractures, 1819 ventricular fibrillation/ventricular malfunction of, 221, 222f
Capnocytophaga, 1071t tachycardia, 159–160, 160f nomenclature, 219–220
Capnocytophaga canimorsus infections, 322 bradyasystolic, 56–57, 57t pacemaker syndrome in, 220–221
Capnogram, 81f differential diagnoses of, 161–162 programming errors in, 222
Capnography, 80–81, 153–154, 158, 250–251, 251f drugs used in resuscitation in, 220
Capsaicin, 1413 amiodarone, 159 tachycardia in, 221–222
in neuropathic pain, 264t atropine, 159 purpose of, 216
Capsicum, 1326t calcium, 158–159 in sudden cardiac death, 54
Captain Morgan technique, 1847, 1848f epinephrine, 158 temporary, 350t
Captopril, 133t, 886t, 1282 lidocaine, 158–159 transcutaneous, 217
in hypertension, 407t lignocaine, 158–159 transvenous, 217–218
Carb counting, 1420 magnesium, 159 Cardiac pump theory on chest compressions,
Carbamates, 1303–1304 sodium bicarbonate, 159 143
Carbamazepine, 234t, 628 epidemiology of, 152 Cardiac rate, 820
in bipolar disorder, 1950t extracorporeal CPR in, 163, 163t Cardiac resuscitation, 153–164
in neuropathic pain, 264t hypothermic, 1344 advance directives, 172
toxicity of, 119–123, 1285–1286 in intubation, 1742 advanced cardiac life support, 155–159
clinical features of, 1286 in mass gatherings, 17 advanced techniques in, 163–164
diagnosis of, 1286 post-cardiac arrest syndrome, 169–171 algorithms for, 159–162
treatment of, 1286 in pregnancy, 167–168, 168t capnography in, 153–154
in vertigo, 1152t toxin-induced, interventions in, 1188t cardiac arrest algorithms, 159–162
Carbapenem, in pneumonia, 445t in trauma, 1675 asystole/pulseless electrical activity,
Carbolic acid (phenol), 1392 Cardiac biomarkers, 1748 160–161, 161f
Carbon monoxide poisoning, 39, 1414–1417. Cardiac disorders. See Heart disorders ventricular fibrillation/ventricular
See also Environmental injuries; Cardiac life support, advanced, 152–159 tachycardia, 159–160, 160f
Poisoning algorithms for, 159–162 chain of survival in, 154–155, 154f

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chest compressions, 153
complications of, 162–163
ventilation, 162
counseling for survivors, 173
defibrillation, 153
epidemiology of, 154
ethical issues in, 172–173
extracorporeal membrane oxygenation in,
154
futility of, 172
nonbeneficial interventions in, 172
outcomes, 172
oxygenation in, 153–154
post-ROSC care in, 154
procedures on recently deceased patients,
172–173
social media and education in, 154
termination of, 172
Cardiac rhythm disturbances. See
Arrhythmias
Cardiac rupture, 1747
Cardiac syncope, 835
Cardiac tamponade
in aortic dissection, 412
in cardiac arrest, 162
causes of, 388t
clinical features of, 387–388
diagnosis of, 388
in end-stage renal disease, 574
nontraumatic, 387–388
pathophysiology of, 387
in penetrating cardiac trauma, 1744
in pericardiocentesis, 223
treatment of, 388
Cardiac trauma, 1742–1751
anatomy in, 1743
blunt injuries in, 1746–1747
cardiac dysfunction in, 1746
cardiac rupture, 1747
cardiac valves, 1746–1747
chordae tendineae, 1746–1747
commotio cordis in, 1746
coronary vessels, 1747
myocardial infarction, 1747
papillary muscles, 1746–1747
pericardial inflammation syndrome,
1747
pericardium, 1746
septum, 1746–1747
epidemiology of, 1742–1743
great vessel injury, 1747–1751
history in, 1743–1744
pathophysiology of, 1743
penetrating, 1744–1746
cardiac tamponade in, 1744
iatrogenic injuries in, 1744
intracardiac missiles in, 1744
pathophysiology of, 1752–1753
pericardiocentesis for, 1744
thoracotomy for, 1745–1746
tranexamic acid for, 1746
treatment of, 1744–1746
physical examination in, 1744
Cardiac troponins, 332–333
Cardioactive steroids, 1248
Cardiogenic pulmonary edema, 177
Cardiogenic shock, 57, 352–357. See also
Cardiovascular disorders
causes of, 353t
clinical features of, 353
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2039
diagnosis of, 353–355, 354f
differential diagnosis of, 353t
early revascularization in, 356
epidemiology of, 352
extracorporeal membrane oxygenation in,
356–357
hemodynamic monitoring in, 355
history in, 353
imaging in, 354–355
inotropes for, 355–356, 356t
intra-aortic balloon pump counterpulsation
in, 356
laboratory testing in, 354
mechanical catastrophe diagnosis, 355
pathophysiology of, 352–353
physical examination in, 353–354
risk factors for, 353t
thrombolytic therapy in, 356
treatment of, 355–356
ventricular assist devices in, 356
Cardiomegaly, 1487
Cardiomyopathy, 380–384. See also
Cardiovascular disorders
arrhythmogenic right ventricular, 53–54
arrhythmogenic ventricular, 838
in children, 833–835
clinical features of, 380t
diabetic, 1425t
diastolic dysfunction in, 383–384
dilated, 381, 833–834, 838
hypertrophic, 53, 383–384, 834–835, 838
inflammatory, 381–383
left ventricular assist devices in, 382, 382f
peripartum, 624, 636
primary, 380t
restrictive, 384
secondary, 380t
septic, 998
in sudden cardiac death, 53–54
systolic dysfunction in, 381–383
uremic, 574
Cardiopulmonary resuscitation, 143–148
airway management in, 144–146
head tilt-chin lift maneuver, 145
jaw thrust maneuver, 145, 145f
suspected opioid overdose, 145
American Heart Association chain of
survival in, 144t
closed chest compressions in, 143–144,
144t, 145f
complications of, 148
defibrillation, 149–153
drugs used in, epinephrine, 158
ethical considerations in, 148
ethnical considerations in, 148
experimental techniques, 148
in foreign body obstruction, 146–148
chest thrust maneuver, 147–148, 148f
finger-sweep maneuver, 148
Heimlich maneuver, 147, 147f
obstruction airway (Heimlich)
maneuver, 147
in mass casualty triage, 2013
mechanical devices for chest compression,
148
open chest cardiac compressions in, 144
sequence of steps in, 143, 144t
systematic approach to, 144t
termination of, 148
ventilation in, 146
Index   2039
mouth-to-mask, 147, 147f
mouth-to-mouth, 146, 146f
mouth-to-nose, 146
mouth-to-stoma or tracheotomy, 146
rescue breathing, 146
Cardiopulmonary system, 31
Cardiorenal syndrome, 569–570
Cardiovascular disorders, 329–423
acute coronary syndromes, 334–352
aneurysm, 415–419
aortic dissection, 412–415
aortic syndromes, 412–415
arterial occlusion, 420–423
cardiogenic shock in, 352–357
cardiomyopathies in, 380–384
chest pain in, 329–333
cocaine in, 1239
in eating disorders, 1957
in end-stage renal disease, 574
heart failure, acute, 367–374
in high-altitude disorders, 1383
in HIV infection, 1039
in hydrocarbon toxicity, 1294
hypertension, systemic, 399–408
hypothyroidism in, 1450
in methylxanthines, 1263, 1265
in nonsteroidal anti-inflammatory drugs,
1260–1261
pericardial, 384–389
in pregnancy, 623–624
pulmonary hypertension, 408–412
in shock, 60t
in sickle cell disease, 1487
in spinal injuries, 1714
syncope, 362–367
in systemic rheumatic diseases, 1908–1910,
1909t
in type II diabetes, 1425
valvular, 374–380
venous thromboembolism, 389–399
in volatile substance toxicity, 1294
Cardioversion
in children, 686
energy requirements for, 689t
defined, 149
equipment in, 149–150
patient positioning in, 150
patient selection, 149
placement of paddles/pads in, 150, 150f
purpose of, 149
steps in, 152
Caregiver fabricated illness, 994–995
Caries, 782, 1581
Carisoprodol, 1219–1220, 1220t
Carnitine, 969
Carotid artery dissection, 1125–1126
Carotid sinus hypersensitivity, 363
Carotid sinus massage, 102t
Carotid stenting, 1135
Carpal bones, 1795
capitate fracture, 1804–1805, 1806f
fractures, 1802–1805, 1802t
hamate fractures, 1804, 1805f
injuries of, 916
pisiform fracture, 1804, 1804f
scaphoid fracture, 1802–1803, 1802f,
1802t
trapezium fracture, 1803–1804, 1804f
trapezoid fracture, 1805
triquetrum fracture, 1803, 1803f
8/2/19 6:02 PM
 2040   Index

Carpal tunnel syndrome, 1161–1162, 1919 Cavernous sinus thrombosis, 1584 periorbital, 765–766
Carvedilol, 126, 407t Cayenne, 1326t postseptal (orbital), 1539, 1539t
Cassava, 1320 CCR-5 antagonist, 1043t preseptal, 1134, 1539t
Castor bean, 1412 CD4+ T-cell counts, 1034–1035 in puncture wounds, 319
Cat bites, 321–322 Cefaclor, 73 purulent, 1005
Cataracts, in children, 771, 771f Cefazolin rashes in, 935–936
Catastrophic antiphospholipid syndrome, in bacterial infections, 933t risk factors for, 1006t
1477, 1910 in facial infections, 1568t treatment of, 1007
Catatonia, 1953, 1956 in intra-abdominal infections, 480t antibiotics in, 1008t
Catecholaminergic polymorphic ventricular Cefdinir, 773t empiric, 1008t
tachycardia, 56 Cefepime vaginal cuff, 665
Catecholamines, 1281 in intra-abdominal infections, 480t Cellulose, 270
Caterpillars, 1357 in pneumonia, 445t Centers for Disease Control and Preven­tion,
Catheterization, 1327–1328 in puncture wounds, 319 21t
arterial, 209–211 in urinary tract infections, 583t, 873t Central cord syndrome, 1709–1710
alternative sites, 209 Ceftibuten, 873t Central herniation syndrome, 1140
complications in, 211t Cefixime Central nervous system
indications for placement in, 209f in gonorrhea, 1015t, 1018 in acute radiation syndrome, 49
materials for, 210t in urinary tract infection, 873t disorders of, 1172–1178
radial artery anatomy in, 209 Cefotaxime electrical injuries of, 1398
techniques for, 210, 210t, 211f in intra-abdominal infections, 480t fungal infections of, 1175
ultrasound-guided localization of, 210 in pelvic inflammatory disease, 657t hydrocarbon toxicity in, 1294–1295
obturator technique in, 588, 590f in urinary tract infections, 583t infections of, 1172–1176
peel-away sheath technique in, Cefotetan, in pelvic inflammatory disease, lesions, 1159
588–589 657t nonsteroidal anti-inflammatory drug effects
in pneumothorax, 460 Cefoxitin on, 1260–1261
suprapubic, 587–589 in deep space infection, 1915t procedures and devices, 1179–1185
urethral, 587, 588f in flexor tenosynovitis, 1915t cerebrospinal fluid shunts, 1180–1184
Catheters Cefpodoxime halo devices, 1183–1184
complications in pediatric cancer patients, in bacterial sinusitis, 773t intrathecal baclofen, 1184–1185, 1184f,
965 in urinary tract infection, 582t, 873t 1185t
complications of, 602–604 Ceftazidime lumbar puncture, 1179–1180
Foley, 588f, 603 in intra-abdominal infections, 480t peripheral nerve stimulation, 1185
indwelling venous, 979–980 in pneumonia, 445t spinal cord stimulation, 1185
leakage of, 603 in puncture wounds, 319 stimulators, 1185
nasogastric, 475 in urinary tract infection, 873t tumors of, 958
obstruction, 603 Ceftizoxime, 657t clinical features of, 958
pigtail, 460 Ceftriaxone, 948 diagnosis of, 958
small-size, 460 in bacterial sinusitis, 773t epidemiology of, 958
urinary, 475 in chancroid, 1015t treatment of, 958
Word, 653f in diverticulitis, 528t Central retinal artery, 1523
Cathinones, 1239, 1244t, 1245–1246 in endocarditis, 833 Central retinal artery occlusion, 1555
Cat-scratch disease, 322, 322f, 322t, 769, 787 in gonorrhea, 1015t, 1017 hyperbaric oxygen therapy in, 139
Cattle prod, 1403 in intra-abdominal infections, 480t Central retinal vein occlusion, 1555
Cauda equina syndrome, 1163, 1710, 1887 in pelvic inflammatory disease, 657t Central venous access, 202–208
Cauliflower ear, 1564 in pneumonia, 445t anatomy in, 202–203
Caustic ingestions, 1296–1300 for sexual infection prophylaxis, 1970t neck, 203f
acids in, 1297, 1298f in syphilis, 1016t torso and lower extremities, 204f
alkali injuries in, 1297 in urinary tract infections, 582t–583t, 873t in children, 721–723, 721t
clinical features of, 1297 Cefuroxime, in bacterial sinusitis, 773t complications in, 203t
common caustic compounds, 1297t Celecoxib, in nonneuropathic pain, 264t in external jugular vein, 203
complications in, 1300 Celiac disease, 851 in femoral vein, 207–208, 722
diagnosis of, 1297–1298 Cellulitis, 1005–1008. See also Infections in infants, 721–723, 721t
endoscopy in, 1298–1299 antibacterial drugs, 931–932 in internal jugular vein, 203–206, 721–722
epidemiology of, 1294 antibiotics for, 1568t materials for, 203t
history in, 1297 in breast, 660 placement of catheters in, 721
imaging of, 1298 in children, 935–936 preprocedure checklist for, 203t
laboratory testing in, 1298 clinical features of, 1006 Seldinger technique in, 204f, 204t
laundry detergent pods, 1300 definition of, 1005 in subclavian vein, 206–207, 206f–207f,
pathophysiology of, 1297 diagnosis of, 1007 721
physical examination in, 1297 differential diagnosis of, 1007t techniques for, 203–208
treatment of, 1299–1300 disposition and follow-up in, 1007–1008 ultrasound-guided, 203t
antibiotics in, 1299 dissecting, of the scalp, 1631–1632, 1632f venous cutdown in, 208
decontamination in, 1299 epidemiology of, 1005 Central venous oxygen saturation, 216, 216t
esophageal stenting and dilation in, facial, 1566 Central venous pressure, 213–214
1299 of hand, 1914–1915 contributors to, 213t
fluid resuscitation in, 1299 nonpurulent, 1005, 1007 invasive measurement of, 214
nutritional support in, 1300 orbital, 766–767, 766f noninvasive measurement of, 214
steroids in, 1299 organisms in, 1006, 1006t ultrasonography, 214
systemic toxicity in, 1300 pathophysiology of, 1006 waveforms, 214f

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 Index   2041

Central venous thrombosis, in pregnancy, 627 treatment of, 1883 lime, 1395
Centrally mediated abdominal pain syndrome, Cervical spine lyes, 1394–1395
261t, 264t algorithms for clearance, 709f metal, 1395
Cephalexin cancer of, 1883 methacrylic acid, 1394
in asymptomatic bacteriuria, 626 clearance for, 6t nitric acid, 1394
in bacterial infections, 933t imaging of, 1671t, 1711–1712 ocular burns, 1396
in cellulitis, 1915t injuries of, 2012 oxalic acid, 1394
in cystitis, 626 in children, 698, 706–709 pathophysiology of, 1391
in endocarditis, 833 clinical features of, 707 percutaneous absorption in, 1391t
in facial infections, 1568t diagnosis of, 707, 708f phenol, 1392
in felon/paronychia, 1915t in elderly, 1678 Portland cement, 1395
in urinary tract infection, 873t epidemiology of, 706 potassium permanganate, 1396
Cephalic tetanus, 1049 history in, 707 sulfur mustard, 1395
Cephalosporin, 73 imaging of, 707–709 sulfuric acid, 1392
in hemolytic anemia, 1492t laboratory testing in, 707 systemic effects of, 1392t
in intra-abdominal infections, 480t ligamentous, 1711–1712 treatment of, 1391–1392, 1393t
in pelvic inflammatory disease, 657t pathophysiology of, 706 vesicants, 1395
in peritonitis, 578 physical examination in, 707 white phosphorus, 1396
in pneumonia, 444t–445t radiographic evaluation of, 707–708, Chemical conjunctivitis, 1553
in puncture wounds, 319 708f Chemical disasters, 35–41. See also Disaster
toxicity of, 1327 spinal motion restriction in, 706–707 situations
in typhoid fever, 1082 treatment of, 80, 708–709, 1713–1714 community risk for, 36
Cephalothin, 578 instability of, 1910 decontamination in, 37
Cerebellar ataxia, 1143 trauma in, 1685t exposure-limit guidelines, 35–36
Cerebellar hemorrhage, 1126 Cervical spondylosis, 1883 hazmat response in, 36, 38
Cerebellar stroke, 1146, 1150t Cervix, dilatation of, 637 high-risk chemicals, 38–41, 39t
Cerebellar testing, 1106, 1106f Cesarean delivery, perimortem, 1683 asphyxiants, 38–39
Cerebellum Cesarean scar pregnancy, 616 biotoxins, 41, 41t
heat stroke effects on, 1368 Cestodes, 1090 botulinum toxin, 41
neurologic examination of, 1106, 1106f Cetirizine, 1622t chemical asphyxiants, 39–40
Cerebral arterial gas embolism, 1370 Chaconine, 1411t, 1413 incapacitating agents, 40
Cerebral blood flow, in head trauma, 1683 Chagas’ disease, 1087 irritant agents, 39
Cerebral edema Chainsaws, 303 nerve agents, 40
in diabetic ketoacidosis, 974–975, 1439, Chalazion, 1540, 1540f ricin, 41
1440t Chamomile, 1325t toxic inhalants, 38
in high-altitude disorders, 1381, 1381f Chance fracture, 1713 vesicants, 40–41
Cerebral infarction, 1125 Chancroid, 1015t, 1021 identification of substances in, 36, 36t
Cerebral ischemia, 946–947 clinical features of, 1018t, 1021, 1021f isolation and scene control in, 36–37, 37f
Cerebral palsy, 981, 981t diagnosis of, 1021 personal protective equipment, 38f
Cerebral perfusion pressure management, treatment of, 1021 recognition of, 36
1689 Channelopathies, 54–56 scene response in, 36
Cerebral salt-wasting syndrome, 84 Channels (radio frequencies), 4 triage in, 37–38
Cerebral venous thrombosis, headache in, Chaparral, 519t, 1326t Chemical pneumonitis, 448t
1110 Charcot’s foot, 1873 Chemical terrorism, 35
Cerebrospinal fluid Charcot’s triad, 514 Chemosis, 1551f, 1552
in bacterial meningitis, 756, 1173t Charlotte rule, 392, 394t Chemotherapeutic agents
leaks in head trauma, 1689–1690 Cheeks antidotes for, 1519
Cerebrospinal fluid shunts, 1180–1184 anatomy of, 291, 291f extravasation of, 1518t, 1519
abdominal complications of, 1181 lacerations of, 291 in hemolytic anemia, 1492t
clinical presentation of, 1181–1182 Chemical asphyxiants, 39–40 Chemotherapy
evaluation of, 1182 Chemical burns, 1391–1396. See also Burns nausea in, 1518–1519
infection of, 1183 acetic acid, 1392 vomiting in, 1518–1519
loculation of, 1181 acid, 1392–1394 Chest compressions, 153
malfunctions of, 1181 airbag burns, 1396 Chest CT angiography, in venous
mechanical failure of, 1181 alkali, 1394–1395, 1395f thromboembolism, 392–395, 394f
obstruction in, 1181 alkyl mercury compounds, 1396 Chest pain, 329–333. See also Cardiovascular
overdrainage of, 1181 cantharides, 1395 disorders
in technology-dependent children, 980, carbolic acid (phenol), 1392 acute, 329
980t chromic acid, 1392 in acute coronary syndrome, 329, 352
treatment of malfunction in, 1183 classification of chemicals, 1392t in acute myocardial infarction, 326
Cerumen, 1564–1565 dimethyl sulfoxide, 1395 in acute pericarditis, 332
Cervarix®, 1023 epidemiology of, 1391 anginal equivalents, 330
Cervical artery dissection, 1125, 1136 to eye, 1552–1553 in aortic dissection, 331
Cervical collars, 6–7 formic acid, 1392 cardiac biomarkers, 332–333
Cervical disk herniations, 1884 gasoline, 1409 causes of, 331t
Cervical myelopathy, treatment of, 1884 hot tar, 1395 in chest wall pain syndromes, 332
Cervical plexopathy, 1163 hydrocarbons, 1395 classic, 329
Cervical radiculopathy hydrochloric acid, 1392 clinical features, 329–330
differential diagnosis of, 1882t hydrofluoric acid, 1392–1394, 1394t clinical risk scores, 329–330, 333
signs and symptoms of, 1882t lachrymators or tear gas, 1396 in cocaine toxicity, 1241

FB:Cardiologia Siglo XXI

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 2042   Index
Chest pain (Cont.):
cocaine-associated, 330
diagnosis of, 330–332
diagnostic testing of, 332–333
electrocardiography in, 332
epidemiology of, 329
in esophageal rupture, 331
gastrointestinal pain in, 332
history of, 329–330
in hypertension, 401
imaging in, 332
initial assessment of, 329
ischemic symptom equivalent, 330
in mitral valve prolapse, 332
nonclassic, 329–330
pathophysiology of, 329
physical examination of, 330
in pneumonia, 331
postprocedure, 352
in pregnancy, 624
in pulmonary embolism, 331
response to therapy, 330
risk factors, 330
in sickle cell disease, 945
spontaneous pneumothorax, 332
Chest thrust maneuver, 147–148, 148f
Chiari malformation, 981–982, 982t
Chicken pox, 931, 1027–1029
clinical features of, 1028, 1028f
diagnosis of, 1028–1029
pathophysiology of, 1028, 1029f
treatment of, 1029
vaccines for, 1028
Chiggers, 1356
Chikungunya fever, 1031, 1085
Chilblains, 1333
Children
abdominal pain in, 857–864
abdominal trauma in, 697–698
blunt, 697
hollow viscous injury, 697
liver and spleen injuries, 697
pancreatic injury, 697
renal injury, 697
abuse and neglect of, 988–995
behavioral disorders in, 985
in BRUEs/ALTEs, 742–743
caregiver-fabricated illness, 994–995
of children with special healthcare
needs, 979
epidemiology of, 988–989
imaging in, 992–993
laboratory testing for, 992
neglect, 989
physical abuse in, 990–993
reporting, 995
sexual abuse in, 993–994
treatment of, 993
agitation in, 1940
airway management in, 714–719
altered mental status in, 902–904
anatomy of, 669, 690–691, 690t
appendicitis in, 526–527
ataxia or gait disorder in, 1140t, 1145,
1145t
bacteremia in, 747
behavioral disorders in, 982–988
bomb and blast injuries in, 33
bradycardia decision tree for, 688f
carbon monoxide poisoning in, 1417
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2042
cardiac physiology of, 820
central venous access in, 721–723, 721t
cervical spine injuries in, 698, 706–709
cyanosis in, 676–677, 677t
death of, 689, 689t, 2006
dehydration in, treatment of, 853–854, 853t
dental trauma in, 781
developmental stages, 670t
diarrhea in, 844
dysrhythmias in, 686–687, 839–841
ear disorders in, 756–762
electrical injuries in, 1400–1401
electrical injuries of, 1401f
electroencephalography in, 841–842
emergency care of, 669–671
diagnosis in, 670
epidemiology, 669
history in, 669
imaging in, 670
laboratory evaluation in, 670
physical examination in, 669–670
eye disorders in, 763–771
amblyopia, 764
blepharitis, 765
cataracts, 771, 771f
conjunctivitis, 768–770
corneal abrasion, 767
dacryoadenitis, 765
dacryocele, 765
dacryocystitis, 764–765, 765f
dacryostenosis, 764–765
glaucoma, 770
leukocoria, 770–771, 771t
ophthalmia neonatorum, 767–768, 768t
orbital cellulitis, 766–767, 766f
periorbital cellulitis, 765–766
red eye, 767–770
retinal hemorrhages, 771
retinoblastoma, 771
strabismus, 764
facial fractures in, 1721
fever in, 746–752
fluid and electrolyte therapy in, 851–856
foot and leg lacerations in, 306
foreign bodies in, 679–680
in conscious children, 679
in unconscious children, 679–680
fractures in, 904–921
ankle, 919–921
carpal bone fractures, 913
clavicle, 908–909, 908f
of elbow, 909–914
foot and toe injuries in, 921
forearm, 914–916
greenstick, 907–908
hip, 917
humerus, 909
lower extremity injuries, 909–918
medial epicondyle, 910, 913f
olecranon, 910, 913f
pelvic, 917
phalangeal, 916
physeal, 905–906
plastic deformities, 907–908, 908f
proximal tibia, 919
radial head and neck, 910, 914f
slipped capital femoral epiphysis,
917–918
of tibia and fibula diaphyses, 919
torus, 906–907, 907f
gastrointestinal bleeding in, 864–870
gastroschisis in, 678
genitourinary trauma in, 1762
gynecologic problems in, 879–880
hand lacerations in, 294
headaches in, 896–902
heart disorders in, 819–835
acquired, 830–835
congenital, 811–819
heart rate, normal, 841, 841t
heat emergencies in, 1350
hematologic disorders in, 949–955
anemia, 953–954
hemophilia, 949–952
neutropenia, 955
thrombocytopenia, 954–955
vitamin K deficiency bleeding, 952–953
von Willebrand’s disease, 952
hypoglycemia in, 672
hypothermia in, 672, 1344
hypoxemia in, 672
immunizations in, 671t
intraosseous access in, 719–721
intubation in, 710–718
malaria in, drugs for, 1061t
medication calculations in, 683–684, 684t
meningitis in, 747, 752–756
metabolic emergencies in, 965–971
congenital adrenal hyperplasia, 970–971
hypoglycemia, 966–967
inborn errors of metabolism in, 967–970
minor head injury and concussion in,
698–705
mouth and throat disorders in, 775–782
aphthous ulcers, 776–777, 776f
caries, 781
gingivitis, 782
group A b-hemolytic Streptococcus
pharyngitis, 779–780, 780t
hand, foot, and mouth disease,
777, 778f
herpangina, 777
herpes simplex gingivostomatitis,
777–778, 778f
pharyngitis, 778–780
soft tissue injuries, 781–782
stomatitis, 777–778
uvulitis, 780–781
neck masses in, 782–789
neck trauma in, 1729
omphalocele in, 678
oncologic disorders in, 955–965
bone and soft tissue sarcomas, 960–961
cardiopulmonary complications in, 965
catheter-related complications in, 965
central nervous system tumors, 958
complications in, 961–965
Ewing’s sarcomas, 961, 961f
gastrointestinal complications in, 965
genitourinary complications in, 965
germ cell tumors, 960, 960f
Hodgkin’s lymphoma, 957, 958f
infection in, 961–962
infections, 961–962
intracranial pressure in, 964
leukemia, 957
metabolic complications in, 962–965
nephroblastoma (Wilms’ tumor),
959, 959f
neuroblastoma, 958–959
8/2/19 6:02 PM

neurologic emergencies in, 964–965
non-Hodgkin’s lymphoma in, 958
osteosarcomas, 960–961, 961f
retinoblastoma, 959–960
rhabdomyosarcoma, 960
seizures in, 964–965
spinal cord compression in, 964
stroke in, 964
superior mediastinal syndrome in,
963–964
superior vena cava syndrome, 963–964
oral problems in, 781–782
orthopedic injuries in, 904–921
otitis media in, 756–761
pain management in, 723–727
pathophysiology of, 669
peripheral venous access in, 721
physiology of, 690t, 691
pneumonia in, 811–819
pneumothorax in, 677–678
pruritus in, 548
pulseless arrest decision tree, 687f
rabies in, 1056
rashes in, 925–944
renal emergencies in, 881–888
acute kidney injury, 881–882
chronic kidney disease, 876
glomerulonephritis, 883–885
hematuria, 887–888
hypertension, 885–887
nephrotic syndrome, 882–883
renal tubular acidosis, 885
resuscitation of, 679–689
airway management in, 680
bag-valve mask, 682
basic life support, 679–680, 680f–681f,
681t
breathing, 682
choking and foreign-body management,
679–680, 682f
circulation, 682
coping with death of child, 689, 689t
drugs for, 683t, 684–686
family presence during, 689
fluids, 683
mouth-to-mouth, 682
neonates, 673–679
termination of, 687
unconscious children, 679–680
vascular access, 682
sedation in, 728–731
seizures in, 888–896
sepsis in, 747
septic arthritis in, 921–922
sexual abuse and assault of, 1971
sickle cell disease in, 944–949
sinusitis in, 747, 772–774
with special healthcare needs, 976–982
autism spectrum disorders in,
980–981
cerebral palsy in, 981, 981t
checklist for emergency care in, 978t
congenital heart disease, 976–978
congenital or developmental disorders
in, 977t
Down’s syndrome in, 981
emergency information form, 976
epidemiology of, 976
gastrointestinal disorders in, 978–979
history in, 976
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Tintinalli_Index_p2025-2116.indd 2043
intellectual disability in, 980
metabolic disorders in, 978
musculoskeletal disorders in, 979
neglect and abuse of, 979
neural tube defects in, 981–982, 981t
physical examination in, 976
respiratory disorders in, 978
seizures in, 978
skin disorders in, 979
technology-dependent, 979–980
treatment of, 976–979
urinary tract infection in, 982
spinal cord injury in, 698
stridor in, 789–798
syncope in, 835–839
tachycardia decision tree for, 688f
thoracic and lumbar spine injury, 698
thrombocytopenia in, 1470
tracheoesophageal fistula in, 678
transport of, 671–673
trauma in, 689–698. See also Pediatric
trauma
treatment of, 670–671
legal issues in, 2016–2017
tuberculosis in, 456
urinary tract infection in, 747, 870–874
urologic disorders in, 874–879
vascular access in, 719–722
vital signs in, 670t, 691t
vomiting in, 842–843
von Willebrand’s disease in, 1482
weight estimation in, 683–684, 689t
wheezing in, 798–810
Chlamydia pneumoniae infections, 436
Chlamydia psittaci, 43t
Chlamydia trachomatis infections, 875–876,
1014–1017
clinical features, 1014
diagnosis of, 1014
with gonorrhea, 1014
in pneumonia, 811
in pregnancy, 812t
premature rupture of membranes in, 634
treatment of, 1014–1017, 1015t
in urinary tract infections, 581–582
Chlamydial conjunctivitis, 728, 1541
Chlamydophila pneumoniae infections, in
pneumonia, 440t, 441
Chlamydophila psittaci, 1071t
Chloral hydrate, 1220, 1220t
Chloramine gas, 1297
Chlorine, 39, 1319t, 1320
Chlorophenoxy herbicides, 1305
Chloroprocaine, 237t
Chloroquine, 1063t, 1328
Chloroquine phosphate, 1056
Chlorpromazine, 622t, 901
in agitation, pediatric dosing of, 987t
in hiccups, 428t
in migraine headache, 1112t
in serotonin syndrome, 1204
Chlorthalidone, 132, 133t
Choking, in children, 679–680, 682f
Cholangiocarcinoma, in Crohn’s disease,
489t
Cholangiopancreatography, 514
Cholangitis, 512, 1000
in Crohn’s disease, 489t
treatment of, 515
Cholecalciferol, 1308t
Index   2043
Cholecystectomy, complications of, 560t
Cholecystitis, 478t, 512–516. See also
Gastrointestinal disorders
acalculous, 516
acute, 515
acute acalculous, 513
chronic, 513, 516
clinical features of, 513
diagnosis of, 513–514, 513t
emphysematous, 512, 515, 1426t
epidemiology of, 512–513
gangrenous, 512–513
in gastrointestinal surgery complications,
559
history in, 513
imaging in, 514–515, 515t
in infants and children, 863
laboratory testing in, 514
pathophysiology of, 513
physical examination in, 513
postcholecystectomy syndrome in, 516
in pregnancy, 628
in sepsis, 1000
treatment of, 515
Cholecystographic agents, 1456t
Choledocholithiasis, 513
imaging for, 514–515
Cholelithiasis, in Crohn’s disease, 489t
Cholera, 1089–1090
Cholescintigraphy, 514
Cholesteatoma, 762f
Cholestyramine, 1456
Cholinergics, 1190t, 1411t, 1537t
Cholinesterase, 1301
Chondroitin, 1325t
Chondromalacia patellae, 1900
Chopart joint, 1870
Chordae tendineae, 1746–1747
Choreoathetosis, 1239
Chosen name, 1998t
Christmas disease, 951t
Chromic acid, 1392
Chromic gut, 274t
Chromium, 1318t
Chronic diseases, in natural disasters, 27
Chronic hypertension
aortic syndromes in, 412
categories of, 399
diastolic dysfunction in, 368
in pregnancy, 631–632
vasopressors in, 61
Chronic kidney disease
antihypertensives in, 407t
in children, 888
cold urticaria in, 1333
hyponatremia in, 86
imaging in, 567
stages of, 567t
urine outflow obstruction in, 568
Chronic obstructive pulmonary disease,
177, 467–471. See also Pulmonary
emergencies; Respiratory disorders
clinical features of, 467–468
diagnosis of, 467–469
differential diagnosis of, 469t
disposition and follow-up in, 470
epidemiology of, 467
exacerbations of, 468–470, 469t
in high-altitude disorders, 1383
indications for hospital admission, 470t
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 2044   Index
Chronic obstructive pulmonary disease
(Cont.):
indications for intensive care admission,
471t
pathophysiology of, 467
treatment of, 468–470
adrenergic agents in, 469
antibiotics in, 470
anticholinergics in, 469–470
assisted ventilation in, 470, 470t
corticosteroids in, 470
methylxanthines in, 470
noninvasive ventilation in, 470, 470t
oxygen in, 468–469
pharmacotherapy in, 468
secretion mobilization in, 468
smoking cessation in, 468
Chronic pain, 259–266
abdominal pain, 260–262
aberrant drug-related behavior and,
265–266
of the bowel, 261, 261t
clinical features of, 259–260
diagnosis of, 262
disposition and follow-up in, 265
in elderly, 256–257, 263–265
epidemiology of, 259
of esophagus and stomach, 261
in mentally impaired, 263–265
neuropathic, 260t
neuropathic pain syndromes, 260t
nonneuropathic pain syndromes, 259t,
262–263, 264t
pathophysiology of, 259
pelvic pain, 260–261, 262t, 263, 264t
signs and symptoms, 259t, 262t
treatment of, 262–265
Chronic pelvic pain syndromes, 262–263, 264t
Chronic sensorimotor distal symmetric
polyneuropathy, 1426t
Chronic thromboembolic pulmonary
hypertension, 389
Chronic transfusion therapy, 948–949
Chronotropy, 820
Churg-Strauss syndrome, 1906t
Churg-Strauss vasculitis, in pulmonary
infiltrates, 448t
Ciguatera poisoning, 1065–1067, 1068t
Cilostazol, 1509t, 1510
Cimetidine
in anaphylaxis, 70t
in peptic ulcer disease, 507
Cinnarizine, 1152t
Ciprofloxacin
in chancroid, 1015t, 1021
in diarrhea, 486t–487t
in diverticulitis, 528t
in granuloma inguinale, 1016t
in HIV-related infections, 1036t
in intra-abdominal infections, 480t
in otitis externa, 761
in pneumonia, 445t
in postrepair oral prophylaxis, 324
in prostatitis, 597
in puncture wounds, 319
in urinary tract infections, 582t–583t
Circulating anticoagulants, 1474
Circulation
in head trauma, 1688
in neck trauma, 1723–1724
Tintinalli_Index_p2025-2116.indd 2044
in pediatric trauma, 692
in trauma, 1671–1674
Circumcision, complications of, 606
Cirrhosis, 519–520
Cisgender, 1998t
Citalopram, 264t
Clarithromycin
in HIV-related infections, 1036t
in pneumonia, 444
Claudication
in arterial occlusion, 422, 422t
neurogenic, 1887
Clavicle fractures, 1822–1823
anatomy in, 1822
in children, 907f, 908–909, 908f
clinical features of, 1822
diagnosis of, 1822
distal, 909, 1823, 1823f
medial, 909
middle, 1822–1823, 1823t
middle third, 908–909
Clavicle strap, 1786
Clenbuterol, 1236
Clenched fist injuries, 294f–295f, 1916f
Clevidipine, 130
in acute renal failure, 402, 403t
in aortic dissection, 415
in hypertension, 405t, 406
in hypertensive encephalopathy, 403t
in subarachnoid hemorrhage, 403t
Clindamycin, 325t
in animal bites, 1915t
in bacterial infections, 933t
in bacterial vaginosis, 1015t
in balanoposthitis, 593
in endocarditis, 833
in facial infections, 1568t
in felon/paronychia, 1915t
in malaria, 1061t
in pelvic inflammatory disease, 657t
in pneumonia, 445t
in postpartum endometritis, 636, 636t
in premature rupture of membranes, 635
toxicity of, 1327–1328
Clinical rabies, 1056–1057, 1056t
Clomipramine, 1195t
Clonazepam, 1144, 1152t
Clonidine, 132, 133t, 402, 886t
in hypertension, 406, 407t, 408t
for hypertensive pediatric patients, 408t
toxicity of, 1281
Clonus, 1106, 1106f
Clopidogrel, 1509–1510
dosing and administration, 1509t
in NSTEMI, 345t
in STEMI, 344t
Closed chest cardiac massage, 143
Closed chest compressions in, 143–144,
144t, 145f
Closed-fist injury, 323
Clostridial myonecrosis, 140
Clostridium botulinum infections, 43t, 45t,
325t, 558, 1066t, 1163
in injection drug users, 1982
Clostridium difficile infections, 451
colitis in, 486–488
in diarrhea, 851
diarrhea in, 486–488
Clostridium jejuni infection, 1156
Clostridium perfringens, 1066t
FB:Cardiologia Siglo XXI
Clostridium tetani infection, 1048–1049
Clotrimazole, 932t, 1037t, 1653t
in balanoposthitis, 593
in Candida vaginitis, 650t
in HIV-related infections, 1036t
Clotting disorders, 1474–1477. See also
Hematologic disorders
acquired, 1476–1477
antiphospholipid syndrome in, 1477
hypercoagulable states in, 1474t, 1477,
1477t
hyperhomocysteinemia in, 1476
inherited, 1475–1476
malignancy in, 1476
pathophysiology of, 1474–1475
in pregnancy, 1476
thrombophilia, 1474
treatment of, 1475
Cluster headache, 1108t, 1112
C-MAC Video Laryngoscope, 187, 188f
CNS. See Central nervous system
Coagulation cascade, 1465
Coagulation disorders, 951t, 1471–1474
acquired, 1471–1474
circulating inhibitors in, 1474
disseminated intravascular, 1472–1474
in electrical injuries, 1399
liver disease in, 1471–1472
Coagulation factor products, 1495t
Coagulation factor VIIa (recombinant),
1498
Coagulation necrosis, 1297
Coagulation proteins, 1475t
Coagulopathy, 520–521, 575
reverse, 1118
trauma-induced, 63
in upper gastrointestinal bleeding,
497
in vaginal bleeding, 609
warfarin-induced, 1504–1505, 1504f
Coarctation of the aorta, 825
Coated polyglactin 910, 274t
Cobalt, 1318t
CobraPLA®, 178
Cocaine, 1108, 1238–1242
in acute coronary syndrome, 352
in body stuffers and body packers,
1242
cardiovascular effects of, 1239
in chest pain, 330
chest pain in, 1241
drug interactions with, 1242
dysrhythmias in, 1241
in fever, 1979
in hemoptysis, 433
in hypertension, 403t, 1241–1242
pharmacokinetics of, 1238t
pharmacology of, 1238
in pregnancy, 629, 1240
sedation in, 1238–1239
toxicity of, 1238–1242
cardiovascular, 1239
clinical features of, 1239–1240
diagnosis of, 1240–1241, 1240t
endocrine, 1240
gastrointestinal effects of, 1240
laboratory testing in, 1240–1241
neurologic syndromes in, 1239–1240
pregnancy and, 1240
pulmonary effects of, 1240
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 Index   2045

renal effects of, 1240 Community-acquired pneumonia, in pulmonary trauma, 1740

treatment of, 1238–1240 439–440 in seizures, 1155
withdrawal from, 1242 clinical features of, 440 in shock, 59–60
Cocaine washout syndrome, 1240 pathophysiology of, 439–440 in soft tissue foreign bodies, 310–311, 312f
Coccyx fracture, 1706f, 1713 Commotio cordis, 118f in subarachnoid hemorrhage, 1115,
Cochlear implantation, 756 Compartment syndrome, 1774, 1782, 1115f–1116f
Cock-up wrist splint, 1776 1876–1879 of thoracic great vessels, 1750, 1750t, 1751f
Codeine, 231, 232t, 1232 anatomy in, 1876 in urologic stone disease, 600–601, 600f
Cogwheeling, 1103 clinical features of, 1877–1878 of wounds, 268
Colchicine, 1413 complications of, 1879 Concussion, 1692–1695
Cold agglutinin disease, 1491 in crush injuries, 33–34 biomarkers for, 1694
Cold diuresis, 1339 diagnosis of, 1878–1879 diagnosis of, 1694
Cold injuries, 1333–1337. See also exertional, 1862 electroencephalogram of, 1695
Environmental injuries of foot, 1931 neuroimaging in, 1695
chilblains or pernio, 1333 of hand, 1793–1794 pathophysiology of, 1693
frostbite, 1334–1337 in hemophilia, 1479 physical examination in, 1694
nonfreezing, 1333 history in, 1877 recurrent, 1695
panniculitis, 1333 hyperbaric oxygen therapy in, 139–140 second impact syndrome in, 1707
trench foot, 1333 laboratory testing in, 1879 signs and symptoms of, 1694t
urticaria, 1333 measurement of pressure in, 1878–1879 treatment of, 1695
Colic, 735, 863 pathophysiology of, 1876–1877 Concussion in children, 698–705
Colitis physical examination in, 1877–1878 clinical features of, 699
Clostridium difficile-associated, 486–488 in snakebites, 1360t disposition and follow-up in, 703
diarrhea in, 488–491 treatment of, 1879 dizziness in, 703
ulcerative, 491–492 Compazine, 628 epidemiology of, 698–699
Collagen, 270 Complete abortion, 620t headache in, 700–703
Colles’ fascia, 591 Complete heart block, in acute coronary history of, 699
Colles’ fracture, 1805–1806, 1807f syndrome, 349 imaging in, 700
Colloid cysts, 1113–1114 Complex partial seizures, 1154 nausea in, 703
Colloids, 62, 66, 2011 Complex regional pain syndromes, pathophysiology of, 699
Colonoscopy, complications of, 561 260, 264t post-discharge counseling in, 703–705
Color flow Doppler ultrasound, 1725 Complicated cyst rupture, 613 fatigue, 705
Colorado tick fever, 1032, 1074 Complicated urinary tract infection lifestyle measures, 704
clinical features of, 1072t clinical features of, 579–580 mood, 705
treatment of, 1073t treatment of, 583 return to learn, 703
Coltsfoot, 519t Complications return to sports, 703–704, 705f
Coma, 1140–1142 of breast surgery, 558 sleep, 704–705
antidotes for, 1142 of drug therapy, 558 treatment of, 700–703
central herniation syndrome in, 1140 of general surgical procedures, 555–561 Conduction and repolarization abnormalities,
clinical features of, 1141 genitourinary, 556–557 119–123
diagnosis of, 1141–1142, 1141t respiratory, 556 arrhythmogenic right ventricular
in hyponatremia, 85t vascular, 558 cardiomyopathy, 123
infratentorial lesions in, 1141 wound, 557–558 Brugada syndrome, 120–122
intracranial pressure in, 1142 Compression duplex ultrasound, 625 long QT syndrome, 122
pathophysiology of, 1140–1141 Compression fractures, 1713 short QT syndrome, 122–123
pseudocoma, 1141 Computed tomography, 361 Wolff-Parkinson-White syndrome,
supratentorial lesions in, 1141 in abdominal pain, 476–477, 857 119–122
testing for weakness of patients in, in abdominal trauma, 1753 Conduction disturbances, in acute coronary
1104f in abdominal/pelvic pain, 613 syndrome, 349–350
toxic-metabolic, 1141 in aneurysms, 417–418, 418f Conductive gel, 149
in trauma, 1674 in ankle injuries, 1864 Condyle fractures, 1825–1826
treatment of, 1142 in anorectal abscess, 545f Cone snail injuries, 1365–1366
uncal herniation syndrome in, 1140 in aortic dissection, 413, 414f–415f Confidentiality, 2017–2018
Coma blisters, 1215 in appendicitis, 524–526, 526f, 860–861, Confinement hyperpyrexia, 1346
Combitube®, 5t 861f Confrontation visual fields, 1526
Comedo, 1614f, 1614t in back pain, 1885 Confusion Assessment Method, 1942,
Comfrey, 519t, 1326t in bacterial meningitis, 1173 1960–1962
Committee on Accreditation of Medical in brain imaging, 1126–1127 Confusion Assessment Method–Intensive
Transport Systems, 9–10 in cervical spine imaging, 1711 Care Unit, 1942, 1943t
Common cold, 437 of cervical spine injuries, 708 Congenital adrenal hyperplasia, 735,
diagnosis of, 437 in child abuse and neglect, 993 970–971
epidemiology of, 437 in cholecystitis, 514, 516f clinical features of, 970–971
pathophysiology of, 437 in head trauma, 694, 1685–1687, 1686f, diagnosis of, 971
treatment of, 437 1687t history in, 970–971
Commotio cordis, 1746 in headache, 1109t pathophysiology of, 970
Communication system of headache in children, 901 physical examination in, 971
in disasters, 22, 24 in pancreatitis, 511f treatment of, 971
in emergency medical services, 1–3 in pediatric trauma, 694 Congenital diaphragmatic hernia, 678
in mass gatherings, 16–17 in pelvic fracture, 1841 Congenital factor deficiencies, replacement
in prehospital care, 4 in pneumothorax, 458, 458f therapy for, 1498t

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 2046   Index
Congenital heart disease, 819–835. See also
Heart disorders
in children with special healthcare needs,
976–978
clinical features of, 822t
complications of, 828–830, 829t
anemia in, 829
anticoagulation, 829
bacterial illness in, 830
digoxin toxicity in, 829
diuretic, 828–829
dysrhythmias, 817
endocarditis in, 830
polycythemia in, 829
pulmonary hypertensive crisis, 828
surgical shunt dysfunction, 828
viral infections, 829–830
congestive heart failure in, 826–827
anomalous left coronary artery arising
from pulmonary artery, 827
atrial septal defect, 826–827
clinical features of, 827–828
diagnosis of, 827
endocardial cushion defect, 827
history in, 816
patent ductus arteriosus, 827
physical examination in, 827
treatment of, 827–828
ventricular septal defect, 827
cyanosis in, 820–823
clinical features of, 823–825
diagnosis of, 824
physical examination in, 823
tetralogy of Fallot in, 821
total anomalous pulmonary venous
return in, 823
transposition of great arteries in, 821–823
treatment of, 824
tricuspid atresia, 823
truncus arteriosus, 823
epidemiology of, 820
interventional and surgical repair of,
828, 829t
murmurs in, 817, 829t
in neonates, 733
shock in, 825–826
aortic stenosis, 825
clinical features of, 825–826
coarctation of the aorta, 825
diagnosis of, 826
hypoplastic left heart syndrome, 825
patent ductus arteriosus, 825
physical examination in, 825–826
treatment of, 826
in sudden cardiac death, 54
Congestive heart failure
in congenital heart disease, 826–827
anomalous left coronary artery arising
from pulmonary artery, 827
atrial septal defect, 827
clinical features of, 827–828
diagnosis of, 827
endocardial cushion defect, 827
history in, 827
patent ductus arteriosus, 827
physical examination in, 827
treatment of, 827–828
ventricular septal defect, 827
in pulmonary infiltrates, 448t
in thyroid storm, 1457
Tintinalli_Index_p2025-2116.indd 2046
Conjugated equine estrogen, 610t
Conjunctival abrasion, 1544–1545
Conjunctival laceration, 1544–1545
Conjunctivitis, 1540–1542. See also Eye
disorders
allergic, 770, 1541–1542, 1541f
bacterial, 769–770, 1540–1541, 1540f
chemical, 1553
in children, 768–770
chlamydial, 739, 1541
epidemic keratoconjunctivitis, 1541, 1541f
follicular, 768
gonococcal, 739, 1541
hemorrhagic, 769
herpes simplex in, 769
in Kawasaki’s disease, 770
in pediculosis, 770
viral, 768, 1541
Consent
in forensic examination of sexual abuse/
assault victims, 1968
informed, 2014–2016
Constipation, 492–495. See also
Gastrointestinal disorders
abdominal pain in, 863–864
in bowel obstruction, 531
in children, 863–864
clinical features of, 493–494
differential diagnosis of, 493t
disposition and follow-up in, 495
epidemiology of, 492–493
fecal impaction in, 495
functional, 494
history in, 493
imaging in, 493–494, 493f
intestinal pseudo-obstruction
(Ogilvie’s syndrome), 495
in neonates, 737–738
opioid-induced, 494
organic, 495
in palliative care, 2003
pathophysiology of, 493
physical examination in, 493
treatment of, 494t, 864t
Constrictive pericarditis, 388
Contact activation pathway, 1465
Contact burns, 1403
Contact dermatitis, 1007t, 1637t,
1640–1641, 1641f
Contact precautions, 1098–1099
Contact vulvovaginitis, 652
Continuous (running) percutaneous sutures,
275–276, 275t, 277f
Continuous interstitial glucose monitoring,
1423
Continuous positive airway pressure,
6, 175–177
Continuous subcuticular sutures, 275t, 276,
278f
Contraception, in sexual abuse and assault,
1969–1970, 1970t
Contractility, 820
Contrecoup injury, 1690
Conus medullaris syndrome, 1163, 1887
Convulsants, 1411t, 1412
Cooley’s anemia, 1488
Cooling blankets, 1349
Coombs test, 1462t
Copper, 1318t
Coracoacromial arch, 1889, 1889f
FB:Cardiologia Siglo XXI
Coral snakes, 1361–1362
Corkscrew maneuver, 643
Cormack-Lehane scale, 183f
Cornea, 1523. See also Eye disorders
abrasion of, 767, 1545, 1545f, 1545t
anatomy of, 1525f, 1529f
examination of, 1532f
foreign bodies in, 1545f, 1546–1547, 1546f
infections of, 1542–1544, 1543f
herpes simplex keratoconjunctivitis, 1542
herpes zoster ophthalmicus, 1541–1542
ulcer, 1543
ultraviolet keratitis, 1543–1544
laceration of, 1545
rust ring in, 1546–1547
transplantation of, 1993–1994
transverse section of, 1525f
Corns, 1659t, 1662–1663, 1663t
Coronary angiography, 361
in aortic dissection, 413–414
Coronary arteries, anatomy of, 335f
Coronary artery disease, 334, 1425t
Coronary emboli, 624
Coronary stents, 345
Coronary thrombosis, in cardiac arrest, 162
Coronary vasospasm, 624
Coronavirus, 1092
Coronoid fractures, 1819
Corpus luteum cysts, 613
Corpus spongiosum, 591f
Corticosteroids, 1519t
in adrenal insufficiency, 1459
in anaphylaxis, 70
in asthma, 465, 806–807, 806t
in bronchiolitis, 802
in chronic obstructive pulmonary disease,
470
in Crohn’s disease, 490
in croup, 792
in disk herniation, 1886
in impingement syndrome, 1891
in nausea and vomiting, 484t
in premature rupture of membranes, 635
in skin disorders, 1619–1623
in spinal injuries, 1713–1714
systemic, 1619–1620
in thyrotoxicosis, 1456t
topical, 1620–1622
in vertigo, 1152t
Cortisol, 1457, 1458
Corynebacterium diphtheriae infections, 1593
in gonococcal pharyngitis, 780
Corynebacterium spp, in human bite wounds,
294
Costochondritis (Tietze’s syndrome), 332
Cotinine, 1266
Cotton fever, 1979
Cough, 428–429
acute, 428–429
chronic, 428–429, 429t
clinical features of, 428
diagnosis of, 428–429, 432f
differential diagnosis of, 428t
subacute, 428–429
treatment of, 428–429
Coumarins, 1411t
Cowpox, 1078
Coxa saltans, 1899
Coxiella burnetii, 43t, 1071t
Coxsackievirus A9, 926
8/2/19 6:02 PM
 Index   2047

Coyotillo, 1412 Crush syndrome, 34 treatment of, 824

Crack cocaine, 1246 Crust, in skin lesions, 1618f, 1618t tricuspid atresia, 823
Crack dancing, 1239 Crutches, 1780–1781 truncus arteriosus, 823
Crack eye, 1240 Cryoprecipitate, 1497–1498 diagnosis of, 430
Cracked tooth syndrome, 1581 Cryotherapy, in impingement syndrome, 1890 differential diagnosis of, 430t
Cranial nerve palsies, 1556–1557 Cryptic shock, 58 factors in physical appearance of, 430t
diabetic/hypertensive, 1556–1557, 1556f Cryptitis, 541–542, 542f in hypoxemia, 427
Horner’s syndrome, 1555–1556, 1557f Cryptococcal meningitis, 1037 in infants, 740
idiopathic intracranial hypertension, 1557 Cryptococcosis, 1036t in neonates, 676–677, 677t
posterior communicating artery aneurysm, Cryptococcus chorioretinitis, 1038 peripheral, 433
1557 Cryptococcus neoformans infection, 444, 1035 pseudocyanosis, 430
pseudotumor cerebri, 1557 Cryptosporidiosis, 1036t treatment of, 430
Cranial nerves, 1102–1103 Cryptosporidium, 1067t, 1068 Cyclic antidepressants, 234, 1194–1199, 1194t.
Craniofacial neuralgias, 1584 Cryptosporidium parvum, 43t See also Antidepressants
Crazy glue, 1553 Crystal supergrass, 1246 pharmacokinetics of, 1194–1195
C-reactive protein, 1178 Crystal-induced synovitis, 1926 pharmacology of, 1194–1195, 1195t
Creatine kinase-MB, 333 Crystalloids, 62, 65–66 toxicity of, 1195
Creatine phosphokinase, 636, 639 in anaphylaxis, 70 altered level of consciousness in,
Creatinine, 564t, 566–567, 1436 in military medicine, 2011 1197
Creatinine kinase, 570 CT pulmonary angiography, 410 cardiac conduction abnormalities in,
Creeping eruption, 1091 Cubital tunnel syndrome, 1162 1198–1199
Cricoarytenoid joint arthritis, 1906 Cuboid fractures, 1874 clinical features of, 1196
Cricoid maneuver, 182 Culdocentesis, 618 diagnosis of, 1196
Cricothyrotomy Cullen sign, 416 dysrhythmias in, 1198–1199
anatomy in, 195–196 Cuneiform injuries, 1874 ECG in, 1197f–1198f
complications in, 197–198 Cunningham technique, 1829, 1831f gastrointestinal decontamination in,
equipment in, 196t Current flow, 1397 1196
injuries requiring, 194 Cushing reflex, 1688 hypotension in, 1198
patient preparation and positioning in, 196 Cutaneous abscesses, 1008–1010 lipid emulsion in, 1199
percutaneous, 198–199, 198f Cutaneous anthrax, 1078 seizures in, 1197–1198
procedure, 196, 196t, 197f Cutaneous infections, in HIV infection, sodium bicarbonate for treatment of,
Seldinger technique in, 197 1040–1041 1196–1197
surgical (open), 195–198 Cutaneous injuries, in lightning injuries, 1403 treatment of, 1196, 1197t
Crimean-Congo hemorrhagic fever, Cutaneous larva migrans, 1091, 1658t, 1664, Cyclic vomiting syndrome, 261t, 264t,
1085–1086 1664f 483–484
Critical-care units, 2 Cutis marmorata, 1371 diagnosis of, 483
Crohn’s disease, 261t, 264t Cyanide, 39 pathophysiology of, 483
clinical features of, 488–491 Cyanide poisoning, 1320–1322. See also treatment of, 483–484
complications, 490–491 Poisoning Cyclobenzaprine, 1195t
diagnosis of, 488–490 antidotes for Cyclophosphamide, 1169
diarrhea in, 488–491 dicobalt edetate, 1322 Cyclospora, 1067t
disposition in, 491 dimethylaminophenol, 1322 Cyproheptadine, 1204
epidemiology of, 488 from cassava, 1320 Cystatin C, 567
extraintestinal manifestations of, 489t clinical features of, 1319 Cystic fibrosis, in pneumonia, 818
in gastrointestinal bleeding, 868 hyperbaric oxygen therapy in, 140 Cystic hygroma, 788
pathophysiology of, 488 laboratory testing in, 1319t Cysticercosis, 1086
treatment of, 490 pathophysiology of, 1320–1322 Cystitis, 578
Crossed-leg test, 1863, 1864f signs and symptoms, 1319t clinical features of, 580
Croup, 790–792 treatment of, 1320t, 1321–1322 in pregnancy, 626–627
clinical features of, 790 nitrites, 1322 treatment of, 582
corticosteroids in, 792 sodium thiosulfate, 1322 Cysts, in skin lesions, 1611f, 1611t
diagnosis of, 790–791 Cyanoacrylate tissue adhesives, 282–284, Cytochrome P450 pathway, 1218
drugs for, 793t 283f, 284t Cytokine release syndrome, 1520, 1520t
epinephrine in, 792 in chemical ocular injury, 1553 Cytomegalovirus infection, 1030
severity of, 792t Cyanocobalamin, 1323t, 1325 clinical features of, 1030
treatment of, 791–792 Cyanocobalamin deficiency anemia, 1464t diagnosis of, 1030
Crown (teeth), 1579 Cyanogenic plants, 1413 in HIV patients, 1035
Crush injuries, 33–35. See also Blast injuries Cyanogens, 40 pathophysiology of, 1030
clinical features in, 34 Cyanosis, 430 pharyngitis in, 779
compartment syndrome in, 33–34 in BRUEs/ALTEs, 740 retinitis in, 1038, 1038f
crush syndrome in, 34 central, 433 treatment of, 1030, 1036t
diagnosis of, 34 clinical features in, 430 Cytomegalovirus radiculitis, 1160
epidemiology in, 33–34 in congenital heart disease, 820–823
fasciotomy for, 34–35 clinical features of, 823–825 D
hyperbaric oxygen therapy for, 35 diagnosis of, 824 Dabigatran, 1505
pathophysiology in, 34 physical examination in, 823 in deep venous thrombosis, 397t
rhabdomyolysis in, 572 tetralogy of Fallot in, 821 in pulmonary embolism, 397t
treatment of, 34–35 total anomalous pulmonary venous Dacryoadenitis, 765
Crush injuries, hyperbaric oxygen therapy in, return in, 823 Dacryocele, 765
139 transposition of great arteries in, 821–823 Dacryocystitis, 765, 765f

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 2048   Index
Dacryostenosis, 764–765
Dactylitis, 944
Daddy long-legs spider, 1355
Daffodils, 1414
Dalteparin, 1508t
in deep venous thrombosis, 397t
in pulmonary embolism, 397t
Dalton’s law, 1369
Dan shen, 1326t
Dantrolene, 1212
Darunavir, 1042t
Date rape drugs, 1969
Datura species, 1247t, 1248
D-dimer, 392, 394t, 625
De Quervain’s tenosynovitis, 1918–1919
Death
imminent, 2003
notification of, 2004–2007
autopsy in, 2006
effect on physicians of, 2004
effect on survivors of, 2004
GRIEV_ING© method for, 2004–2006
long-distance, 2006
medical examiner cases in, 2006
organ donation in, 2006
in pediatric death, 2006
withdrawal of life-sustaining treatment,
2007
witnessed resuscitation in, 2006
sudden cardiac death, 53–57
sudden infant death syndrome in,
745–746
Debridement, 271, 271f
Decompression illness, 1372
Decompression sickness, 1371–1374.
See also Diving disorders;
Environmental injuries
classification of, 1371t
clinical features of, 1371–1372
diagnosis of, 1372–1373
hyperbaric oxygen therapy in, 139
imaging in, 1373
laboratory testing in, 1373
neurologic symptoms in, 1372
pain in, 1372
patent foramen ovale in, 1372
pathophysiology of, 1392
pulmonary symptoms in, 1372
treatment of, 1373
vestibular symptoms in, 1372
Decontamination, 37, 1190–1192
activated charcoal in, 1192
in anaphylaxis, 69
in disasters, 22–23
emesis, 1191
gastrointestinal, 1191, 1192t
guidelines, 23t
ocular, 1191
orogastric lavage, 1191
in radiation exposure, 50, 51t
in warm zone, 37
whole-bowel irrigation, 1192
Deep peroneal nerve block, 243
Deep peroneal nerve entrapment, 1162
Deep sulcus sign, 458
Deep vein thrombosis (DVT), 1007t
clinical features of, 391–392
diagnosis of, 397f
drugs for, 397t
Well’s score for, 393t
Tintinalli_Index_p2025-2116.indd 2048
Deep venous thrombosis, 558 Delirium Triage Screen, 1137, 1138f
in pregnancy, 624–625 Delta gap, 74
Deferasirox, 1292 Delta-opioid receptor, 229
Deferiprone, 1292 Delusion, 1953
Deferoxamine, 1291–1292 Delusional disorder, 1955–1956
Deferoxamine chelation therapy,, 949 Dementia, 1138–1140. See also Neurologic
Defibrillation, 149–153 disorders
anesthesia and, 151 classification of, 1139t
with automated external defibrillators, clinical features of, 1137t, 1139, 1944
151–152 diagnosis of, 1139–1140
automated external defibrillators, 686 in elderly, 1943–1944
in cardiac resuscitation, 153 features of, 1941t
in children, 152, 686–687, 689t HIV-associated, 1035
electrode position in, 686 pathophysiology of, 1139, 1944
paddle size in, 686 treatment of, 1140
placement of paddles/pads in, types of, 1942
151f, 686 Demyelinating anthracenones, 1412
complications in, 151 Dendrid, 1542
defined, 149 Dengue, 1031, 1031f, 1081–1082
double sequential, 153 Dental anesthesia, 1589–1594
equipment in, 149–150 anatomy in, 1589, 1590f
hands-on, 152–153 buccal injections in, 1592
in high performance CPR, 152–153 complications of, 1592–1593
internal, 152 equipment in, 1590
manual, 151 inferior alveolar nerve block in, 1590–1591,
outcomes assessment, 151 1593f
patient positioning in, 150 mandibular injections in, 1590–1591
patient selection, 149 maxillary injections in, 1590
placement of paddles/pads in, 150, 151f palatal injection in, 1590, 1592f
in pregnancy, 168–169 supraperiosteal infiltration in, 1590, 1591f
purpose of, 149 Dental fractures, 1586–1587
risks and precautions in, 152 classification of, 1586f
sedation and, 151 crown-root, 1587
self-adhesive electrodes, 686 enamel, 1586
steps in, 151–152 enamel-dentin, 1586
Defibrillators, 4–5 enamel-dentin-pulp, 1586–1587
Degenerative disk disease, 1883 root, 1587
Dehiscence, 664–665 Dentin, 1579
Dehydration Dentoalveolar trauma, 1586–1587
causes of, 852t Depolarizing agents, in rapid-sequence
in children, 844 intubation, 186–187
assessment of, 852t Depression, 1946–1949. See also Mood
clinical features of, 852–853 disorders
laboratory testing in, 853 in children, 988
maintenance treatment in, 853–854 clinical features, 1947
physical examination in, 852–853 cross-cultural issues in, 1949
treatment of, 853, 853t in elderly, 1945
disposition and follow-up in, 808 in HIV infection, 1037
in ischemic stroke, 1128 pathophysiology of, 1946–1947
moderate and severe, 853 postpartum, 1949
in neonates, 737 suicide risk, 1947
pathophysiology of, 851–852 treatment of, 1947–1949
Delamanid, 456 Dermal exposure, 1093
Delavirdine, 1042t Dermalon®, 273t
Delirium, 1137–1138. See also Neurologic Dermatitis. See also Skin disorders
disorders allergic contact, 1414
in antipsychotics overdose, 1210 atopic, 940, 940f–941f, 1636t–1637t, 1639f,
causes of, 1139t, 1943t 1640–1641, 1660, 1660f
clinical features of, 1137, 1137t, 1941–1942, contact, 1633–1634, 1637t, 1640–1641,
1941t 1641f
diagnosis of, 1137 diaper, 940–941, 941f
in elderly, 1941–1943 exfoliative, 1627, 1627f
history in, 1941 of hand and foot, 1658–1665
imaging in, 1942 irritant, 1414
laboratory testing in, 1942 phytodermatitis, 1414
pathophysiology of, 1137 plant-induced, 1413–1414, 1414t
physical and mental examination in, seborrheic, 939–940, 940f, 1629, 1629f,
1941–1942 1630t, 1635–1637, 1636t, 1639f, 1652t,
treatment of, 1137–1138, 1942 1654
Delirium tremens, 1224 shiitake, 1409
FB:Cardiologia Siglo XXI
8/2/19 6:02 PM
 Index   2049

Dermatitis herpetiformis, 1658t, 1663–1664, clinical features of, 1425 adverse food reactions in, 850–851
1663f, 1664t dermatologic complications, 1426t antibiotic-associated, 851
Dermatomes, sensory, 1103, 1104f diagnosis of, 1425, 1426t causes of, 844t, 1088t
Dermatomyositis, 1906t disposition and follow-up in, 1428–1429 in children, 844
Dermis, 1384, 1384f epidemiology of, 1424 clinical features of, 485
Dermoid cysts, 613–614, 788 foot and lower extremity complications, Clostridium difficile-associated, 486–488
Designer drugs, 1242 1425, 1432t in colitis, 488–492
Desipramine, 1194, 1195t infectious complications in, 1426t in Crohn’s disease, 488–491
Desmopressin, 950, 1481 medical history in, 1426t diagnostic stool evaluation, 485
Desmopressin acetate, 612 neurologic complications in, 1425 bacterial stool culture, 485
Desomorphine, 1236, 1982 ophthalmologic complications, Clostridium difficile toxin assay, 485
Desonide, 1630t 1425–1427, 1426t epidemiology of, 484–485
Desvenlafaxine, 1202 pathophysiology, 1424 gastroenteritis in, 834–838
Detemir, 622 physical examination in, 1427t in graft-versus-host disease, 1986
Dexamethasone, 1112t, 1519t renal complications in, 1425t–1426t history in, 485
in adrenal crisis, 1459t treatment of, 1425–1428 in HIV infection, 1040
in croup, 792, 793t undiagnosed, 1423–1424 in ileitis, 488–491
dosages of, 806t Diabetic amyotrophy, 1164 in inflammatory bowel disease, 488–491
in high-altitude disorders, 1380t Diabetic cardiomyopathy, 1425t mechanisms of infectious diarrheal diseases,
in nausea and vomiting, 484t Diabetic ketoacidosis, 971–974, 1433–1441. 845t
Dexmedetomidine, 252t, 255, 731 See also Endocrine disorders in neonates, 737
Dexrazoxane, 1518t, 1519 bicarbonate therapy in, 974 with or without vomiting, 850–851
Dextromethorphan, 1247t, 1248 causes of, 1435, 1435t parasitic infections in, 851
Dextrose, 65t, 85, 94, 124, 678, 735, 967, 967t, cerebral edema in, 974–975 pathophysiology of, 484–485
1187, 1188t, 1256t, 1274, 1278, 1449, clinical features of, 972, 1435 physical examination in, 485
1484, 1517 complications of, 1439–1440, 1440t in travelers, 485–486, 851, 1088–1089
Dezocine, 233t diagnosis of, 1435–1436 treatment of, 485
Diabetes insipidus, 87–88 diagnostic criteria for, 1445t Diastolic, 383–384
classification of, 88t differential diagnosis of, 1436, 1436t Diastolic blood pressure, in shock, 60t
Diabetes mellitus. See also Endocrine disposition and follow-up in, 1440 Diastolic dysfunction, 368
disorders electrolyte replacement in, 973 Diastolic pressure, 212
in children, 971–975 epidemiology of, 1433–1434 Diazepam
classification of, 1420t euglycemic, 1435 in back pain, 1886
coagulation disorder in, 1478 fluid resuscitation in, 973 in nausea and vomiting, 484t
cranial nerve palsy in, 1556–1557, 1556f imaging in, 1459 in status epilepticus, 1157
diagnosis of, 1419, 1420t insulin deficiency in, 1434, 1434f in vertigo, 1144, 1152t
drug therapy for, 1429–1430 insulin in, 973–974 Diazoxide, 887t, 1433
acarbose, 1430 laboratory testing in, 972–973, 973t, 1436 Diclofenac, 235t
alpha-glucosidase inhibitors, 1430 pathophysiology of, 972, 1434 Dicloxacillin, 1915t
amylin analogues, 1430 in patients with insulin pumps, 1441 in facial infections, 1568t
dipeptidyl peptidase 4 inhibitors, 1430 pitfalls during treatment of, 1440t in felon/paronychia, 1915t
glitazones, 1429 in pregnancy, 623, 1441 Dicobalt edetate, 1322
glucagon-like peptide 1 (GLP-1), 1430 recurrent, 1440–1441 Didanosine, 1042t
incretin analogues, 1430 treatment of, 973–974, 1436–1439, 1437f Dietary supplements, 518
metformin, 1428–1429 bicarbonate in, 1439 Diethylcarbamazine citrate, 1091
miglitol, 1430 insulin in, 1438–1439 Dieulafoy lesions, upper gastrointestinal
nateglinide, 1430 potassium replacement in, 1438 bleeding in, 496
repaglinide, 1429–1430 volume repletion in, 1437–1438 Dieulafoy’s lesion, 867
sulfonylureas, 1429–1430 Diabetic nephropathy, 1425t Difficult intubation, 180
foot injuries in, 308f Diabetic neuropathy, 1425 Difficult laryngoscopy, 180
glycemic complications in, 1420–1422 drugs for, 1431t Digital amputations, 296–297
hypoglycemia in, 1431–1433 manifestations of, 1431t Digital glycosides, 1267–1270
insulin in, 1419–1420 painful, 260, 264t digoxin-antibody fragments in,
pathophysiology of, 1419 treatment of, 1431t 1266–1267
pneumonia in, 443 Diabetic peripheral neuropathy, 1164 pharmacology of, 1270–1271
in pregnancy, 622–623 Diabetic retinopathy, 1426t sources of, 1267
type I, 1419–1424 Diabetic ulcers, 1425, 1656–1657, 1657f toxicity of, 1267–1270
epidemiology of, 1419 Dialysis acute, 1267
falsely elevated capillary glucose in, in acute kidney injury, 569, 569t chronic, 1267
1420 dementia in, 573 clinical features of, 1267
glucocorticoid therapy, 1424 disequilibrium, 576–577 diagnosis of, 1266t, 1267–1269
hyperglycemia in, 1420 hemodialysis, 575–577 treatment of, 1269–1270
hypoglycemia in, 1420–1422 peritoneal, 577–578 Digital nerve blocks, 239–240
pramlintide in, 1424 Diaper dermatitis, 940–941, 941f Digital nerve injuries, 297
transplants in, 1424 Diaphragmatic injuries, 1737 Digoxin, 131–132, 1267–1270
treatment of, 1419 Diaphyseal fractures, 915 actions of, 131
type II, 1424–1433 Diaphysis, 905 adverse effects of, 132
cardiovascular complications of, Diarrhea, 484–492. See also Gastrointestinal digoxin-antibody fragments in, 1266–1267
1425, 1426t disorders dosing and administration, 132
chronic complications in, 1425t–1426t acute infectious, 485–486 indications for, 132

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 2050   Index

Digoxin (Cont.): Disaster situations Diuresis, cold, 1339

pathophysiology of, 1267 in bioterrorism, 41–47 Diuretics, 132, 133t, 1279–1281
pharmacokinetics of, 131–132, 132t bomb and blast injuries, 30–33 adverse effects of, 408t
in resuscitation of poisoned patient, 1188t characteristics of, 19 in barbiturate overdose, 1215
sources of, 1267 chemical disasters, 35–41 in congenital heart disease, 828–829
toxicity of, 1267–1270 decontamination, 22–23 in heat emergencies, 1346
acute, 1267 definition of, 19 loop, 371
chronic, 1267 ED disaster response, 24–25 mechanism of action, 1280t
clinical features of, 1267 initial response, 24 toxicity of, 1279–1281
in congenital heart disease, 829 patient care, 25 Diverticulitis, 478t, 527–529. See also
diagnosis of, 1266t, 1267–1269 security, 24 Gastrointestinal disorders
digoxin-Fab administration for, triage, 24–25, 25t antibiotics for, 528t
1269–1270, 1270t field disaster response, 23–24 clinical features of, 527
enhanced elimination in, 1269 communication system, 24 complicated, 529
GI decontamination for, 1269 distribution of casualties, 24 complications and treatment failure in,
treatment of, 1269–1270 field triage, 23–24 529t
Dihydroergotamine, 902, 1112t on-site medical teams, 24 diagnosis of, 527
Dihydropyridines, 1275, 1276t natural, 25–30 differential diagnosis of, 528t
1,25-Dihydroxycholecalciferol, 96 preparedness and planning, 19–23 disposition options for, 529t
Dilatation and curettage, 620 communication system, 22 epidemiology of, 527
Dilated cardiomyopathy, 381, 833–834, 838 community agencies in, 20t imaging in, 528
Diltiazem, 129, 1276t emergency operations center, 21–22 pathophysiology of, 527
actions of, 129 emergency operations plan, 21, 21t treatment of, 528–529
adverse effects of, 130 federal response resources, 21t uncomplicated, 528
in atrial fibrillation/flutter, 109, 109t–110t hazard vulnerability analysis, 19–20 in young patients, 529
in atrioventricular blocks, 101t hospital capacity in, 22 Diverticulosis, lower gastrointestinal bleeding
dosing and administration, 130, 130t hospital community coordination, in, 498
indications for, 129 20, 20t Diving disorders, 1368–1374. See also
IV to oral conversion, 130t Joint Commission requirements, 20 Environmental injuries; Marine
pharmacokinetics of, 129, 130t mental health services in, 23 trauma
Dilute Russell viper venom time, 1468t minor treatment area, 23 barotrauma of ascent in, 1370
Dimenhydrinate morgue facilities in, 23 barotrauma of descent in, 1369–1370
in nausea and vomiting, 484t presurgical holding area in, 23 decompression sickness, 1371–1374
in vertigo, 1152t recovery, 23 nitrogen narcosis, 1373
Dimercaprol, 1314, 1317t resuscitation in, 23 oxygen toxicity in, 1373–1374
Dimercaptosuccinic acid, 1314 supplies, 22 pulmonary edema in, 1373
Dimethyl sulfoxide, 1395, 1518t, 1519 support areas, 22 Diving reflex, 102t
Dimethylaminophenol, 1322 training and drills, 21 Dix-Hallpike test, 1147
Dipeptidyl peptidase 4 inhibitors, 1430 triage in, 22–23 Do not resuscitate order, 2003
Diphenhydramine, 237t, 1622t radiation injuries in, 47–52 Dobutamine, 828
in agitation, 987t types of, 19, 20t actions of, 137
in vaso-occlusive crisis, 948 Disinfection, in wound preparation, 269 adverse effects of, 137
Diphenoxylate hydrochloride–atropine Disk herniation, 1886–1887 in cardiogenic shock, 355, 356t
sulfate, 1236 Diskitis, 1888 cardiovascular effects of, 134t
Diphenoxylate, in diarrhea, 486t Dislocation, 1767–1768 contraindications, 134t
Diphenhydramine, 622t Dissecting cellulitis of the scalp, 1631–1632, dosing and administration, 134t
in anaphylaxis, 70t 1632f indications for, 137
in nausea and vomiting, 484t Disseminated intravascular coagulation, pharmacokinetics of, 137t
in vertigo, 1152t 957, 999, 1472–1474 in pregnancy, 168t
Diphtheria, 780, 797–798, 1595 clinical features of, 1472–1473 in pulmonary hypertension, 411t
Diphyllobothrium latum, 1090 conditions associated with, 1472t–1473t in resuscitation of children, 683t
Dippers (drug), 1246 differential diagnosis of, 1473 in shock, 61t
Dipstick test, 581, 872 laboratory testing in, 1473, 1473t Docusate sodium, 494t
Dipylidiasis, treatment of, 1075t pathogenesis of, 1472 Dofetilide, 129
Dipyridamole, 1509t, 1510 pathophysiology of, 1473f actions, 129
Diquat, 1305 treatment of, 1473–1474, 1473t adverse effects of, 129
Direct hand-held ophthalmoscope, 1529 Distal femur, 719–720 drug interactions, 129
Direct thrombin inhibitors, 1505 Distal fibular fractures, 920 indications for, 129
in NSTEMI, 345t Distal humerus, 1809 Dog bites, 321–322
Dirty bombs, 48 Distal humerus fractures, 1816 Dogbane, 1412
Disability Distal phalanx fractures, 1793 Dolasetron, in nausea and vomiting, 484t
intellectual, 980 Distal radioulnar joint disruption, 1809 Dolutegravir, 1043t, 1096t
in neck trauma, 1724 Distal radius, 1794–1795 Domestic violence. See Intimate partner
in pediatric trauma, 692–693 Distal radius physeal fractures, 915–916 violence and abuse
in trauma, 1674 Distal tibia Domperidone, 483
Disaster Medical Assistance Teams anatomy of, 720f Donath-Landsteiner antibody, 1491
(DMATs), 21t fractures of, 920–921 Donovanosis, 1015t–1016t
Disaster Mortuary Operational Response Distal ulna, 1794–1795 Dopamine, 135, 828
Teams, 21t Distributive shock, 57 actions of, 135
Disaster plan, 3 Disulfiram, 1409, 1962 adverse effects of, 134

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in bradyarrhythmias, 101t
in cardiogenic shock, 356, 356t
cardiovascular effects of, 134t
contraindications, 134t
dosing and administration, 134t
indications for, 135
pharmacokinetics of, 135t
in pregnancy, 168t
in psychoses, 1970
in resuscitation of children, 683t
in shock, 61t
Dopamine receptor antagonists, 1519t
Double sequential defibrillation, 153
Down’s syndrome, 981
Doxazosin, 886t, 1281
in urologic stone disease, 602
Doxepin, 1195t
Doxofylline, 1262
Doxycycline, 933t, 1063t
in chlamydial infections, 1015t
in diarrhea, 487t
in facial infections, 1568t
in granuloma inguinale, 1015t, 1022
in lymphogranuloma venereum, 1016t,
1022
in malaria, 1061t
in pelvic inflammatory disease, 657t
in pneumonia, 444
in postpartum endometritis, 636
for sexual infection prophylaxis, 1970t
in syphilis, 1016t, 1019
in urinary tract infections, 582t
Doxylamine, 622t
Dressings
auricular pressure, 290, 290f
in hand lacerations, 293–294
immobilization, 1776–1780
in lacerations, 290f
in postrepair wound care, 324
semipermeable, 324
in wounds, 324
Dressler’s syndrome, 351
Dronedarone, 128
actions of, 128
adverse effects of, 128, 128t
contraindications, 128, 128t
dosing and administration, 128
indications for, 128
pharmacokinetics of, 128t
Droperidol, 628, 902, 1112t
Droplet precautions, 1098
Drowning, 1374–1376. See also Diving
disorders; Environmental injuries;
Marine trauma
asymptomatic, 1376
disorder and injuries associated for, 1374t
epidemiology of, 1374
event algorithm, 1374f
hypothermia in, 1345
pathophysiology of, 1374
prevention of, 1376
prognosis in, 1376
symptomatic, 1376
treatment of, 1374–1376
Drug overdose, 162
Drug rash with eosinophilia and systemic
symptoms (DRESS) syndrome,
1627–1628, 1628f
Drug rash with eosinophilia and systemic
symptoms syndrome, 1624t, 1628f
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Tintinalli_Index_p2025-2116.indd 2051
Drug reactions, cutaneous, 941–942, 942t
Drug use
in children, 988
in elderly, 1945
headache in, 1108
in pregnancy, 629, 630t
treatment of emancipated minors, 2017
Drug users, injection, 1979–1984
altered mental status in, 1981
back pain in, 1981
bone and joint infections in, 1983
clinical features of, 1979–1981
dyspnea in, 1979
epidemiology of, 1979
evaluation of, 1980t
fever in, 1979
hepatic disorders in, 1983–1984
HIV infection in, 1981
infections in, 1982–1984
infective endocarditis in, 1981–1982
neurologic abnormalities in, 1981
ophthalmologic infections in, 1984
pathophysiology of, 1979
pulmonary infections in, 1982
risk behaviors of drug users, 1979
skin and soft tissue infections in, 1982
vascular infections in, 1983
Drugs
in advanced cardiac life support
amiodarone, 159
atropine, 159
beta-blockers, 159
calcium, 159
epinephrine, 158
lidocaine, 158–159
lignocaine, 158–159
magnesium, 159
sodium bicarbonate, 159
vasopressin, 157, 159
adverse reactions to
in HIV patients, 1041–1043,
1042t–1043t
soft tissue lesions in, 1584–1585
in systemic rheumatic diseases,
1912, 1913t
allergic reactions to, 72–73
in cardiopulmonary resuscitation,
epinephrine, 158–159
cutaneous drug reactions, 941–942, 941f,
942t
dosing and administration, in obese
patients, 1995
herb-drug interactions, 1326t
in resuscitation of children, 684–686
skin reactions to, 1646–1647, 1647f,
1647t
Drug-seeking behavior. See Aberrant
drug-related behavior
Dry-suit squeeze, in barotrauma of descent,
1370
DTaP vaccine, 1050–1051
Dual-isotope stress testing, 361
Duke criteria, 1045, 1046t
Duloxetine, 234t, 1202
in neuropathic pain, 264t
DUMBELS syndrome, 40
Dupuytren’s contracture, 1919, 1919f
Dynamic airway compression, 799
Dynamic hyperinflation, 192
Dysarthria, 1101–1102
Index   2051
Dysautonomias, 1168–1169
Dyshemoglobinemias, 1329–1332
methemoglobinemia, 1329–1332
sulfhemoglobinemia, 1332
Dyshidrosis, 1658t, 1660, 1660f
Dyspepsia, 261t, 506
Dysphagia, 501t
clinical features of, 501
neoplasms in, 501
Dysphasia, 1101–1102
Dyspnea, 368, 425
causes of, 425t
clinical features in, 425
in injection drug users, 1981
noninfectious causes of, 1981
in palliative care, 2003
treatment of, 426
Dysrhythmias. See also Arrhythmias; Heart
disorders
in acute coronary syndrome, 349–350,
349t
in children, 686–687, 839–841
atrioventricular block, 839
long QT syndrome, 840–841
sick sinus syndrome, 841
supraventricular tachycardia, 839
Wolff-Parkinson-White syndrome,
839–840, 840f, 840t
in cocaine toxicity, 1241
in congenital heart disease, 817
in cyclic antidepressants, 1198–1199
in monoamine oxidase inhibitors, 1207
Dystonia, 1210–1211, 1954
Dysuria, 582t, 871t
E
Ear
bomb and blast injuries in, 31
electrical injuries of, 1399
external squeeze, 1370
foreign bodies in, 762
inner ear barotrauma, 1370
lacerations of, 289–290, 290f
in lightning injuries, 1403
Ear disorders, 1560–1566
anatomy of, 757f, 1560–1561, 1560f
barotitis, 1369–1370
bullous myringitis in, 1564
cerumen impaction in, 1564–1565
in children, 756–762
external ear in, 1370, 1560
foreign bodies in, 1564
hematoma in, 1564, 1565f
inner ear in, 1560–1561, 1560f
mastoiditis, 761–762
middle ear in, 1560, 1560f
otalgia in, 1560t, 1561
otitis externa, 761, 1562–1563
otitis media, 1563–1564
otitis media with effusion, 759–761
sudden hearing loss in, 1561–1562,
1562t
tinnitus, 1560t, 1561
tympanic membrane perforation in,
1565–1566
Ear squeeze, in barotrauma, 1369–1370
Early postoperative bowel obstruction,
480–481
Early repolarization syndrome, 55, 55f
Earthquakes, 28
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 2052   Index

Eating disorders, 1956–1959 heat, 1346–1347 barriers to detection of, 1978

complications in, 1956–1958 myxedema, treatment of, 1449t caregiver neglect in, 1974–1975
criteria for, 1957t myxedema crisis, 1447–1450 categories of, 1974t
diagnosis of, 1958 thyroid hormone replacement in, diagnosis of, 1975–1976
in elderly, 1946 1449–1450 emotional or psychological, 1975
epidemiology of, 1956 treatment of, 1449–1450 financial or material exploitation, 1975
history in, 1956 papilledema, 1108, 1529, 1530f history in, 1975–1976
hospital admission criteria for, 1958t peripheral legal considerations in, 1978
imaging in, 1958 in high-altitude disorders, 1382 in long-term care facilities, 1978
laboratory testing in, 1958 in hypertension, 401 physical abuse, 1974
in men, 1959 pulmonary, 1373 physical examination in, 1976
pathophysiology of, 1956 characteristics of, 367t resources for, 1977t
physical examination in, 1956 in diving disorders, 1373 risk factors in, 1975
in pregnant women, 1959 in high-altitude disorders, 1381–1382 self-neglect, 1975
SCOFF questionnaire, 1958t in hypertension, 400t, 402, 403t sexual, 1975
treatment of, 1958–1959 immersion cooling, 1373 treatment in, 1976–1978
Ebola virus, 43t, 45t, 1032, 1085 in injection drug users, 1981 acute pain management in, 235
Ebstein’s malformation of the tricuspid valve, in scrotum, 591 agitation in, 1940
838 uvular, 1596 bleeding in, 1679–1680
Ecallantide, 72 Edetate calcium disodium, 1314 burns in, 1677
Echinacea, 519t, 1325t Edmonton protocol, 1424 carbon monoxide poisoning in, 1417
Echinococcus granulosus, 1078 Edoxaban, 1465, 1506 cervical spine injuries in, 1678
Echocardiogram Edrophonium, 1167 chest trauma in, 1678
in aortic regurgitation, 378f Efavirenz, 1042t chronic pain in, 256–257
in blunt cardiac injuries, 1757 Effective osmolality, 82, 82t DTaP booster in, 438
in cardiac tamponade, 388 Effusion, of knee, 1855 environmental and iatrogenic injuries in,
diagnosis of, 387t Ehrlichia, 1071t 1680
in endocarditis, 1046 Ehrlichiosis, 1073–1074 falls in, 1677
in hypertrophic cardiomyopathy, 384f clinical features of, 1072t gait in, 1144–1145
in low-probability acute coronary treatment of, 1073t genitourinary trauma in, 1762
syndrome, 360–361 Eikenella corrodens infections, 294, 323 head injuries in, 1678–1680
in mitral stenosis, 376f Elapids, 1361–1362 heat emergencies in, 1350
in pericardiocentesis, 225 Elbow hip injuries in, 1850
in pericarditis, 385 anatomy of, 1809–1811, 1810f, 1810t hypothyroidism in, 1450
Echovirus 9, 926 arthrocentesis of, 1922, 1922f mental health disorders in, 1940–1946
Eclampsia, 633, 633t diagnosis of, 1813 bipolar disorder, 1945–1946
in hypertension, 400t, 401–402 dislocation of, 911, 1815–1816, 1815f delirium, 1941–1943
signs and symptoms of, 400t epicondylitis of, 1815 dementia, 1943–1944
Econazole, 1653t fractures of, 1816–1820 depression, 1945
Ecstasy (drug), 1245 articular surface, 1819 eating disorder, 1963
Ectopic beats, 103–105 capitellum, 1819 psychosis, 1946
premature atrial contractions, 104 in children, 909–914 schizophrenia, 1946
premature ventricular contractions, condyle, 1825–1826 substance abuse, 1945
104–105 coronoid, 1819 suicide, 1945
Ectopic pregnancy, 615–622 distal humerus, 1816 in motor vehicle crashes, 1677
abdominal, 616 epicondyle, 1818 orthopedic injuries in, 1679
abdominal pain in, 479t intercondylar, 1817–1818 in pedestrian-motor vehicle collisions,
cervical, 616 lateral condyle, 910, 912f 1677
diagnosis of, 616–618, 619f medial epicondyle, 910, 913f pneumonia in, 443
differential diagnosis of, 616t Monteggia, 910 respiratory failure in, 1679–1680
discriminatory zone, 618 olecranon, 910, 913f, 1819 rib fractures in, 1679–1680
disposition and follow-up in, 620 proximal ulna, 1819 sedation in, 256–257
epidemiology of, 615–616 radial head, 1819–1820 sexual abuse and assault of, 1971
history in, 616 radiographic evaluation of, 909 shock in, 1680
b-human chorionic gonadotropin, 616–617 subluxation of radial head, 911–914 syncope in, 365
pathophysiology of, 616 supracondylar, 910, 911f–912f, trauma in, 1677–1680
physical examination in, 616 1816–1817 Electrical arc injuries, 1397–1398
progesterone in, 617 trochlea, 1819 Electrical burns, 1397. See also Burns
risk factors for, 616t imaging of, 1813f Electrical injuries, 1396–1401. See also
separation pain in, 619 immobilization of, 1814t Lightning injuries
treatment of, 618–620 joint aspiration of, 1922 auditory injuries in, 1399
ultrasonography in, 617–618, 618f lacerations of, 294 blast injuries in, 1399
Eczema, 1640–1641 ossification centers, 909 cardiac injuries in, 1398
Eczema herpeticum, 926f, 930, 1630 physical examination of, 1812–1813 in children, 1400–1401
Edema soft tissue injuries of, 1813–1815 clinical features of, 1398–1399
angioedema, 71–72, 1282, 1644–1646 Elderly coagulation disorders in, 1399
cerebral abdominal pain in, 477 complications of, 1400t
in diabetic ketoacidosis, 974–975, 1439, abdominal trauma in, 1678–1679 current flow in, 1411–1412
1440t abuse of, 1677, 1974–1978 cutaneous burns in, 1398
in high-altitude disorders, 1381, 1381f abandonment, 1975 diagnosis of, 1399–1400

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effects of current in, 1397t
electrical arc in, 1397–1398
electrical burns in, 1397
epidemiology of, 1397
fluid resuscitation in, 1400
gastrointestinal injuries in, 1399, 1415t
high-voltage, 1397, 1400
inhalation injuries in, 1399
light injuries, comparison with, 1401t
low-voltage, 1397, 1400
mechanisms of, 1397–1398
myoglobinuria in, 1400
ocular injuries in, 1399
orthopedic injuries in, 1398
in pregnancy, 1400
prehospital care in, 1399t
rescuer safety in, 1399
scene/prehospital care in, 1399
spinal cord injury in, 1398
tetanic contractions in, 1398
treatment of, 1399–1400, 1400t
vascular injuries in, 1398–1399
Electrocardiogram, 5
in acute coronary syndrome, 336–342,
337t, 338f–340f
in aortic dissection, 413
in atrial fibrillation, 107f
in atrial flutter, 108f, 108t
in atrioventricular block, first-degree, 111f
in atrioventricular block, second-degree
Mobitz type I, 112f, 112t
in atrioventricular block, second-degree
Mobitz type II, 113f, 113t
in atrioventricular block, third-degree,
113f, 114t
in Brugada syndrome, 121f, 121t
in carbon monoxide poisoning, 1416
in cardiogenic shock, 354
in digoxin toxicity, 1268, 1268f
in heart failure, 369
in hyperkalemia, 92f
in hypocalcemia, 96f
in idioventricular rhythms, 106f, 106t
in junctional rhythm, 105f, 106t
in long QT syndrome, 122f
in low-probability acute coronary
syndrome, 358
in mitral stenosis, 376f
in multifocal atrial tachycardia, 111f, 111t
in paroxysmal supraventricular tachycardia,
111f, 111t
in pericardiocentesis, 224f–225f, 225, 228
in pericarditis, 385, 385t, 386f
in premature atrial contractions, 104t
in premature ventricular contractions,
105f
in pulmonary hypertension, 409, 409f
in syncope, 365
of thoracic great vessels, 1749, 1749f
in thyroid storm, 1453
in venous thromboembolism, 391, 391f,
392t
in wide-complex tachycardias, 111f
in Wolff-Parkinson-White syndrome,
119f, 119t, 120f
Electroencephalography
in children, 841–842
chamber size, 842
heart rate, 841
P and QRS axes, 841, 842t
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Tintinalli_Index_p2025-2116.indd 2053
PR, QRS, and QT intervals, 842
T waves, 842
in seizures, 1155
Electrolyte disorders, 569
Electrolytes, 81–99. See also Resuscitation
calcium, 95–98
in children, 851–856
in diabetic ketoacidosis, 974, 1436
disturbances in, 576t
in heat emergencies, 1349
imbalance in transfusion, 1500
magnesium, 91–94
in nonketotic hyperglycemic coma,
1446–1447
phosphorus, 98–99
potassium, 88–89
sodium, 81–88
Electronic (E)-cigarettes, 1265
Electronic control device injuries, 1403–1404
Electronic medical record, 4
Elephant’s ear, 1413
Ellis classification system, 781, 781f–782f
Emancipated minors, 2016–2017
Embolectomy, 399
Embolic stroke, 1121t
Embolism
air, 138, 577, 1738–1739
in arterial occlusion, 420, 421t
in endocarditis, 1045
thromboembolism
in malignancy, 1518
in pregnancy, 624–626
in systemic rheumatic diseases,
1909–1910
venous, 389–399
Emergency decompressive surgery, 1887
Emergency delivery, 637–647. See also Labor
and delivery
cervical dilatation in, 637
clamping the umbilical cord in, 640–641
clinical evaluation in, 638–640
completion of delivery in, 640
complications, 642–644
breech presentation, 644, 645f
shoulder dystocia, 642–643, 642t
umbilical cord prolapse, 642
delivery of placenta in, 641–642
epidemiology of, 637
episiotomy in, 640, 642f
equipment and supplies for, 637t
fetal distress in, 638, 639f, 642t
gestational age in, 640
history in, 640
medications for, 638t
normal delivery, 641f
out-of-hospital, 637
pelvic examination in, 640
physical examination in, 642
postpartum hemorrhage in, 644, 646f,
646t
preterm delivery, 647–649
rupture of membranes in, 637
stages of labor in, 638, 638t
true vs. false labor in, 638, 638t
uterine inversion and rupture in,
644–646
Emergency medical services, 1–3
access to care, 2
air transport in, 2, 9–13
challenges and future trends in, 3
Index   2053
communication system in, 1–2
consumer participation, 2
critical-care units, 2
disaster plan, 3
facilities, 2
key elements of, 1–3, 2t
legal issues in, 2014–2024
manpower, 1
mutual aid, 3
patient recordkeeping in, 2
patient transfer, 2
public information/education, 2
public safety agencies, 2
in radiation exposure, 49–50, 50t
review and evaluation in, 2–3
training in, 1
transportation in, 1–2
Emergency medical technicians (EMTs), 1
basic skills of, 1
pharmaceutical supplies, 9
training, 1
Emergency Medi­cal Treatment and Active
Labor Act, 636
Emergency Medical Treatment and Active
Labor Act, 2, 636, 2019–2022
Emergency Planning and Community
Right-to-Know Act, 36
Emergency Severity Index, 1934
Emesis, 1191
Emollients, 494t
Emphysema, subcutaneous, 1738
Emphysematous cholecystitis, 1426t
Emphysematous pyelonephritis, 1426t
Empyema, 449–450. See also Pulmonary
emergencies; Respiratory disorders
clinical features of, 449
common organisms in, 450t
diagnosis of, 449
epidemiology of, 449
treatment of, 449–450
EMS. See Emergency medical services
EMS Systems Act of 1973, 1
Emtricitabine, 1042t, 1096t
Enalapril, 1282
Enalaprilat
in hypertension, 404, 406
in hypertensive pulmonary edema, 403t
Encainide, 56
Encephalitis
cerebrospinal fluid in, 1173t
headache in, 1109–1110
HSV, 1025
Japanese, 1086
signs and symptoms of, 43t
viral, 1175–1176
West Nile virus, 1075
zoonotic, 1075
Encephalopathy, 516
in carbon monoxide poisoning, 1417
hepatic, 520, 520t
HIV-associated, 1035
hypertensive, 401–402, 403t
Endarterectomy, 1135
Endocardial cushion defect, 827
Endocarditis, 832–833, 1043–1048
arterial embolization in, 1045
cardiac manifestations of, 1045
clinical features of, 832–833, 1044–1045,
1045t
in congenital heart disease, 830
8/2/19 6:02 PM
 2054   Index
Endocarditis (Cont.):
cutaneous findings in, 1045
diagnosis of, 833, 1045–1046
blood cultures in, 1045–1046
Duke criteria in, 1046t
echocardiography in, 1046
Duke criteria for, 1045, 1046t
epidemiology of, 1043
fever in, 1045
in HIV infection, 1035
hospital admission in, 1045
infective, 1981–1982
in injection drug users, 1043–1044,
1981–1982
marantic, 1044
microbiology of, 1044, 1044t
modified Duke criteria for, 833
of native valves, 1047
neurologic manifestations of, 1045
pathophysiology of, 1044
prophylaxis for, 833, 834t, 1047–1048,
1048t
prosthetic valve, 1047
risk factors for, 832t, 1047t
risk of recurrence, 1048
treatment of, 833, 1046–1047, 1047t
Endocrine disorders, 1419–1460
adrenal insufficiency, 1457–1460
cocaine in, 1237–1238
diabetes mellitus, type I, 1419–1424
diabetes mellitus, type II, 1424–1433
diabetic ketoacidosis, 1433–1441
in eating disorders, 1957
hyperosmolar hyperglycemic state,
1443–1447
hyperthyroidism, 1450–1457
hypothyroidism, 1447–1450
ketoacidotic syndromes, 1441–1443
myxedema crisis, 1447–1450
Endometrial ablation, 666
Endometriomas, 614
Endometriosis, 262, 262t, 264t, 614
Endometritis, postpartum, 636, 636t
Endophthalmitis, 1544
Endoscopy
analgesia in, 253
in caustic ingestions, 1298–1299
in esophageal foreign bodies, 503
in lower gastrointestinal bleeding, 500
in peptic ulcer disease, 506t
procedural sedation in, 253
in upper gastrointestinal bleeding,
497–498
Endothelin receptor antagonists, 411, 412t
Endotracheal intubation, 5–6
in children, 712–713
complications of, 185, 185t
converting supraglottic airway to, 178–179
equipment in, 712–713, 713t
location of, 183–185
Endovascular aortic repair, 418
Endovascular therapy, 1132–1134
End-stage renal disease, 573–578
amyloidosis in, 575
biosynthetic failure in, 573
bleeding diathesis of, 575
clinical features of, 573–575
complications in, 573–575
bone disease, 575
cardiovascular, 574
Tintinalli_Index_p2025-2116.indd 2054
hematologic, 574–575
neurologic, 573–574
epidemiology of, 573
excretory failure in, 573
hemodialysis in, 575–577
immunologic deficiency in, 575
pathophysiology of, 573
peritoneal dialysis in, 577–578
regulatory failure in, 573
End-tidal capnogram, 81f
End-tidal carbon dioxide, 682, 803
Enemas, 494t
Enfuvirtide, 1043t
Enoxaparin, 1508t
in deep venous thrombosis, 397t
in NSTEMI, 345t
in pulmonary embolism, 397t
in STEMI, 344t
Entamoeba histolytica infections, 1067t, 1068
Enteric viruses, 1069
Enterobiasis, 1090
Enterobius vermicularis, 548, 654
Enteroviruses, 753, 926
Entry and fusion inhibitors, 1043t
Environmental controls, 1098
Environmental injuries, 1333–1417
bites and stings, 1350–1358
burns in, 1384–1391
carbon monoxide poisoning in,
1414–1417
cold injuries, 1333–1337
diving disorders, 1368–1374
drowning, 1374–1376
in elderly, 1680
electrical injuries, 1396–1401
heat emergencies, 1345–1350
high-altitude disorders, 1376–1383
hypothermia, 1337–1345
lightning injuries, 1401–1403
marine envenomations, 1364–1368
marine trauma, 1362–1363
mushroom poisoning, 1404–1409
poisonous plants, 1410–1414
snake bites, 1358–1362
Eosinophilic esophagitis, 502
Eosinophilic lung disease, in pulmonary
infiltrates, 448t
Ephedra, 1326t
Ephedrine, 1239
in pregnancy, 168t
in resuscitation in pregnancy, 166
Epicondyle fractures, 1825
Epicondylitis, 1815
Epidemic keratoconjunctivitis, 1541, 1541f
Epidemic louse-borne typhus, 1084
Epidermis, 1384, 1384f
Epidermoid cyst, 1012
Epididymis, 592
Epididymitis, 595t, 596, 597t, 875, 875f
Epidural abscess, 1177–1179, 1883
clinical features of, 1178
diagnosis of, 1178
epidemiology of, 1177–1178
history in, 1178
pathophysiology of, 1178
physical examination in, 1178
treatment of, 1178–1179
Epidural compression syndrome, 1887
Epidural hematoma, 1690–1691, 1691f
Epigastric pain syndrome, 261t
FB:Cardiologia Siglo XXI
Epiglottitis, 792–793, 1596–1597, 1597f
clinical features of, 792
diagnosis of, 793
treatment of, 793, 793t
Epilepsy, 1153
seizures in, 895
Epinephrine, 135, 236, 237t, 238, 257,
270, 727
actions of, 135
adverse effects of, 135
in anaphylaxis, 69–70, 70t
in asthma, 464t, 466
in bradyarrhythmias, 101t
in cardiac arrest, 158
in cardiogenic shock, 356, 356t
cardiovascular effects of, 134t
contraindications, 134t
in croup, 792, 793t
dosing and administration, 134t
indications for, 135
pharmacokinetics of, 135t
in pregnancy, 168t
in resuscitation in pregnancy, 166
in resuscitation of children, 683t, 685
in sepsis, 1002
in shock, 61t
Epinephrine autoinjector injuries, in puncture
wounds, 320–321
Epiphyseal plate fractures, 1767–1768
Epiphysis, 903
Epiploic appendagitis, 478t
abdominal pain in, 480
Episclera, 1523
Episcleritis, in Crohn’s disease, 489t
Episiotomy, 640, 642f
Epistaxis, 433
Epistaxis of nose, 1572–1575
anatomy in, 1572–1573
anterior nasal packing in, 1574
balloons in, 1574
chemical cauterization in, 1573–1574
clinical features of, 1573
diagnosis of, 1573
direct nasal pressure in, 1573
epidemiology of, 1572
in infants and children, 775
pathophysiology of, 1572–1573
posterior nasal packing in, 1574, 1575f
ribbon gauze packing in, 1574, 1575f
tampons or sponges in, 1574, 1574f
thrombogenic foams and gels in, 1574
treatment of, 1573–1575
Eplerenone, 1281
Epley maneuver, 1149f
Eprosartan, 1282
Epsilon wave, 123
Epstein pearls, 776
Epstein-Barr virus infection, 779, 1029–1030
clinical features of, 1029
diagnosis of, 1029–1030
pathophysiology of, 1029
treatment of, 1030
Eptifibatide, 347, 1510
in NSTEMI, 345t
in STEMI, 344t
Equipment and supplies
in airway management, 174–175
in cardiac pacing, 216–217, 217t–218t
in chemical exposures, 38f
in cricothyrotomy, 196t
8/2/19 6:02 PM

in defibrillation, 149–150
in dental anesthesia, 1590
in disasters, 22
in gastrointestinal disorders
Sengstaken-Blakemore tube, 552–553,
553f
transabdominal feeding tubes, 554–555,
554t
tube replacement, 555
in intubation in children, 712–713, 713t
in jet ventilation, 198–199, 199f, 199t
in mass gatherings, 15, 16t
in military medicine, 2007, 2008t
in monitoring radiation, 48
in neonate resuscitation, 674, 674t
in orotracheal intubation, 182–185
in pediatric intubation, 712–713, 713t
in pericardiocentesis, 227t
personal protective, 4
in prehospital care, 4–9
for radiation exposure measurement, 48, 48t
in sedation, 250
for stabilization, resuscitation, and
treatment, 5–10
vascular access, 6
Equivalent, 82t
Erectile dysfunction, complications of devices
for, 606
Erosion
differential diagnosis of, 1618f, 1618t
in skin lesions, 1608f, 1608t
Erosive gastritis, upper gastrointestinal
bleeding in, 495
Ertapenem, 480t
in urinary tract infections, 583t
Eruption cysts, 776
Erysipelas, 1005. See also Infections
antibiotics for, 1567t
butterfly rash of, 1007f
in children, 935–936, 935f
clinical features of, 1006–1007
definition of, 1005
diagnosis of, 1007
differential diagnosis of, 1007t
disposition and follow-up in, 1007–1008
epidemiology of, 1005
of face, 1566
organisms in, 1006
rashes in, 935–936
risk factors for, 1006t
treatment of, 1007, 1008t
Erythema infectiosum, 929–930, 929f–930f
Erythema migrans, 1645–1646, 1646f
Erythema multiforme, 942, 942f, 1623–1626,
1624t, 1625f, 1626t, 1645
Erythema nodosum, 1658t, 1660–1661
causes of, 1662t
in Crohn’s disease, 489t
Erythema toxicum, 939, 939f
Erythroblastopenia, 954
Erythromycin, 325t
in bacterial infections, 933t
in premature rupture of membranes, 635
Erythromycin base
in chancroid, 1015t
in chlamydial infections, 1015t
in granuloma inguinale, 1015t–1016t, 1022
in lymphogranuloma venereum, 1016t
Erythromycin ethylsuccinate, in chlamydial
infections, 1015t
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2055
Erythroplakia, 1585
Escharotomy, 1390, 1390f
Escherichia coli, 1066t
in bacterial meningitis, 1172–1173
enteroaggregative, 846t
enterohemorrhagic, 1066t
enteroinvasive, 846t
enteropathogenic, 846t
enterotoxigenic, 846t, 1066t
in foodborne illnesses, 1065
in mastitis, 660
Shiga toxin-producing, 846t, 1066t
in spontaneous bacterial peritonitis, 520
in urinary tract infections, 580–581
Eslicarbazepine acetate, 1288
Esmarch’s technique, 293
Esmolol, 126, 887t
actions of, 126
in aortic dissection, 403t, 415
in atrial fibrillation/flutter, 109
in atrioventricular blocks, 101t
in hypertension, 405t, 408t
for hypertensive pediatric patients, 408t
indications for, 125t
in intracerebral hemorrhage, 404t
pharmacokinetics of, 125t
in subarachnoid hemorrhage, 403t
in thyroid storm, 1454
Esophageal and gastric varices, upper
gastrointestinal bleeding in, 495
Esophageal dysphagia, 501t
Esophageal injuries, 1737
Esophageal perforation, 502
Boerhaave’s syndrome, 502
causes of, 502
clinical features of, 502
diagnosis of, 502
pathophysiology of, 502
Esophageal reflux, 332
Esophageal rupture (Boerhaave’s syndrome),
chest pain in, 331
Esophagitis, 502, 1036t
eosinophilic, 502
infectious, 502
inflammatory, 502
upper gastrointestinal bleeding in, 495
Esophagus, 500–505
anatomy of, 500–501, 501f
disorders of, 500–505
dysphagia, 501, 501t
esophageal perforation, 502
esophagitis, 502
gastroesophageal reflux disease, 501–502
foreign bodies in, 503–505, 503f, 503t
button batteries, 504–505, 504f
coins, 503f, 504
food impaction in, 504
narcotics, 505
sharp objects, 505
pathophysiology of, 500–501
perforation of, 502–503
Essential hypertension, 885
Essure® microinsert, 664
Esters, 236, 237t
Estradiol, 1999
Estrogen, 165t
in clotting disorders, 1476
feminizing hormones, 1999
in massive uterine bleeding, 611
in menstrual cycles, 607
Index   2055
in ovarian cysts, 613
in pregnancy, 1450, 1476
side effects, 1999
topical, 879–880
in vaginal bleeding, 609, 611
in venous thromboembolism, 290t
in vulvovaginitis, 648
Estrogen-progestin, 1970t
Eszopiclone, 1220t
Ethambutol
in HIV-related infections, 1036t
toxicity of, 1329
in tuberculosis, 454, 455t
Ethanol, 1190t, 1222–1224
chemical structure of, 1222f
metabolic blockade with, 1231–1232
metabolism of, 1223f
pathophysiology of, 1222–1223
toxicity of, 1222–1224
clinical features of, 1223
diagnosis of, 1223
treatment of, 1223
Ethchlorvynol, 1221–1222
Ethics, 172
Ethilon®, 273t
Ethosuximide, 1287
Ethylene glycol, 1227–1232
pathophysiology of, 1228–1229, 1229f
poisoning, 1229–1232
acidosis in, 1231
anion gap in, 1230, 1230f
clinical features of, 1229
diagnosis of, 1229–1230
hemodialysis for, 1231–1232
metabolic blockade in, 1231–1232, 1231t
osmolar gap in, 1230, 1230f, 1230t
treatment of, 1226t, 1231–1232
vitamin therapy for, 1232
structure of, 1222f
Etomidate, 251t, 254
in rapid-sequence intubation, 186, 186t,
715t
in sedation, 731
Euglycemic diabetic ketoacidosis, 1435
Euthyroid sick syndrome, 1447, 1957
Evisceration, 665
Ewing’s sarcomas, 961, 961f
Exanthem subitum, 931
Excoriation, in skin lesions, 1608f, 1608t
Exenatide, 1430
Exercise capacity, 1378
Exercise testing, 360, 360t
Exertional compartment syndrome, 1862
Exfoliative dermatitis, 1624t, 1627, 1627f
Exfoliative erythroderma, 1624t
Exogenous poisoning, 74t
Expository positive airway pressure, 176
Extension corner avulsion fracture, 1702f
Extensive drug-resistant tuberculosis, 456
Extensor hallucis longus tendon, 1875
Extensor tendons, 1784, 1790f
injuries of, 1790–1792
lacerations of, 294–295
zone classification of, 1790–1792
External fixation, 1841
External hemorrhage, in bomb and blast
injuries, 32
External iliac artery endofibrosis, 421t
External rotation (Kocher’s technique),
1829, 1829f
8/2/19 6:02 PM
 2056   Index

External snapping hip syndrome, 1899 in children, 763–771 Eye drops, in myasthenia gravis, 1166t
Extracellular fluids, 81, 83f amblyopia, 764 Eye worm, 1091
Extracorporeal life support, 159 blepharitis, 765 Eyebrow lacerations, 286
Extracorporeal membrane oxygenation, 154, cataracts, 771, 771f Eyelids
1344–1345 conjunctivitis, 768–770 anatomy of, 286–287, 288f, 1524f
in cardiac arrest, 159 corneal abrasion, 767 cross-section of, 288f
in pregnancy, 169 dacryoadenitis, 765 double eversion of, 1528
Extracorporeal removal, 1193–1194, 1193t dacryocele, 765 examination of, 1527–1528, 1528f
Extrapulmonary tuberculosis, 456 dacryocystitis, 764–765, 765f infections of, 1539–1542
Extrapyramidals, 1190t dacryostenosis, 764–765 blepharitis in, 1540
Extremities examination of, 752–754 chalazion in, 1540, 1540f
aneurysms in, 419 glaucoma, 770 conjunctivitis in, 1540–1542, 1540f
ankle-brachial index of, 1763 leukocoria, 770–771 stye in, 1539–1540, 1540f
diabetic complications in, 1425, 1430–1431, ophthalmia neonatorum, 767–768, 768t subconjunctival hemorrhage in,
1432t orbital cellulitis, 766–767, 766f 1542, 1542f
lacerations in, 305 periorbital cellulitis, 765–766 lacerations of, 287–288, 287f, 1547
lower, muscles in, 1105t red eye, 767–770 Eyes
orthopedic injuries in, 1679 retinal hemorrhages, 771 chemical burns, 1396
skin disorders of, 1655–1665 retinoblastoma, 771 electrical injuries of, 1399
trauma to, 1762–1766 strabismus, 764 lightning injuries of, 1402–1403
arterial injury in, 1764 complications in, in type II diabetes, 1425, in systemic rheumatic diseases, 1910
bleeding in, 1764 1426t Ezogabine, 1288
clinical features of, 1762–1763, 1763t corneal abrasion, laceration, and foreign
diagnosis of, 1762–1764, 1764f body, 1543–1546 F
epidemiology of, 1772 corneal transplantation in, 1993–1994 Face
imaging of, 1763 cranial nerve palsies, 1556–1557 cellulitis of, 1566
pathophysiology of, 1762 drug therapy in, 1531, 1534t–1537t erysipelas of, 1566
soft tissue foreign bodies in, 1765 examination of, 1108, 1523–1531 fractures of, 1718–1721
treatment of, 1764–1766 flashing lights, 1556 blow-out, 1719f
upper, anatomy of, 201f floaters in, 1556 in children, 1721
upper, muscles in, 1105t glaucoma in, 1552–1554 frontal, 1718, 1718f, 1729f
Extremity blocks, 246–247 history in, 1523 Le Fort, 1720, 1721f
femoral nerve block, 246–247 infections in, 1533–1544 mandible, 1721f, 1731–1732
hematoma block, 247, 248f blepharitis in, 1540–1541 midfacial, 1720, 1721f
Extrinsic allergic alveolitis, in pulmonary chalazion in, 1540, 1540f orbital, 1719–1720, 1719f
infiltrates, 448t conjunctivitis in, 1540–1542, 1540f zygoma, 1719f, 1720, 1720f
Extrusive luxation, 1587 corneal ulcer, 1542–1543 impetigo of, 1566–1567
Eye herpes simplex keratoconjunctivitis, infections of, 1566–1570
anatomy of, 763f, 1527f 1542 antibiotics for, 1568t
bomb and blast injuries in, 32 herpes zoster ophthalmicus, 1541–1542 differential diagnosis of, 1567t
examination of, 1523–1531 in injection drug users, 1984 of salivary glands, 1567–1569
adnexa in, 1527–1528 preseptal and postseptal cellulitis in, sialolithiasis, 1569
confrontation visual fields in, 1526, 1526f 1533–1539 suppurative parotitis, 1569
external eye in, 1527–1528 stye, 1539–1540, 1540f lacerations of, 285–292
fluorescein in, 1528–1529, 1531f subconjunctival hemorrhage in, 1542 pathophysiology of, 285
funduscopic, 1529 ultraviolet keratitis, 1543–1544 skin tension lines in, 286f
intraocular pressure in, 1529–1530 infections of, 1543 suturing guidelines for, 287t
movement of eye in, 1526–1527, 1527f endophthalmitis, 1544 skin disorders of, 1629–1631
ocular motility in, 1526–1527, 1527f iritis, 1543, 1544t temporomandibular joint disorders of,
ophthalmoscope in, 1529, 1529f uveitis, 1543 1570–1572
periorbital skin in, 1527–1528 vitreous detachment and hemorrhage, trauma of, 1714–1721
pupils in, 1527 1544 clinical features of, 1715–1717,
Seidel test in, 1530, 1530f lachrymal system problems in, 764–765 1715f–1717f, 1715t
slit lamp in, 1530–1531, 1531f optic neuritis in, 1555 diagnosis of, 1717–1718
tonometer in, 1530, 1530f red eye in, 1531–1533, 1538t–1539t imaging of, 1717–1718
visual acuity in, 1525–1526 retinal detachment in, 1556 pathophysiology of, 1714–1715
extraocular movements of, 763, 1527f temporal arteritis, 1556 treatment of, 1717–1721
extraocular muscles of, 1527f trauma in, 1544–1552 viral parotitis (mumps), 1568–1569
funduscopic examination of, 763, 1529 blunt eye trauma, 1548–1552 Face masks, 1098
visual acuity of, 763 chemical injuries, 1552–1553 Face squeeze, in barotrauma of descent, 1370
Eye disorders, 1523–1560 conjunctival abrasion, 1544–1545 Facial nerve blocks, 244–246
anatomy in, 1523, 1524f conjunctival laceration, 1544–1545 auricular, 245
blunt injuries in, 1548–1552 corneal abrasion, 1545, 1545f, 1545t infraorbital, 244
hyphema, 1548 corneal foreign bodies, 1546–1547, 1546f intercostal, 245
orbital blow-out fractures, 1548–1549, corneal laceration, 1546 mental, 244–245
1549f foreign bodies, 1544–1545 supraorbital, 244
orbital hemorrhage, 1550–1552 lid lacerations, 1547 supratrochlear, 244
ruptured globe, 1549–1550, 1550f in type II diabetes, 1425 Facial space infections, 1582
central retinal artery occlusion in, 1555 ultrasonography in, 1556–1559 Factor IX deficiency, 951t
central retinal vein occlusion, 1555 vision loss in, 1553–1556, 1553t Factor level assay, 1468t

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2056 8/2/19 6:02 PM

 Index   2057

Factor V Leiden, 1468t, 1475 Crimean-Congo hemorrhagic, 1085–1086 Fishhooks, removal of, 315–317, 315f–316f
Factor VIII inhibitors, 1474 cysticercosis, 1086 Fissures, in skin lesions, 1609f, 1609t
Factor Xa (FXa) inhibitors, 1506 dengue, 1081–1082 Fistula
in deep venous thrombosis, 397t Ebola, 1085 aortoenteric, 417
in intracerebral hemorrhage, 1118t in endocarditis, 1045 aortovenous, 417
in pulmonary embolism, 397t in headache, 1107 in gastrointestinal surgery complications, 559
Fainting. See Syncope in HIV infection, 1035 perilymph, 1151
Fallopian tube, 616 in injection drug users, 1035, 1979 vesicovaginal, 665
Famciclovir, 1016t, 1020, 1036t–1037t, 1542 in ischemic stroke, 1128 Fistula-in-ano, 542–543, 542f
Family information center, in disasters, 22 Lassa, 1086 Fixed drug eruptions, 1647, 1647f
Famotidine, 507, 1622t leptospirosis, 1084 Fixed-wing air medical transport, 12–13
FARES technique, 1829, 1831f in malaria, 1081 FLACC scale, 724f
Fascia lata syndrome, 1899 Marburg virus, 1085 Flail chest, 177, 1738
Fasciotomy, for crush injuries, 34–35 metal fume, 1318 Flank, trauma to, 1755–1757
FAST (focused assessment with sonography neutropenic, 962t Flare, 1531
for trauma) examination, 1841, 1841f pharyngoconjunctival, 768 Flash burns, 1403
Fast-absorbing gut, 274t postoperative, 555–556, 557t Flashover, 1401
Fat embolism, in pulmonary infiltrates, 448t relapsing, 1085 Flea bites, 1649
Fatigue, 705 rickettsial spotted, 1084 Fleas, 1357
Febrile neutropenia, 1517–1518 in sickle cell disease, 945–946, 948 Flecainide, 56, 124–125
Febrile seizures, 756, 894–895 snail, 1087 in atrial fibrillation/flutter, 109, 109t
Fecal impaction, 495 in travelers, 1081–1085 in tachydysrhythmias, 101t
Federal Bureau of Investigation, 21t typhoid, 1082 Flexible fiberoptic laryngoscopy, 188–189
Federal Communications Commission yellow, 1085 Flexion teardrop fracture, 1699f
(FCC), 4 Zika virus, 1084–1085 Flexor hallucis longus, 1875
Federal Select Agent Program, 42 Feverfew, 1325t Flexor hallucis longus rupture, 1931
Feeding tubes, in technology-dependent Fexofenadine, 1622t Flexor tendon sheath nerve block, 240
children, 979 Fiber, 494t Flexor tendons, 1784
Felbamate, 1288 Fibrillation, ventricular, 56, 117–118, 118f injuries of, 1789–1790
Felodipine, 1276t Fibrin degradation product, 1468t lacerations of, 296
Felon, 1915t, 1917, 1917f Fibrinogen, 1498 Flexor tenosynovitis, 1915–1916, 1915t
Feminizing hormones, 1999 Fibrinolysis Flies, 1357
Femoral artery aneurysm, 419 in pulmonary embolism, 398–399 Floaters, 1556
Femoral head systemic, 398–399 Floods, 29
avascular necrosis of, 944, 1902t, 1903f Fibrinolytics, 1503, 1510–1512 Fluconazole
fractures of, 1844 in acute coronary syndrome, 345–346, 346t in balanoposthitis, 593
Femoral hernia, 535 anistreplase, 1511 in Candida vaginitis, 650t
Femoral neck fractures, 1844–1845 complications of, 1511 in HIV-related infections, 1036t
Femoral nerve, 1895 contradictions to, 1511, 1511t in sporotrichosis, 1013
Femoral nerve block, 246–247, 247f in hemostasis, 1465–1467, 1467f Flucytosine, 1036t
Femoral shaft fractures, 917, 1845–1846 in hypertension, 404 Fluid balance
Femoral vein reteplase, 1511 hypercalcemia in, 97–98
central venous access in, 207–208, in STEMI, 344t hyperkalemia in, 89–91
207f–208f, 721–722 streptokinase, 1511 hypernatremia in, 85–87
techniques for access to, 207–208, 207f–208f tenecteplase, 1511 hyperphosphatemia in, 101
ultrasound-guided localization of, 208 tissue plasminogen activator, 1511 hypocalcemia in, 95–97
Femur, fractures of, 1842f, 1843t Fibrocystic breast disease, 662 hypokalemia in, 88–89
Fenoldopam, 887t, 1283 Fibromatosis colli, 789 hypomagnesemia in, 93–94
in acute renal failure, 402, 403t Fibromyalgia, 260, 264t hyponatremia in, 83–85
in hypertension, 406, 407t, 408t Fifth metatarsal fractures, 1874 hypophosphatemia in, 98–99
in hypertensive encephalopathy, 403t Fight bite, 294 Fluids, 81–99
for hypertensive pediatric patients, 408t Figure of 8 stitch, 270f in acclimatization, 1377
Fentanyl, 252t, 257, 1236, 2011 Figure-of-eight bandage, 1776 in burns, 1389, 1389t
in acute pediatric pain, 725 Filoviruses, 43t, 45t calcium and, 95–98
dose of, 232t Finasteride, 1999 in children, 851–856
in emergency delivery, 638t Fingers, lacerations of, 296 in diabetic ketoacidosis, 973
in rapid-sequence intubation, 186t, 715t Finger-sweep maneuver, 148, 148f in electrical injuries, 1400
in sedation, 255, 731 Fingertip injuries, 297 electrolyte concentrations of, 82t
transdermal, 231 amputations, 297f extracellular, 81, 83f
in vaso-occlusive crisis, 948 anatomy in, 297f in heat emergencies, 1349
Ferritin, 1462t with exposed bone, 297–298 interstitial, 81, 83f
Festinating gait, 1143 with skin and pulp tissue loss only, 297 intracellular, 81, 83f
Fetal circulation, 819–820 Finkelstein test, 1919f and magnesium, 91–94
Fetal distress, 638, 639f, 642t Fire coral, 1367 in necrotizing soft tissue infections, 1012
Fever Fireworms, 1367 in pediatric trauma, 692
beaver, 1068 First afebrile seizures, 895 and phosphorus, 98–99
Chikungunya, 1085 First Responder Network Authority and potassium, 88–89
in children, 746–752 (FirstNet), 4 in shock, 60–61
evaluation of, 748–751 Fish bites, 323 and sodium, 81–88
treatment of, 748 Fish tapeworm, 1090 vasopressors in, 61

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 2058   Index

Flumazenil, 257 dermatitis of, 1658–1665 lacerations of, 294

as benzodiazepine antagonist, 1218 ganglions of, 1930 physical examination of, 1812–1813
contraindications to, 1218t ingrown toenail of, 1929, 1929f soft tissue injuries of, 1813–1815
in resuscitation of poisoned patient, 1188t injuries of, 1870–1876 Forefoot injuries, 1874–1875
Flunarizine, 1152t calcaneus, 1870–1872 Forehead laceration, 285
Fluocinolone acetonide, 1621 in children, 921 clinical features, 286
Fluorescein, 1528–1529, 1531f cuboid, 1874 pathophysiology of, 285
Fluoroquinolones cuneiform, 1874 repair of, 286
in acute kidney failure, 566 fifth metatarsal, 1874 Foreign bodies
avoiding in pregnancy, 627–628 forefoot, 1874–1875 in abdominal/pelvic pain, 614
in generalized arthropathy, 1902 hindfoot, 1870–1872 airway management, 794–796
in intra-abdominal infections, 480t history in, 1870 airway obstruction, 146–148
in otitis externa, 761 Lisfranc, 1872–1873, 1873f chest thrust maneuver, 147–148, 148f
in pneumonia, 444t–445t metatarsal, 1874–1875 finger-sweep maneuver, 148, 148f
in postrepair wound care, 325t metatarsophalangeal, 1875 Heimlich maneuver, 147f
in prostatitis, 597 midfoot, 1872–1874 obstruction airway (Heimlich)
in puncture wounds, 319 navicular, 1873–1874 maneuver, 147
toxicity of, 1328 phalange, 1875 airway obstruction in
in typhoid fever, 1082 physical examination in, 1870 chest thrust maneuver, 147–148, 148f
Fluoroscopy, in soft tissue foreign bodies, stress fractures, 1875 Heimlich maneuver, 147
312–314 talus, 1872 anorectal, 547–548, 547f, 549f, 553f
Flutter waves, 107 tendon, 1875 in cornea, 1545f, 1546–1547
Focal mononeuropathies, 1161–1162 treatment of, 1876t in ear, 1564
Folate, 948, 1323t, 1325 lacerations, 299–307 in ear canal, 762
Foley catheter, 588f digital, 306 in esophagus, 503t, 504–506, 504f
in esophageal foreign bodies, 504 dorsal, 305–306 button batteries, 504–505, 504f
nondeflation of, 603 hair-thread tourniquet syndrome, 306 coins, 503f, 504
Folic acid, 1325 interdigital, 306 food impaction in, 504
Folinic acid, 970 physical examination of, 300–301 narcotics, 506
Follicular conjunctivitis, 768 plantar, 306 sharp objects, 506
Follicular cysts, 613 treatment of, 302–303 in eye trauma, 1544–1545
Folliculitis, 1012, 1650, 1651f nerve entrapment syndromes of, 1930 in foot and leg lacerations, 306
clinical features of, 1012 nerves of, 304f intraocular, 1559, 1560f
definition of, 1005 plantar fasciitis of, 1930 in knee, 1858
diagnosis of, 1012 plantar interdigital neuroma of, 1931 in nose, 774–775, 1578
epidemiology of, 1012 sensory innervation of, 305f removal of, 313–317
hot tub, 1650 soft tissue problems of, 1929–1931 removal of, in wound preparation,
organisms in, 1012 tarsal tunnel syndrome of, 1930 271–272
superficial, 1650 tendon lesions of, 1931 in soft tissues, 307–317, 1765
treatment of, 1012 tendons of, 304f clinical features, 307–308
Fomepizole, 1221, 1231 Foot and ankle blocks, 242–244 history in, 307
Fondaparinux, 347–348, 1507t, 1508 deep peroneal nerve block, 243 imaging of, 309–314, 309f, 309t,
in deep venous thrombosis, 397t posterior tibial nerve block, 243 310f–314f
in NSTEMI, 345t saphenous nerve block, 244 metallic needles, removal of, 314–315,
in pulmonary embolism, 397t superficial peroneal nerve block, 243–244 314f–315f
in STEMI, 344t sural nerve block, 244 pathophysiology of, 307
Food allergies, 72 Football helmet removal, 7–8, 8f physical examination in, 308–309, 309f
Foodborne illnesses, 1063–1070 Forearm removal of, 313–317, 315f
agents for, 1064t anatomy of, 1809–1811, 1812f treatment of, 314
bacterial, 1066t compartments of, 1877f wood splinters, removal of, 315, 315f
chronic sequelae of, 1067 diagnosis of, 1813 in urethra, 597
ciguatera poisoning in, 1065–1067 dorsal, 294 vaginal, 654, 880
clinical features of, 1064, 1064t, extensor compartments in, 294t Forensics
1066t–1067t flexor tendons in, 296t in bomb and blast injuries, 33
diagnosis of, 1065 fractures of, 914–916, 1820–1821 in child sexual abuse, 994
disposition and follow-up in, 1065 of both radius and ulna, 1820 in sexual abuse and assault, 1968–1969
enterohemorrhagic E. coli in, 1065 in children, 914–916 Formic acid, 1227, 1392
epidemiology of, 1063 Galeazzi’s fracture-dislocation, 1821 Formoterol, 465
hemolytic-uremic syndrome, 1065 isolated ulna, 1820 Fosamprenavir, 1042t
parasitic, 1067t Monteggia fracture-dislocations, Fosaprepitant, 1519t
pathophysiology of, 1063–1064 1820–1821 Foscarnet, 1036t
scombroid poisoning in, 1065–1067 physeal, 915 Fosfomycin, in urinary tract infections,
toxinogenic, 1068t of proximal two thirds of radius, 1821 581, 582t
treatment of, 1065, 1066t–1067t radial, 915 Fosinopril, 1282
viral, 1067t radius, 1821 Fosphenytoin, 1283–1285
Foot torus, 915 drug interactions with, 1284t
anatomy of, 299, 1870, 1871f ulna, 1820–1821 hypersensitivity reactions to, 1285
bursitis of, 1929–1930 ulnar, 915 mechanisms of action of, 1283
compartment syndromes of, 1931 imaging of, 1813f metabolism of, 1284
deep peroneal nerve entrapment of, 1930 immobilization of, 1814t pathophysiology of, 1283–1284

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 Index   2059

pharmacokinetics of, 1283 distal humerus, 1816 imaging of, 1771

protein binding in, 1284 epicondyle, 1818 of knee, 1852–1853
in seizures, 891–892 intercondylar, 1817–1818 clinical features of, 1851
in status epilepticus, 1158 olecranon, 1819 femoral condyle, 1852
toxicity of proximal ulna, 1819 patella, 1852
cardiovascular, 1282 radial head, 1819 tibial plateau, 1853
central nervous system, 1284 supracondylar, 1816–1817 tibial spine, 1852–1853
clinical features of, 1285t trochlea, 1819 tuberosity, 1852–1853
treatment of, 1285 facial, 1718–1721 of leg, 1859–1861
vascular and soft tissue, 1285 blow-out, 1719f midshaft fibula, 1861
Fournier’s gangrene, 592–593, 592f in children, 1721 pilon, 1860–1861
Foxglove, 1412 frontal, 1718, 1718f–1719f proximal fibula (Maisonneuve’s fracture),
Fractures, 1767–1782 Le Fort, 1720, 1721f 1861
ambulation in, 1780–1781 mandible, 1721, 1721f stress, 1861
angulation, 1772, 1773f midfacial, 1720, 1721f line orientation, 1771, 1771f
of ankle, 1868–1870 orbital, 1719–1720, 1719f location of, 1771
of carpal bones, 1802t zygoma, 1719f, 1720, 1720f mechanism of injury, 1770t
capitate, 1804–1805, 1806f femoral shaft, 1845–1846 of necessity, 1821
hamate, 1804, 1805f of foot neurologic deficit in, 1781
pisiform, 1804, 1804f calcaneus, 1870–1872 neurovascular injuries, 1768–1769
scaphoid, 1802–1803, 1802f, 1802t cuboid, 1874 of nose, 1575–1577
trapezium, 1803–1804, 1804f cuneiform, 1874 anatomy in, 1575–1576, 1575f
trapezoid, 1805 fifth metatarsal, 1874 clinical features of, 1576
triquetrum, 1803, 1803f forefoot, 1874–1875 diagnosis of, 1576–1577
in children, 904–921 hindfoot, 1870–1872 examination of, 1576
ankle, 919–921 history in, 1870 imaging of, 1576–1577
carpal bone fractures, 916 Lisfranc, 1872–1873, 1873f treatment of, 1577
clavicle, 908–909, 908f metatarsal, 1874–1875 open, 1768, 1775, 1870
of elbow, 909–914 metatarsophalangeal, 1875 management of, 1774
foot and toe injuries in, 921 midfoot, 1872–1874 vs. closed, 1771
forearm, 914–916 navicular, 1873–1874 orbital blow-out, 1548–1549, 1549f
greenstick, 907–908 phalange, 1875 pain management in, 1773
humerus, 909 physical examination in, 1870 pathologic, 1514, 1767
lower extremity injuries, 909–918 stress fractures, 1875 pathophysiology of, 1767–1768
pelvic, 917 talus, 1872 pelvic, 1838–1840, 1838t
phalangeal, 916 treatment of, 1876t acetabular, 1839–1840
physeal, 905–906 of forearm, 1820–1821 anterior-posterior compression, 1838
physical abuse in, 991–992, 991f–992f, in both radius and ulna, 1820 avulsion, 1838–1839, 1839f, 1839t
991t Galeazzi’s fracture-dislocation in, 1821 complications of, 1841–1842
plastic deformities, 907–908, 908f in isolated ulna, 1820–1821 lateral compression, 1838, 1838f
proximal tibia, 919 Monteggia fracture-dislocations in, open-book fracture, 1838, 1838f
radial head and neck, 910, 914f 1820–1821 single-bone, 1838–1839, 1839t
torus, 906–907, 907f in proximal two thirds of radius, 1821 treatment of, 1840–1841
circulatory compromise in, 1775 in radius, 1821 vertical shear, 1838, 1839f
clavicle, 908–909, 908f, 1822–1823 in ulna, 1820–1821 physical examination, 1770t
clinical features, 1769–1771 of hand, 1793 prehospital care in, 1769–1771
closed, 1771 Bennett’s, 1793 radiography in, 1771–1773
common, 1767 boxer’s, 1793 reducing deformity, 1769
compartment syndrome in, 1774, 1782 distal phalanx, 1793 of rib, 1738
complications in, 1781–1782 metacarpal, 1793 rotational deformity, 1772
definition of, 1767 metacarpal base, 1793 salter (epiphyseal plate), 1767
deformity in, 1774 metacarpal head, 1793 Salter-Harris, 905–906, 1773, 1773f,
dental, 1586–1587 metacarpal neck, 1793 1773t, 1774f
diagnosis of, 1771–1773 metacarpal shaft, 1793 of scapula, 1823–1824
discharge instructions in, 1781 middle phalanx, 1793 separation, 1771, 1772f
dislocation, 1767–1768, 1772 proximal phalanx, 1793 shortening, 1771, 1773f
irreducible, 1774 Rolando’s, 1793 of skull, 1689–1690, 1689f–1690f
reduction of, 1774 thumb metacarpal, 1793 splinting techniques in, 1769, 1775–1780
displacement, 1771, 1772f healing, 1768 of sternum, 1738, 1739f
distal radius and ulna, 1805–1809, 1806t hemorrhage in, 1781 stress, 1767
Barton’s fracture, 1808, 1808f of hip, 1679, 1844–1845 subluxation, 1767–1768, 1772
Colles’ fracture, 1805–1806, 1807f femoral head, 1844 surgical intervention in, 1775
distal radioulnar joint disruption, 1809 femoral neck, 1844–1845 torus, 906–907, 907f
radial styloid, 1808–1809, 1809f intertrochanteric, 1845 treatment of, 1773–1774
Smith’s fracture, 1806, 1808f occult, 1845 types of, 1767–1768
of elbow, 1816–1820 subtrochanteric, 1845 vascular injuries in, 1781–1782
articular surface, 1819 trochanteric, 1845 Framingham criteria, 362
capitellum, 1819 history in, 1769–1770 Francisella tularensis, 43t, 45t, 1071t, 1074
condyle, 1825–1826 of humeral shaft, 1833–1834 Frenulum lacerations, 1589
coronoid, 1819 of humerus, 1834f Frequencies, radio, 4

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 2060   Index
Fresh frozen plasma (FFP), 66, 1497, 1497t.
See also Blood products
Froment’s sign, 1162
Frontalis muscle, 286
Frontotemporal dementia, 1944
Frostbite, 1334. See also Cold injuries
body parts affected by, 1334t
classification of, 1334t, 1335f
clinical features of, 1334–1335, 1335f
diagnosis of, 1334–1336
epidemiology of, 1334
factors in, 1334t
infections in, 1336
pathophysiology of, 1334
pulse deficits in, 1336
risk factors for, 1334t
sequelae in, 1337
treatment of, 1336–1337, 1336t
Fulminant liver failure, 518
Functional abdominal pain syndrome, 261t,
264t
Functional dyspepsia with epigastric pain
syndrome, 264t
Functional residual capacity, 78
Fundus, examination of, 763
Funduscopic examination, 1529
Fungal meningitis, 753
Funnel-web spiders, 1355
Furosemide, 568–569, 827–828, 887t, 1281
in heart failure, 372t
Furuncles, 1005, 1008–1010
Fusobacterium necrophorum, 1595
Fusobacterium necrophorum infections, 780,
1595
G in children, 845–851
Gabapentin, 234t, 1288
in hiccups, 430
in neuropathic pain, 264t
in vertigo, 1152t
Gait disorder, 1143–1144
in alcoholic patients, 1145
apraxic, 1143
cerebellar ataxic, 1143
in children, 1145, 1145t
classification of, 1143t
clinical features of, 1144
diagnosis of, 1144
in elderly, 1144–1145
etiologies of, 1143t
examination of gait in, 1106
festinating, 1143
history in, 1144
motor ataxic, 1143
physical examination in, 1144
waddling, 1143
Galactose-alpha-1,3-galactose (alpha-gal)
allergy, 72
Galeazzi fracture, 915, 915f
Galeazzi’s fracture-dislocation, 1809
Galeazzi’s fracture-dislocation, 1821
Gallbladder perforation, 512
Gallstones, 512, 945
asymptomatic, 515
ileus, 515
types of, 513t
Gamma hydroxybutyric acid (GHB), 1969
Gamma rays, 48
Gamma-hydroxybutyrate, 1220–1221
Ganciclovir, 1036t
Tintinalli_Index_p2025-2116.indd 2060
Ganglion cysts, 1919, 1919f, 1930 in infants and children, 864–870
Ganglionitis, vestibular, 1151–1152 lower GI bleeding, 865t, 867–868, 868f
Gardasil®, 1023 physical examination in, 865
Gardnerella vaginalis infections, 636 resuscitation in, 864
Garlic, 1325t stability of patient in, 864
Gas embolism treatment of, 868–869, 869f
arterial, 1372–1373 upper GI bleeding, 865t, 866–867
cerebral arterial, 1370 Gastrointestinal decontamination, 1191, 1192t
hyperbaric oxygen therapy in, 138 Gastrointestinal disorders, 473–561
Gas gangrene, hyperbaric oxygen therapy in, acute abdominal pain, 473–481
140 in acute radiation syndrome, 49
Gas laws, 1368–1369 anorectal disorders, 536–561
Gases in blood, 78–81 appendicitis, 523–527
alveolar gas exchange, 79 bowel obstruction, 530–532
arterial blood gas analysis, 79–80 in children with special healthcare needs,
capnography, 80–81 978–979
functional residual capacity, 78 cholecystitis, 512–516
minute ventilation, 78 cocaine in, 1240
oxygen delivery to alveolar space, 79 constipation, 492–495
pulse oximetry, 80 diarrhea, 484–492
respiratory physiology in, 78 diverticulitis, 527–529
tidal volume of, 78 in eating disorders, 1957
venous blood gas analysis, 80 esophageal emergencies, 500–505
Gases, properties of, 35 gastritis, 505–508
Gaskin maneuver, 643, 644f hepatic disorders, 516–522
Gasoline, 1395 hepatitis, 516–520
Gastric bypass surgery, complications of, hernias, 532–536
560t in HIV infection, 1039–1040
Gastric lavage, 1277 hydrocarbon toxicity in, 1295
Gastritis, 505–508. See also Gastrointestinal lower gastrointestinal bleeding, 498–500
disorders in methylxanthines, 1263–1264
pain in, 332 in natural disasters, 27
reactive, 867 nausea, 481–484
Gastroenteritis, 845–851 in nonsteroidal anti-inflammatory drugs,
Campylobacter, 849 1260–1261
pancreatitis, 508–512
clinical features of, 845, 846t in pediatric cancer, 965
discharge instructions in, 850t peptic ulcer, 505–508
epidemiology of, 845 in pregnancy, 628
in gastrointestinal bleeding, 868 procedures and devices, 551–555
imaging in, 847 anoscopy, 552
laboratory testing in, 845–846 complications of, 555–561
pathophysiology of, 845 nasogastric aspiration, 551–552,
Salmonella, 849 551t–552t
stool cultures in, 847 orogastric lavage, 552
stool tests for, 847 ostomy complications, 555
treatment of, 846t, 847–850, 848f paracentesis, 553–554, 554f
adsorbents, 849 Sengstaken-Blakemore tube, 552–553,
antibiotics, 849–850 553f
antidiarrheals in, 849 transabdominal feeding tubes, 554–555,
antiemetics in, 848–849 554t
antisecretory agents, 849 tube replacement, 555
IV hydration in, 848 in systemic rheumatic diseases, 1911–1912,
maintenance phase and diet in, 849 1911t
oral hydration therapy in, 847–848 upper gastrointestinal bleeding, 495–498
probiotics, 849 vomiting, 481–484
zinc, 849 Gastroparesis, 261t, 264t, 482–483
Gastroesophageal reflux disease, 501–502 diagnosis of, 483
apparent life-threatening event in, 742 pathophysiology of, 482–483
in children, 843–844, 867 treatment of, 483
in neonates, 736–737 Gastroschisis, in children, 678
in pregnancy, 628 Gel pads, 149
Gastrointestinal bleeding, 864–870 Gelatin, 270
age-based causes of, 866–868 Gelfoam®, 270
amount of blood in, 865 Gender, 1998t
assessment of, 864 Gender affirmation, 1998t
causes of, 865t–866t Gender dysphoria, 1998t
clinical approach to, 864–868 Gender expression, 1998t
diagnosis of, 865–866 Gender fluid, 1997, 1998t
history in, 865, 866t Gender identity, 1998t
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Gender nonbinary, 1997, 1998t
Gender nonconforming, 1997, 1998t
General anesthesia, 249
Generalized anxiety disorder, 1951
Geneva score, 392
Genital feminizing procedures, 1999–2000
Genital masculinizing procedures, 2000
Genital warts, 1023
Genitourinary trauma, 1757–1762
bladder injuries in, 665, 1759–1760
in children, 1762
clinical features of, 1757–1758
in elderly, 1762
after gynecologic procedures, 665
history in, 1757–1758
imaging for, 1758t
injuries to external genitalia, 1761–1762
kidney injuries in, 1758–1759, 1759t
physical examination in, 1758
in pregnancy, 1762
ureteral injuries in, 1759
urethral injuries in, 1760–1761
Gentamicin, 578
in granuloma inguinale, 1016t
in pelvic inflammatory disease, 657t
in postpartum endometritis, 636
in urinary tract infection, 873t
in urinary tract infections, 583t
Geographic tongue, 775f, 776
Germ cell tumors, 960, 960f
German measles, 927
Germander, 519t
Gestation age, 620t
Gestational age, 640
Gestational hypertension, 631–632
Gestational trophoblastic disease, 621
Ghon complex, 451, 451f
Giant cell arteritis, 1556, 1907t, 1914t
Giardia, 1067t
Giardia lamblia, 1068
Giardiasis, 1088
Gilbert’s syndrome, 520
Ginger, 622t
Gingival abscess, 1583
Gingival hyperplasia, 1584–1585, 1585f
Gingivitis
acute necrotizing ulcerative, 1583
in infants and children, 782
Gingivostomatitis, 1025, 1026f
Ginkgo, 1325t–1326t, 1414
Ginseng, 1325t
Glanders, 43t
Glargine, 622, 975
Glasgow Coma Scale (GCS), 692, 693t,
699t, 1140, 1140t, 1674, 1674t,
1685, 1685t
Glaucoma, 1554–1555. See also Eye disorders
acute-angle closure, 1108, 1114, 1554–1555,
1554f, 1554t
pathophysiology of, 1554
pediatric, 770
treatment of, 1554–1555, 1554t
Glenohumeral joint dislocation, 1825–1828
anterior, 1827–1828
inferior, 1830
posterior, 1829–1830, 1832f
GlideScope Video Laryngoscope®, 187, 188f
Glinides, 1429–1430, 1429t
Glitazones, 1429, 1429t
Global travelers, 1079–1092
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2061
abdominal and urinary diseases in, 1087
abdominal pain-associated diseases in,
1088–1089
chronic fever-associated diseases in,
1086–1087
CNS-associated diseases in, 1086
diagnostic testing in, 1080–1081
diarrhea-associated diseases in,
1088–1089
evaluation of returning traveler,
1080–1081
eye or skin diseases in, 1090–1091
fever in, 1081–1085
fever-associated diseases in, 1081–1085
hemorrhage-associated diseases in,
1085–1086
history in, 1080, 1080t
incubation period, 1080t
physical examination in, 1080–1081,
1082t
pulmonary diseases in, 1091–1092
risk of exposure, 1080t
tropical infections in, 1083t–1084t
Globe, ruptured, 1549–1550, 1550f, 1558f
Glomerular filtration rate, 564t, 566–567
Glomerulonephritis, 563, 566, 569,
883–885
in children, 883–885
clinical features of, 883
hemolytic-uremic syndrome, 884
Henoch-Schönlein purpura, 884
IgA nephropathy, 884
laboratory testing in, 883
pathophysiology of, 883
poststreptococcal, 883–884
Glory lily, 1412–1413
Glossitis, 1585
Gloves, 1098
Glucagon
in anaphylaxis, 70t, 71
in beta-blocker toxicity, 1273
in bradyarrhythmias, 101t
in calcium channel blocker toxicity, 1279
in esophageal foreign bodies, 504
in hypoglycemia, 966, 1422, 1433
in resuscitation of poisoned patient, 1188t
Glucagon-like peptide 1 (GLP-1),
1424, 1429t, 1430
Glucocorticoids
in adrenal insufficiency, 1457, 1459
in endocrine disorders, 1424
in immunosuppression, 1912
Glucosamine, 1325t
Glucose
in head trauma, 1688
in resuscitation of children, 683t
Glucose-6-phosphate dehydrogenase
deficiency, 1488–1489
classification of, 1489t
clinical features of, 1489
diagnosis of, 1489
Heinz bodies in, 1488, 1489f
treatment of, 1489
Glucose-dependent insulinotropic
polypeptide, 1424
Glutamyl transpeptidase, 517
Gluten sensitivity, 1676
Glutethimide, 1222
Glyburide, 623
Glycemic control, 163, 1002
Index   2061
Glycerin suppository, 494t
Glycomer 631, 274t
Glycoprotein IIb/IIIa inhibitors, in NSTEMI,
344t–345t, 1510, 1510t
Glycopyrrolate, 1303
Glycosides, 1411t
Glyphosate, 1307
Goldman® applanation tonometer,
1530, 1530f
Golfer’s elbow, 1815
Gonadocorticoids, 1457, 1458
Gonadotropin analog, 1999
Gonadotropin-releasing hormone analogs,
1999
Gonococcal conjunctivitis, 739, 1541
Gonococcal pharyngitis, 1595
Gonococcal septic arthritis, 1925–1926
Gonorrhea, 1017–1018
with chlamydia, 1014
clinical features, 1017
diagnosis of, 1017
premature rupture of membranes in, 634
signs and symptoms, 1017
treatment of, 1015t, 1017–1018
Goodpasture’s syndrome, 563
in hemoptysis, 433
in pulmonary infiltrates, 448t
Gout, 1926
Gouty arthritis, 1007t
Gowns, 1098
Graft-versus-host disease, 1986–1988
acute, 1986–1988
chronic, 1986
signs and symptoms of, 1986t
transfusion-associated, 1988, 1989t
Gram stain, 649
Grand mal seizures, 889
Granisetron, 484t, 1519t
Granuloma inguinale, 1022
clinical features of, 1018t, 1022
diagnosis of, 1022
treatment of, 1015t–1016t, 1022
Granulomas, 451
Granulomatosis
in hemoptysis, 433
in pulmonary infiltrates, 448t
Grapefruit juice, 1326t
Graves’ disease, 1450
Grayanotoxins, 1411, 1411t
Greenstick fractures, 907, 907f, 915
Grey Turner sign, 416
GRIEV_ING© method, 2004–2006
Griseofulvin, 932, 1630t
Groin pain, 1897–1898
Ground vehicles, 4
Group A b-hemolytic Streptococcus, 1595
Group A b-hemolytic Streptococcus
pharyngitis, 779–780, 780t
Grunting, 800
Guanadrel, 1282
Guanethidine, 1455
Guillain-Barré syndrome, 1160
clinical features of, 1160
diagnosis of, 1160, 1160t
managing respiratory failure in, 1160t
treatment of, 1160
Gum elastic bougie, 182–183, 183f
Gunshot wound, in head, 1694f
Gut-associated lymphoid tissue, 1171
Guyon’s canal syndrome, 1162
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 2062   Index
Gynecologic disorders, in children, 879–880
imperforate hymen, 880, 880f
labial adhesions, 879–880, 880f
straddle injuries, 880
urethral prolapse, 880
uterine bleeding, 880
vaginal bleeding, 880
vaginal discharge, 880
vaginal foreign bodies, 880
vulvovaginitis, 880
Gynecologic procedures
assisted reproductive procedures, 666–667
clinical features in, 663
complications, 663–667
dehiscence, 665
evisceration, 665
genitourinary injuries, 665
postconization bleeding, 665–666
postembolization syndrome, 667
complications of, 663–667
endoscopic, 665t
hysteroscopy, 664
induced abortion, 666, 666t
intrauterine devices, 666
laboratory testing in, 663
laparoscopy, 663–664
pelvic organ prolapse surgery, 666
physical examination in, 663
Gyromitrin, 1407
H history and examination, 292–293
H2 receptor agonists, 507
Haemophilus aphrophilus infections, 1896
Haemophilus ducreyi infections, 1021
Haemophilus influenzae infections, 436
in bacterial meningitis, 1172–1174
in cellulitis, 1566
in children, 747, 752
in injection drug users, 1982
in otitis media, 1563
in pneumonia, 440t, 441
Hair apposition, 272t, 284, 285f
Hair-thread tourniquet syndrome, 306
Hallucination, in psychoses, 1953
Hallucinogens, 1242–1248, 1244t
amphetamines, 1245
atropine, 1247t
bufotoxins, 1247t, 1248
cathinones, 1245–1246
Datura species, 1247t, 1248
dextromethorphan, 1247t, 1248
hyoscyamine, 1247t
Ipomoea species, 1247t, 1248
ketamine, 1247t, 1248
lysergic acid diethylamide, 1243
marijuana, 1246
mescaline, 1244–1245
morning glory seeds, 1248
myristicin, 1247t, 1248
phencyclidine, 1246
psilocybin, 1243–1244
salvia, 1244–1245
salvinorin A, 1247t
scopolamine, 1247t
toxicity of, 1190t, 1242
assessment of, 1243
treatment of, 1243
Halmagyi head thrust, 1142
Halo device, 1183–1184
Haloperidol, 264t, 483
Tintinalli_Index_p2025-2116.indd 2062
in agitation, 1940t
pediatric dosing of, 987t
in hiccups, 428t
in nausea and vomiting, 484t
Hamate fracture, 1802t
Hamate fractures, 1804, 1805f
Hamman’s crunch, 331
Hampton’s hump, 391
Hand
anatomy of, 1782–1786
extensor tendons, 1784
flexor tendons, 1784
intrinsic muscles in, 1783–1784,
1783f
nerve supply, 1785–1786
vascular supply, 1785
anesthesia for, 1788
bones of, 1782f
carpal tunnel syndrome, 1919
cellulitis of, 1914–1915
compartment syndrome of, 1793–1794
compartments of, 1877f
dermatitis of, 1658–1665
Dupuytren’s contracture of, 1919, 1919f
electrical injuries of, 1401
extensor tendon injuries of, 1790–1792
flexor tendon injuries of, 1789–1790
flexor tenosynovitis, 1915–1916
fractures of, 1793
ganglion cysts of, 1919, 1919f
inspection, 292
motor function, 292, 292t–293t
sensory function, 292
vascular supply, 292–293
imaging of, 293
infections of, 1914–1918
from closed fist injuries, 1916, 1916f
deep space, 1916
felon, 1917, 1917f
herpetic whitlow, 1918
paronychia, 1916–1917, 1917f
injuries of, 1782–1794
burns, 1794
clinical features of, 1786–1788
extensor tendons, 1790–1792, 1791f
flexor tendons, 1789–1790
high-pressure injection, 1794
history in, 1786
imaging in, 1788–1789
nerve testing in, 1787
physical examination of, 1786–1787,
1787t
tendon testing in, 1787–1788
ligamentous injuries and dislocations of,
1792
carpometacarpal joint, 1792
distal interphalangeal joint, 1792
metacarpophalangeal joint, 1792
proximal interphalangeal joint, 1792
thumb carpometacarpal joint, 1792
thumb interphalangeal joint, 1792
thumb metacarpophalangeal collateral
ligament rupture, 1792
nontraumatic disorders of, 1914–1919
tendinitis of, 1918–1919
tenosynovitis of, 1918–1919
tourniquet application, 293
trauma of
in children, 294
FB:Cardiologia Siglo XXI
clenched fist injuries, 294, 295f, 323
digital amputations, 296–297
digital nerve injuries, 297
extensor tendon lacerations, 294–295
finger lacerations, 296
fingertip injuries, 296
flexor tendons lacerations, 296
lacerations, 292–299
nail and nail bed injuries, 298, 298f
palm lacerations, 296
ring tourniquet syndrome, 299
volar, 295–296
wound dressing and postrepair care, 293–294
wound examination of, 1788
wound visualization, 293
Hand and wrist blocks, 240–242
median nerve block, 240–241
radial nerve block, 241
ulnar nerve block, 241–242
Hand-foot-and-mouth disease, 777, 778f,
926, 927f
Handlebar palsy, 1162
Handwashing, 1096
Hangman’s fracture, 1703f
Hantavirus, 1075t, 1077t, 1078
Hare® splint, 8–9, 9f
Hashish, 1246
Hawkins impingement test, 1890f
Hawthorn, 1326t
Hazard vulnerability analysis, 19–20
Hazardous chemicals, 1318
Head impulse test, 1150
Head injuries and concussion in children,
698–705
clinical features of, 699
disposition and follow-up in, 703
dizziness in, 703
epidemiology of, 698–699
headache in, 700–703
history of, 699, 699t
imaging in, 700
nausea in, 703
pathophysiology of, 699
physical examination in, 699–700
post-discharge counseling in, 703–705
fatigue, 705
lifestyle measures, 704
mood, 705
return to learn, 703
return to sports, 703–704, 705f
sleep, 704–705
treatment of, 700–703
Head lice, 1633
Head tilt-chin lift maneuver, 145
Head trauma, 1683–1695
abusive, 992
airway management in, 1687–1688
anticoagulation in, 1695
assessment of, 1675
basilar skull fracture in, 1689–1690
brain injury in, 1683–1684
brain herniation, 1684
cerebral perfusion pressure management
for, 1689
edema in, 1684
goal-directed therapy for, 1689t
mild, 1705–1707
primary, 1683–1684
secondary, 1684
breathing in, 1687–1688
8/2/19 6:02 PM

cerebral blood flow in, 1683
cerebral contusion in, 1690
cerebral herniation in, 1688–1689
cerebral perfusion pressure management
in, 1689
cerebrospinal fluid leaks in, 1689–1690
in children, 694–695
physical abuse in, 992
seizures in, 896
circulation in, 1688
clinical features of, 1684–1686
computed tomography in, 694
concussion in, 1692–1695
diffuse axonal injury in, 1692, 1693f–1694f
in elderly, 1678
epidemiology of, 1683
epidural hematoma in, 1690–1691, 1691f
glucose control in, 1688
history in, 1684–1685
imaging of, 1685–1687, 1686f, 1687t
intracerebral hemorrhage in, 1690
intubation in patients with, 1688t
in military medicine, 2011
pathophysiology of, 1683–1684
patient positioning in, 1688
penetrating injury in, 1692
physical examination in, 1685
postconcussive syndrome in, 1695
prevalence of, 1683
radiography in, 693
scalp lacerations in, 1689
seizures in, 1688
skull fractures in, 1689, 1689f–1690f
subarachnoid hemorrhage in, 1690
subdural hematoma in, 1691, 1692f
temperature control in, 1688
treatment of, 1687–1688
advanced, 1689
checklist for, 1688t
ultrasonography in, 693–694
Head, examination of, 1108
Headache, 1107–1114. See also Neurologic
disorders
causes of, 898t, 1109–1114
acute-angle closure glaucoma, 1114
brain tumor, 1110
carbon monoxide toxicity, 1113
carcinomatous meningitis, 1113
carotid and vertebral artery dissection,
1113
cerebral venous thrombosis, 1110
colloid cysts, 1113–1114
encephalitis, 1109–1110
idiopathic intracranial hypertension,
1111–1112
intracerebral hemorrhage, 1110
intracranial hypotension, 1112
meningitis, 1109–1110
metabolic, 1113t
migraine, 1111
occipital neuralgia, 1111
pituitary apoplexy, 1113
posterior reversible encephalopathy
syndrome, 1110
preeclampsia, 1114
pseudotumor cerebri syndrome,
1111–1112
reversible cerebral vasoconstriction
syndrome, 1110–1111
subarachnoid hemorrhage, 1110
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2063
subdural hematoma, 1110
temporal arteritis, 1111
in children, 896–902
age of onset, 896
alleviating and exacerbating factors in,
898
associated symptoms, 898–899
diagnosis of, 899–901
duration of, 898
epidemiology of, 896
history in, 899–900
imaging of, 901
laboratory testing in, 900
location of, 898
medications for, 901–902, 901t
pathophysiology of, 896
physical examination of, 887t, 900
precipitants of, 898
quality of, 898
severity of, 898
temporal patterns of, 898–899, 899t
treatment of, 901–902
classification of, 896
clinical features of, 896–899, 1107, 1107t
cluster, 897t, 1108t, 1112
diagnosis of, 897t, 1108–1109
epidemiology of, 1107
family history of, 1108
fever in, 1107
history in, 1107–1108
hypertensive, 1113
imaging in, 1108–1109, 1108t
laboratory testing in, 1108
in lumbar fracture, 1109
medication history in, 1108
medication overuse, 259–260
onset of symptoms in, 1107
past medical history in, 1108
pathophysiology of, 1107
patient age in, 1107
physical examination in, 1108
post-lumbar, 1180
in pregnancy, 627–628
primary, 896, 897t
prior history of, 1107
quality of, 1107
secondary, 896, 898t–900t
substance abuse history in, 1108
in temporal arteritis, 1111t
tension-type, 897t
in third ventricle colloid cysts, 1113
thunderclap, 1107, 1107t
Health Alert Network, 21t
Health Insurance Portability and
Accountability Ac, 2, 2018–2019,
2019t
HEAR Score, 358t
Hearing loss, sudden, 1561–1562, 1562t
Heart
trauma of, 1742–1751
blunt injuries in, 1746–1747
cardiac dysfunction in, 1746
cardiac rupture, 1747
cardiac tamponade in, 1744
cardiac valves, 1746–1747
chordae tendineae, 1746–1747
commotio cordis in, 1746
coronary vessels, 1747
epidemiology of, 1752
iatrogenic injuries in, 1744
Index   2063
intracardiac missiles in, 1744
myocardial infarction, 1747
papillary muscles, 1746–1747
pathophysiology of, 1752–1753
penetrating, 1744–1746, 1752–1754
pericardiocentesis for, 1744
pericardium in, 1746
septum, 1747
thoracic great vessels in, 1747–1751
thoracotomy for, 1745–1746
treatment of, 1745–1746
Heart disorders, 367–374
acquired, 830–835
acute coronary syndromes, 334–352
aneurysm, 415–419
aortic dissection, 412–415
aortic syndromes, 412–415
arrhythmias, 99–123
arterial occlusion, 420–423
cardiogenic shock in, 352–357
cardiomyopathies, 833–835
cardiomyopathies in, 380–384
chest pain in, 329–333
in children, 819–835
congenital, 819–835
endocarditis, 832–833
in end-stage renal disease, 574
Kawasaki’s disease, 831–832
myocarditis, 830
pericardial, 384–385
pericarditis, 830–831
sudden cardiac death in, 53–57
Brugada’s syndrome, 55, 55f
cardiomyopathy in, 53–54
catecholaminergic polymorphic
ventricular tachycardia in, 56
congenital heart disease in, 54
early polarization syndrome, 55
early repolarization syndrome, 55f
epidemiology of, 53
factors in, 54t
hereditary channelopathies in, 54–56
ion channel disease in, 54–55
long QT syndrome, 55–56
pathophysiology of, 53–56
prevention of, 56
pulse ventricular tachycardia, 56
pulseless electrical activity, 56–57
resuscitation in, 56–57
severe left ventricular dysfunction in, 53
short QT syndrome, 56
sick sinus syndrome in, 54
sudden arrhythmic death syndrome in,
54
ventricular fibrillation in, 56
transplantation in, 1993
complications in, 1994t
valvular, 54, 374–380
venous thromboembolism, 389–399
Heart failure
acute, 367–374
in acute coronary syndrome, 350
biomarkers in, 369
causes of, 368t
classification of, 368, 368t
diagnosis of, 368–370
diastolic, 368
disposition decisions in, 372, 373f,
373t–374t
drugs for, 372t
8/2/19 6:02 PM
 2064   Index

Heart failure (Cont.): safety, 10 imaging in, 585, 887–888

in endocarditis, 1045 for trauma patients, 11, 12t in kidney stone, 599–600
in end-stage renal disease, 574 Helicopters, 4 laboratory testing in, 585
epidemiology of, 367 Heliox, 466, 792, 807 microscopic, 583, 585t
in hemodialysis, 576 HELLP syndrome, 632–633, 632t pathophysiology of, 584
history in, 368–369 Helmets physical examination in, 887
hypertensive, 370–371, 371t removal, 8f risk factors for, 585t
normotensive, 371–372 types of, 8f treatment of, 585, 888
pathophysiology of, 367–368 Helminths, 1078 Hemiparesis, 1143
physical examination in, 368–369 Hemangioma, 788–790 Hemlock, 1410
precipitants of, 368t Hemarthrosis, 1927 Hemlock water dropwort, 1412
in pregnancy, 624 in hemophilia, 950 Hemodiafiltration, 1287
in systemic rheumatic diseases, 1909 of knee, 961f, 1862 Hemodialysis, 575–577
systolic, 368 Hematemesis, 433, 495–497, 866 in beta-blocker toxicity, 1275
treatment of, 370 Hematochezia, 500 bleeding in, 575–576
in type II diabetes, 1425t Hematologic disorders, 949–955, 1461–1521, complications in, 576–577
in vascular access, 575 1489f disequilibrium, 576–577
HEART Pathway, 359f acquired bleeding disorders, 1469–1471 in end-stage renal disease, 575–577
Heart rate anemia, 953–954, 1461–1463 heart failure in, 576
in children, 841, 841t antithrombotics for, 1502–1512 historical elements for patients in, 577t
in shock, 60t clotting disorders, 1474–1477 inadequate flow in, 575
Heartburn, 261t, 264t, 501 in end-stage renal disease, 574–575 infections in, 575
Heartland virus, 1032 glucose-6-phosphate dehydrogenase in methanol or ethylene glycol poisoning,
Heat cramps, 1347 deficiency, 1488–1489 1231–1232
Heat edema, 1346–1347 in heat emergencies, 1349 physical examination in, 577, 577t
Heat emergencies, 1345–1350. See also hemolytic anemia, 1490–1494 in salicylate toxicity, 1252
Cold injuries; Environmental injuries hemophilia, 949–952, 1478–1481 technical aspects of, 575
acclimation in, 1346 hemostasis, 1464–1468 vascular access for, 575
in children, 1350 hereditary spherocytosis, 1489 vascular insufficiency in, 576
classic heat injuries in, 1346 neutropenia, 955 Hemodynamic management, 162–163
clinical features of, 1367–1368 in nonsteroidal anti-inflammatory drugs, Hemodynamic monitoring, 212–216
complications, 1349–1350, 1349t 1261 of arterial blood pressure, 212
confinement hyperpyrexia, 1346 polycythemia, 1463–1464 of cardiac output, 214–215
cooling techniques in, 1348–1349, 1349t sickle cell disease, 1482–1488 in cardiogenic shock, 355
diagnosis of, 1368 spherocytosis, 1489 of central venous pressure, 213–214
differential diagnosis of, 1368t thalassemia, 1487–1488 invasive blood pressure measurement in,
drugs associated with, 1346 thrombocytopenia, 954–955 212–213
in elderly, 1350 thrombotics for, 1502–1512 invasive CO measurement in, 215
epidemiology of, 1345 transfusion in, 1494–1500 noninvasive blood pressure measurement
evaporative cooling in, 1348 vitamin K deficiency bleeding, 952–953 in, 212
exertional heat injuries in, 1346 von Willebrand’s disease, 952, 1481–1482 of oxygenation and perfusion, 215
heat cramps in, 1347 Hematoma in shock, 60
heat edema in, 1346–1347 auricular, 290 Hemoglobin, 39
heat stress in, 1345–1348 block, 247, 248f in acute kidney failure, 566
heat stroke, 1348 breast, 662 in anemia, 1462t
heat transfer in, 1345 ear, 1564, 1565f hemoglobin C, 1488
models of, 1346 epidural, 1690–1691 hemoglobin H, 1488
pathophysiology of, 1345–1346 nasal septal, 1577, 1578f hemoglobin O-Arab, 1488
prevention of, 1350 postoperative, 557 in sickle cell disease, 1487
prickly heat in, 1347 pulmonary, 1735 Hemolysis
risk factors for, 1346 retrobulbar, 1558, 1730f causes of, 1494t
signs and symptoms of, 1368t subdural, 1109 macrovascular, 1494
treatment of, 1367–1369 subungual, 298 Hemolytic anemia, acquired, 1490–1494.
Heat rash, 1347 wounds, 665 See also Hematologic disorders
Heat stress, 1347–1348 Hematopoietic syndrome, in acute radiation alloimmune, 1492–1494
Heat stroke, 1348 syndrome, 49 autoimmune, 1490–1492
Heimlich maneuver, 147, 147f Hematospermia, 598 causes of, 1496t
Heinz bodies, 1488, 1489f Hematuria, 583–585 differential diagnosis of, 1490t
Helicobacter pylori infection, 506–508 causes of, 584t–585t drug-induced, 1492
eradication of, 507 in children, 887–888 hemolytic-uremic syndrome in, 1493–1494
in infants and children, 867 clinical features of, 584–585, 887 laboratory testing in, 1490t
tests for, 506 comorbidities in, 887 macrovascular hemolysis in, 1494
Helicopter transport, 10–12 diagnosis of, 585, 887–888 microangiopathic, 1492–1493
clinical use, 11–12 differential diagnosis of, 584t Hemolytic disease of the newborn, 1492
environmental factors of, 10–11 epidemiology of, 583–584 Hemolytic-uremic syndrome, 884, 1065,
logistics, 11 false, 584, 585t 1493–1494
medical crew, 11 gross, 583, 589 in children, 884–885
for nontrauma patients, 11–12, 12t in hemophilia, 1481 clinical features of, 884
rules, 11 history in, 887 laboratory testing in, 884

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 Index   2065

pathophysiology of, 884 Hemorrhagic fever, 43t, 1032 in liver transplantation, 522
treatment of, 884–885 Hemorrhagic shock, 63–68 medication dosing in, 522
Hemoperfusion, 1287 clinical features of, 64 nonalcoholic fatty liver disease, 521
Hemophilia, 949–952, 1474, 1478–1481. diagnosis of, 64–65 nonhepatic causes of abnormal liver tests in,
See also Hematologic disorders massive transfusion protocols in, 66–68 517–518
acquired, 1481 pathophysiology of, 63–64 pain control in, 522
bleeding manifestations in, 1478t treatment of, 65–66 palliative care in, 522
in children, 949–952 Hemorrhagic stroke, 1121t, 1126 pathophysiology of, 516
clinical features of, 949, 1478 Hemorrhoids, 537–540 in pregnancy, 522
complications in, 950 anatomy in, 537 spontaneous bacterial peritonitis, 520
diagnosis of, 949, 1478–1479 clinical features of, 537 in travelers, 522
epidemiology of, 957, 1478 external, 537, 539f–540f venous thrombosis, 521
factor inhibitors in, 1480–1481 internal, 537, 539f Hepatic dysfunction
factor IX, 1478 in pregnancy, 628 analgesics and, 235
factor replacement therapy in, 1479–1480 treatment of, 538–541 in children, 697
factor VIII, 1478 Hemostasis, 270–271, 1464–1468 in graft-versus-host disease, 1987
hematuria in, 1480 bleeding patient in, 1464–1465 in hydrocarbon toxicity, 1295
hemophilia A, 951t, 1478, 1480, 1480t diagnosis of, 1465–1469 in nonsteroidal anti-inflammatory drugs,
hemophilia B, 951t, 1478, 1480t fibrinolytic system in, 1465–1467, 1467f 1260–1261
oral and mucosal bleeding in, 1480 normal coagulation in, 1465 Hepatic encephalopathy, 520, 520t
pathophysiology of, 1478 in patients with thrombus, 1465 Hepatic failure, 521
postpartum acquired, 1481 primary, 1465, 1466f, 1467t Hepatic vein thrombosis, 521
severity of, 1479t secondary, 1465, 1466f, 1467t Hepatitis. See also Gastrointestinal disorders
treatment of, 949–950, 1479–1481 tests, 1467, 1467t–1468t acute
Hemophilic arthropathy, 953f Hemostatic agents, 2009 toxic, 518–519
Hemopneumothorax, 1736 Hemostatic-hypotensive resuscitation, 65 viral, 518
Hemoptysis, 432–436. See also Pulmonary Hemothorax, 1732–1733, 1733f arthritis in, 1926t
emergencies; Respiratory disorders indications for operative intervention in, chronic, 518–520
causes of, 433t 1733 clinical features of, 516–517, 518t
clinical features of, 433 in injection drug users, 1981 in Crohn’s disease, 489t
diagnosis of, 433–434 massive, 1733, 1733f disposition and follow-up in, 522
disposition and follow-up in, 434 in pediatric trauma, 696 epidemiology of, 516
epidemiology of, 432 in penetrating neck trauma, 1723 herbal remedies in, 519t
history in, 433 tube thoracostomy in, 1744 in human bites, 324
imaging in, 434 Henbane, 1412 imaging in, 517
massive, 432 Henderson-Hasselbalch equation, 74 laboratory testing in, 517–518
massive or severe, 435f, 436 Henoch-Schönlein purpura, 861–862, pain control in, 523
mild, 434 868, 884, 943–944, 943f, 1907t pathophysiology of, 516
minor, 432 Henry’s law, 1390 in pregnancy, 523
pathophysiology of, 432–433 Heparin, 624, 1506–1508 in sexual abuse and assault, 1969
physical examination in, 433 complications, 1507–1508 treatment of, 518–519
severe, 434 complications of, 1507–1508, 1507t Hepatitis A virus, 518, 1067t
treatment of, 434–435, 435f in deep venous thrombosis, 397t Hepatitis B virus, 518, 1023–1024
airway control in, 434 in frostbite, 1336 exposure to, 1093–1094, 1095t
bronchoscopy in, 434 in intracerebral hemorrhage, 1118t postexposure prophylaxis to, 1095t
definitive bleeding control in, 434, 436f low molecular weight, 347, 1507, 1507t Hepatitis C virus, 518
Hemorrhage in NSTEMI, 345t exposure to, 1094
alveolar, 1908 in pulmonary embolism, 397t Hepatitis D virus, 519
in cardiac arrest, 161 in STEMI, 344t Hepatobiliary iminodiacetic acid scanning,
cerebellar, 1126 in thrombocytopenia, 1476 514
classification of, 1671t unfractionated, 347, 1506–1507, 1507t Hepatorenal syndrome, 520f
in facial trauma, 1718 Hepatic artery aneurysm, 419 Herbal agents, 518, 519t, 1325–1327,
in fractures, 1781 Hepatic disorders, 516–522 1325t–1326t
intracerebral, 404, 404t, 627, 1109, acute hepatitis Herbicides, 1305–1307
1117–1118, 1126 toxic, 518–519 bipyridyl, 1305–1307
intracranial hemorrhage, 735 viral, 518 chlorophenoxy, 1305
junctional, 2009 chronic hepatitis, 519–521 glyphosate, 1307
in military medicine, 2009 cirrhosis, 519–521 organophosphate, 1307
noncompressible, 2010 clinical features of, 516–517 urea-substituted, 1307
ocular, 1425, 1550–1552 disposition and follow-up in, 522 Hereditary angioedema, 72
orbital, 1550–1552 epidemiology of, 516 Hereditary channelopathies, 54–56
in peptic ulcer, 508 genetic and autoimmune liver disorders, Brugada syndrome, 55
postpartum, 644, 646f, 646t 521 catecholaminergic polymorphic ventricular
subarachnoid, 400t, 403t, 404, 627, 1109, hepatic encephalopathy, 520 tachycardia, 56
1114–1117, 1126, 1690, 1691f hepatic failure, 521 early repolarization syndrome, 55
subconjunctival, 1542, 1542f hepatorenal syndrome, 520 ion channel disease, 54
in trauma, 1671–1674 imaging in, 518 long QT syndrome, 55
Hemorrhagic conjunctivitis, 769 in injection drug users, 1983–1984 short QT syndrome, 56
Hemorrhagic cysts, 613, 613f laboratory testing in, 517–518 sudden arrhythmic death syndrome, 54

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 2066   Index

Hereditary spherocytosis, 1489 High-altitude disorders, 1376–1383. See also Hodgkin’s lymphoma, 957, 958f
Hernias, 532–536. See also Gastrointestinal Environmental injuries Hoffman’s sign, 1881
disorders acclimatization in, 1377–1378 Hollow viscous injury, in children, 697–698
abdominal-wall, 578 acute mountain sickness in, 1378–1381 Holly, 1413
anatomy of, 532–535 bronchitis in, 1383 Homan’s sign, 391
anterior abdominal wall, 535f cardiovascular disease in, 1383 Homocystinuria, 1476
diagnosis of, 535 cerebral edema in, 1381, 1381f Hookworm, 1090
femoral, 535 chronic lung disease in, 1383 Horizontal half-buried mattress sutures,
incarcerated, 532, 533f chronic mountain polycythemia, 1383 279, 281f
incisional, 532, 664 epidemiology of, 1376–1377 Horizontal head impulse test, 1103
inguinal, 532, 534f, 862 medications for, 1380t Horizontal mattress sutures, 275t, 277–279,
lateral ventral, 532–535 neurologic syndromes in, 1383 280f
obturator, 535f peripheral edema in, 1382 Hormones
reducible, 532 in pregnancy, 1383 feminizing, 1999
Richter, 535 pulmonary edema in, 1381–1382 masculinizing, 1999
spigelian, 532–535 retinopathy in, 1382–1383 non-medically prescribed, 1999
strangulation in, 532 sickle cell disease in, 1383 for transgender patients, 1998–1999
treatment of, 535–536, 535t syndromes in, 1378–1383 Horner’s syndrome, 1557, 1557f
umbilical, 532, 536f High-pressure injection injuries Hospice care, 2000, 2003
ventral, 532 of hand, 1794 Hospitalized Elderly Longitudinal Project,
Heroin, 433, 1236 in puncture wounds, 320, 320f 2001
Herpangina, 777, 777f, 926, 927f High-sensitivity troponin assays, 333 Hot tar, 1395
Herpes labialis, 930, 1026f Hindfoot injuries, 1870–1872 Hot tub folliculitis, 1650, 1651f
Herpes simplex, 651–652, 652f, 652t, Hip Household pets, zoonoses acquired from,
1025–1027 anatomy of, 1842, 1843f, 1894 1078, 1079t
clinical features of, 1018t, 1020–1021, arthrocentesis of, 1923, 1923f Human bites, 323
1025–1026 bursal syndromes of, 1897–1898 b-Human chorionic gonadotropin, 615, 615t,
conjunctivitis in, 769, 1542 bursitis, 1896t 616–617
diagnosis of, 1020, 1026–1027 dislocation of, 1846–1850 Human immunodeficiency virus (HIV)
drugs for, 1036t anterior, 1848–1850, 1849f infection, 1023, 1032–1043, 1478.
encephalitis in, 1025 posterior, 1846–1848, 1846f See also Acquired immunodeficiency
epidemiology of, 1025 of prosthetic hips, 1850 syndrome (AIDS)
gingivostomatitis, 777–778, 778f, reduction maneuvers, 1846–1848 acute retroviral syndrome in, 1047
785, 1631f disorders of, 1896–1905 antiretroviral therapy in, 1041, 1042t–1043t
in HIV infection, 1041 fractures of, 1679, 1844–1845 arteritis in, 421t
in human bites, 323 in children, 917 arthritis in, 1926t
keratoconjunctivitis in, 1542 femoral head, 1844 chest pain in, 326
labialis, 1026f femoral neck, 1844–1845 clinical features of, 1034–1035
pathophysiology of, 1025, 1025f intertrochanteric, 1845 clinical stages of, 1033, 1033t
rashes in, 930–931, 930f occult, 1845 complications, 1035–1041
sexually transmitted infections in, subtrochanteric, 1845 cardiovascular, 1039
1020–1021 trochanteric, 1845 cutaneous, 1040–1041
skin disorders, 1630–1631, 1631f, 1631t imaging of, 1895–1896 gastrointestinal, 1039–1040
treatment of, 1016t, 1020–1021, 1027, injuries of, 1842–1850. See also neurologic, 1035–1037
1027t, 1036t Musculoskeletal disorders ophthalmic, 1038
Herpes zoster infection, 1027–1029, in athletes, 1850 psychiatric disorders, 1037
1629–1630, 1630f, 1631t, 1648–1649, clinical features of, 1842–1844 pulmonary, 1038–1039
1664f diagnosis of, 1844 renal, 1039
clinical features of, 1007t, 1028 in elderly, 1850 cryptococcal meningitis in, 1037
drugs for, 1037t epidemiology of, 1842 dementia in, 1035
herpes zoster ophthalmicus in, history in, 1842 diagnosis of, 1033–1034
1541–1542 imaging in, 1844 CD4+ T-cell counts, 1034
in HIV infection, 1041 pain control in, 1850 early, 1034
ophthalmicus, 1038 pathophysiology of, 1842 rapid tests in, 1034
of oral cavity, 1584 physical examination in, 1844 testing algorithm in, 1034
pathophysiology of, 1028 joint aspiration of, 1923, 1923f testing methods in, 1034
treatment of, 1029, 1037t muscles, 1105t testing practices in, 1034
vaccines for, 1028 overuse syndromes, 1896t, 1899 diarrhea in, 1040
Herpes zoster ophthalmicus, 1542–1543 pain in, 1894–1905, 1896t disseminated M. avium complex infection
Herpes zoster oticus, 1161 lateral thigh, 1899 in, 1035
Herpetic whitlow, 323, 930, 1661, 1662f, 1915t posterior lateral, 1899 drug interactions and adverse effects in,
Herpetiform aphthae, 1584 posterolateral, 1897–1898 1041–1043, 1042t–1043t
Heterocyclic antidepressants, 1949 transient osteoporosis of, 1904 drugs for, 1036t–1037t
Hiccups, 429–430 transient synovitis of, 922–923 epidemiology of, 1032–1033
diagnosis of, 429 Hippocratic Oath, 2017 esophageal lesions in, 1040
differential diagnosis of, 428t Hirschberg test, 764 exposure to, 1095–1096
drugs for, 429t Hirschsprung’s disease, 863, 868 fever in, 1035
physical maneuvers in, 428t Hirudins, 1508 herpes simplex in, 1041
Hidradenitis suppurativa, 550–551, 551f, 660, Histoplasma capsulatum infection, 444, 1035 herpes zoster ophthalmicus in, 1038
661t, 1652t, 1655, 1655f Hobo spiders, 1353 in human bites, 324

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2066 8/2/19 6:02 PM


immune reconstitution inflammatory
syndrome, 1035
immunization in, 1041, 1041t
Lymphocytic interstitial pneumonia in,
1039
oral candidiasis in, 1040, 1040f
pathophysiology of, 1033
pelvic inflammatory disease in, 654
peripheral neurologic disease in, 1164
pharyngitis in, 779
Pneumocystis pneumonia in, 1039
pneumonia in, 443–444
postexposure prophylaxis, 1970, 1970t
postexposure prophylaxis to, 1095–1096,
1095t–1096t
in pregnancy, 628–629
seizures in, 1156
in sexual abuse and assault, 1969
sexually transmitted infections in, 1041
thrush in, 1040, 1040f
toxoplasmosis in, 1035
treatment of, 1034–1035, 1036t–1037t
antiretroviral therapy in, 1034
initial care in, 1034–1035
Trichomonas vaginitis in, 651
tuberculosis in, 455–456, 1039
urinary tract infection in, 583
varicella-zoster infection in, 1041
Human papillomavirus infections,
1022–1023
clinical features, 1023
treatment of, 1023
Human rabies immunoglobulin, 1055
Humeral shaft fractures, 1833–1834
anatomy in, 1833
clinical features of, 1833–1834
diagnosis of, 1833–1834
specific injuries in, 1839
Humerus fractures, 1834f
anatomy in, 1834f
in children, 909
of humeral diaphysis, 909
proximal, 909
Hurricanes, 28
Hyaluronidase, 1518t, 1519
Hydralazine, 132, 133t, 887t, 1282–1283
in emergency delivery, 638t
in hypertension, 408t
for hypertensive pediatric patients, 408t
in preeclampsia and eclampsia, 633t
Hydrocarbons, 1292–1296
chemical burns, 1395
pathophysiology of, 1293
products containing, 1293t
toxicity of, 1290–1294
cardiac, 1294
clinical features of, 1293–1295, 1294t
CNS, 1294–1295
dermal, 1295
diagnosis of, 1295
gastrointestinal, 1295
hepatic, 1295
peripheral nervous system, 1295
pulmonary, 1293–1294
renal, 1295
treatment of, 1295–1296, 1296t
Hydrocele, 875, 875f
Hydrochloric acid, 1392
Hydrochlorothiazide, 133t, 1279
Hydrocodone
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2067
dose of, 232t
in vaso-occlusive crisis, 947t, 948
Hydrocortisone, 1002
in adrenal crisis, 1459t
in anaphylaxis, 70t
for skin disorders, 1621
Hydrofluoric acid, 1392–1394, 1394t
Hydrogen sulfide, 39, 1322–1323
Hydroids, 1367
Hydromorphone, 601, 948
dose of, 232t
in vaso-occlusive crisis, 947t
Hydrops fetalis, 1492
Hydroxocobalamin, 40, 1322
in resuscitation of poisoned patient, 1188t
Hydroxychloroquine, 1328
Hydroxyethyl starch, 62t
Hydroxyurea, 948
Hydroxyzine
in skin disorders, 1622t
in vertigo, 1152t
Hymenoptera, 1350
Hyoscyamine, 1247t, 1248
Hyperammonemia, 970
Hyperbaric oxygen therapy, 137–141
in air embolism, 138
ambient pressure in, 137
in blood loss anemia, 139
in carbon monoxide poisoning,
140, 1416t
in central retinal artery occlusion, 139
in compartment syndrome, 139–140
complications of, 140–141
barotrauma, 140–141
oxygen toxicity, 141
for crush injuries, 35
in crush injuries, 139
in cyanide poisoning, 140
in decompression sickness, 139
in frostbite, 1336
in gas embolism, 138
in gas gangrene, 140
indications for, 138–140
multiplace chamber, 136f
in necrotizing soft tissue infections, 140
physiologic effects of, 137–138
in sudden sensorineural hearing loss, 139
in thermal burn injury, 140
in traumatic ischemias, 140
Hyperbilirubinemia, 516, 738–739, 738t
Hypercalcemia, 97–98, 455, 856, 1324
causes of, 97t
clinical features of, 97–98
defined, 97
diagnosis of, 98
malignancy in, 1515–1516
signs and symptoms of, 97t
treatment of, 98, 856t
Hypercapnia, 173, 427–428
causes of, 427t
clinical features of, 427
diagnosis of, 427
pathophysiology of, 427
treatment of, 428
Hyperchloremic metabolic acidosis, 76
Hypercoagulable states
acquired, 1474t
clinical features of, 1475
diagnosis of, 1475
inherited, 1474t
Index   2067
Hyperemesis gravidarum, 621
Hyperextension dislocation, 1702f
Hyperextension teardrop fracture, 1702f
Hyperglycemia, 1002
falsely elevated capillary glucose in, 1420
in head trauma, 1688
in ischemic stroke, 1128–1129
new-onset, 975
in patients taking insulin glargine, 975
in patients with prediagnosed diabetes, 975
treatment of, 1428
in type I diabetes, 1420
in type II diabetes, 1424, 1428
Hyperglycemic neuropathy, 1164
Hyperhomocysteinemia, 1476
Hyperkalemia, 89–91, 564, 572, 577,
855–856, 963
in cardiac arrest, 162
causes of, 91t
in children, 855–856
clinical features of, 90
in diabetic ketoacidosis, 1438
diagnosis of, 90–91
electrocardiogram in, 92f
emergency therapy of, 93t
malignancy in, 1515–1516
pathophysiology of, 89–90
Hyperlactatemia, 216
Hyperleukocytosis, 956
Hypermagnesemia, 94, 856
causes of, 94t
clinical features of, 94
defined, 94
diagnosis of, 94
signs and symptoms of, 94t
treatment of, 94, 856t
Hypernatremia, 85–87, 842t, 854–855
brain volume and, 86f
causes of, 85, 87
classification of, 85, 87t
clinical features of, 86–87
defined, 85
diabetes insipidus in, 87–88
diagnosis of, 87
treatment of, 87, 87t, 855t
Hyperosmolality, 85
Hyperosmolar agents, 494t
Hyperosmolar hyperglycemic state,
1443–1447. See also Endocrine
disorders
causes of, 1445t
clinical features of, 1444
comorbidities in, 1444
complications of, 1447
diagnosis of, 1444–1446
diagnostic criteria for, 1445t
disposition and follow-up in, 1447
drugs associated with, 1445t
epidemiology of, 1443
imaging in, 1445
insulin in, 1447
laboratory testing in, 1445–1446
medical history in, 1444
pathophysiology of, 1443–1444
physical examination in, 1444
treatment of, 1446–1447, 1446f
electrolytes in, 1446–1447
fluid resuscitation in, 1446
Hyperosmolar hyponatremia, 83
Hyperoxia, 191
8/2/19 6:02 PM
 2068   Index
Hyperphosphatemia, 99, 99t
Hyperpnea, 425
Hyperreflexia, 1106
Hypersalivation, 253
Hypersensitivity pneumonitis, in pulmonary
infiltrates, 448t
Hypertension. See also Cardiovascular
disorders
in acute kidney injury, 569
acute renal failure in, 401, 403t, 405
aortic dissection in, 402, 403t
asymptomatic, 406–408
in asymptomatic patients, 402
chest pain in, 401
in children, 885–887, 887t
causes of, 886t
clinical features of, 885–886
disposition and follow-up in, 886
treatment of, 886, 886t
chronic, 399
classification of, 400t
clinical features of, 400–401
in cocaine toxicity, 1241–1242
cranial nerve palsy in, 1556–1557, 1556f
disposition and follow-up in, 406
drug-induced, 1134
drugs for, 403t–406t, 404–406
intravenous, 405t
oral, 407t
eclampsia in, 401–402
in end-stage renal disease, 574
essential, 885
idiopathic intracranial, 1111–1112
malignant, 1909
in monoamine oxidase inhibitors, 1207
myocardial infarction in, 402, 403t
neurologic emergencies in, 402–404
neurologic symptoms in, 401
pathophysiology of, 400
perioperative, 400t
peripheral edema in, 401
portal, 516
preeclampsia in, 401–402
in pregnancy, 627, 631–632
pulmonary, 408–412, 838
pulmonary edema in, 402, 403t
sympathetic crisis in, 402
systemic, 399–408
treatment of, 402–406, 403t–405t
Hypertensive acute heart failure, 370–371,
371t
loop diuretics in, 371
nitroglycerin in, 370
nitroprusside in, 371
vasodilation in, 371
Hypertensive emergencies, 399, 400t, 885
treatment of, 403t–405t
Hypertensive encephalopathy, 401–402,
403t
Hypertensive headache, 1113
Hypertensive heart failure, vasodilation in,
370
Hypertensive retinopathy, 400t
Hypertensive urgencies, 400, 885
Hyperthermia. See also Environmental injuries
in heat stroke, 1368
in monoamine oxidase inhibitors, 1207
in poisoning, 1187–1188
Hyperthyroidism, 623, 1450–1457. See also
Endocrine disorders
Tintinalli_Index_p2025-2116.indd 2068
causes of, 1451t
clinical features of, 1450–1451
epidemiology of, 1450
laboratory testing in, 1451
primary, 1450, 1451t
secondary, 1450, 1451t
signs and symptoms of, 1451t
treatment and disposition of, 1452
Hypertonic saline, 802
Hypertransfusion, 948–949
Hypertrophic cardiomyopathy, 53, 383–384
bedside interventions in, 383t
in children, 834–835, 838
clinical features of, 383
diagnosis of, 383–384
epidemiology of, 383
pathophysiology of, 383
syncope and, 363
treatment of, 384
Hypertrophic scars, 267
Hyperventilation syndrome, 1155
in obese patients, 1995t
Hyperviscosity syndromes, 1477–1478, 1518
Hypervitaminosis, 1323–1325, 1323t
Hyphae, 1619f
Hyphema, 1531, 1533f, 1548, 1558
Hypnotics, 1190t
Hypocalcemia, 95–97, 572, 856
causes of, 95t
clinical features of, 95–96
defined, 95
diagnosis of, 97–98
drugs associated with, 95t
electrocardiogram in, 96f
seizures in, 894
signs and symptoms, 96t
treatment of, 97, 856t
Hypoglycemia, 1431–1433
causes of, 1422
in children, 672, 966–967
clinical features of, 966
history in, 966
physical examination in, 966
clinical features of, 1432
diagnosis of, 966, 967f, 1432, 1433t
disposition and follow-up in, 1433
glucagon emergency kits, 1422
in hemodialysis, 577
in hypothyroidism, 1449
in insulin-dependent patients, 1420–1422
pathophysiology of, 966, 1431–1432
in patients using insulin pumps, 1423
in poisoning, 1187
in pregnancy, 623
seizures in, 894
treatment of, 966–967, 967t, 1422,
1432–1433
Hypoglycemics, 1190t
Hypoglycin, 1411t
Hypokalemia, 88–89, 855
in cardiac arrest, 162
causes of, 91t
in children, 855
clinical features of, 88
defined, 88
in diabetic ketoacidosis, 972, 1438
diagnosis of, 89
electrocardiogram in, 90f
medications for, 91t
in methylxanthines, 1263
FB:Cardiologia Siglo XXI
signs and symptoms of, 90t
treatment of, 89, 856t
Hypomagnesemia, 93–94, 856
causes of, 93, 93t
clinical features of, 93
in diabetic ketoacidosis, 1439
diagnosis of, 93
seizures in, 894
signs and symptoms of, 94t
treatment of, 94, 856t
Hyponatremia, 83–85, 963–964
brain volume and, 86f
in children, 854
chronic, 85
classification of, 84t
clinical features of, 84, 84t
defined, 83
diagnosis of, 84–87
differential diagnosis of, 84t
hyperosmolar, 83
hypo-osmolar, 84
in hypothyroidism, 1449
iso-osmolar, 83–84
malignancy in, 1516
osmotic demyelination syndrome in, 85
plasma osmolality and, 83
seizures in, 894
treatment of, 85, 86t, 854, 854t
Hypo-osmolar hyponatremia, 84
Hypophosphatemia, 98–99
causes of, 98t
clinical features of, 98–99
in diabetic ketoacidosis, 1439
drugs associated with, 99t
pathophysiology of, 98–99
signs and symptoms of, 99t
treatment of, 99
Hypoplastic left heart syndrome, 825
Hypopyon, 1533f
Hyposthenuria, 947
Hypotension
in antipsychotics overdose, 1210
in cardiogenic shock, 355–356
causes of, after vasodilator use, 371t
in cyclic antidepressants, 1198
differential diagnosis of, 1276t
during hemodialysis, 576–577
intracranial, 1112
intradialytic, 576
in monoamine oxidase inhibitors, 1207
peridialytic, 576t
permissive, 2010
in prerenal acute kidney injury, 566t
in spinal injuries, 1708
toxicologic causes of, 1272t
Hypotensive resuscitation, 65
Hypothalamus–pituitary–adrenal axis, 1459
Hypothenar hammer syndrome, 421t
Hypothenar muscles, 1783–1784
Hypothermia, 1337–1345. See also
Environmental injuries
accidental, 1337, 1340f, 1358t
in austere environments, 1345
cardiac arrest in, 1344
cardiorespiratory responses to, 1338–1339
causes of, 1358t
in children, 672, 1344
classification of, 1337
clinical features of, 1339
cold physiology in, 1338–1339
8/2/19 6:02 PM

complications of, 1344
continued core cooling in, 1338
core temperature measurement in, 1339
declaration of death in, 1341
diagnosis of, 1339–1341
heat loss in, 1337–1338
heat production and production in, 1338
imaging in, 1341
laboratory testing in, 1341
metabolic responses to, 1339
mild (stage I), 1341
in military medicine, 2011
moderate (stage II), 1341–1342, 1343f
pathophysiology of, 1337–1339
in poisoning, 1187–1188
post-cardiac arrest, in pregnancy, 169
rescue collapse in, 1339
rewarming patients with, 1343f, 1344t
secondary, 1337t, 1338
severe (stage III), 1343f, 1344
stage IV, 1344
therapeutic, 163, 168f, 169–171, 171t,
1337
in children, 171
complications, 171
cooling and supportive care in,
171, 171t
criteria for, 170, 170t
practical considerations in, 170–171
prehospital applications of, 171
treatment of, 1341–1344
triage tool for, 1342f
Hypothyroidism, 1447–1450. See also
Endocrine disorders
in abnormal uterine bleeding, 609
causes of, 1448t
clinical features of, 1447, 1448t
diagnosis of, 1449
in elderly, 1450
epidemiology of, 1447
imaging in, 1449
laboratory testing in, 1449
palpable nodule in, 1450
pathophysiology of, 1447
in patients with cardiac disease, 1450
in pregnancy, 1450
primary, 1447, 1448t
secondary, 1447, 1448t
signs and symptoms of, 1448f
treatment of, 1449
Hypoventilation, in hypoxemia, 426
Hypovolemia, 253
in cardiac arrest, 161
in prerenal acute kidney injury, 566t
Hypovolemic shock, 57
Hypoxemia, 426–427
clinical features of, 427
cyanosis in, 427
diagnosis of, 427
diffusion impairment in, 427
in HIV infection, 1038
hypoventilation in, 426
low inspired oxygen in, 427
mechanical ventilation in, 192
pathophysiology of, 426–427
relative, 426
right-to-left shunt in, 426
in sepsis, 998–999
treatment of, 427
ventilation-perfusion in, 426
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2069
Hypoxia, 426–427
in cardiac arrest, 161
in high-altitude disorders, 1378
with hypercapnia, 173
mechanical ventilation in, 192
without hypercapnia, 173
Hysteroscopy, 664
Hysterotomy, resuscitative, 1683
I for genitourinary trauma, 1758t
Iatrogenic cardiac injury, 1744
Iatrogenic pneumothorax, 460
Ibuprofen, 235t, 901
in acute pediatric pain, 725
dosing and administration, 234t
in vaso-occlusive crisis, 947t
Ibutilide, 129
actions, 129
adverse effects of, 129
in atrial fibrillation/flutter, 109, 109t
dosing and administration, 129
indications for, 129
pharmacokinetics of, 129
in tachydysrhythmias, 101t
Icatibant, 72, 1282
Idarucizumab, 1505
Idiopathic anaphylaxis, 68
Idiopathic facial nerve palsy, 1160–1161
Idiopathic hypertrophic subaortic stenosis,
838
Idiopathic intracranial hypertension, 1557
headache in, 1111–1112
Idiopathic thrombocytopenic purpura, 1470
Idioventricular rhythms, 106, 106f, 106t
Idoxuridine, 1542
IgA nephropathy, 884
i-gel®, 177
Ileitis, diarrhea in, 488–491
Ileus, 480–481, 531t
Iliac artery aneurysm, 419
Ilioinguinal nerve entrapment, 1897
Iliopectineal bursitis, 1898
Iliopsoas bursitis, 1898
Iliotibial band syndrome, 1900–1901, 1901f
Iloprost, 1356–1357
Imaging
of abdomen, 476–477
in abdominal pain, 857
in abdominal/pelvic pain, 613
in abnormal uterine bleeding, 610
in acute kidney injury, 882
in adrenal insufficiency, 1459
in aneurysms, 417–418
in ankle injuries, 1864, 1865f
in aortic dissection, 413–414
in appendicitis, 524–526, 525f–526f
in arterial gas embolism, 1373
in arterial occlusion, 423
in back pain, 1885
in behavioral disorders in children, 983
in bowel obstruction, 531, 531f
in carbon monoxide poisoning, 1416
in cardiogenic shock, 354–355
of cervical spine, 1711–1712
of cervical spine injuries, 707–709
in chest pain, 332
in child abuse and neglect, 992–993
in child neglect, 989
in cholecystitis, 514–515, 515t
in constipation, 493
Index   2069
in decompression sickness, 1373
in delirium, 1942
in diverticulitis, 528
in eating disorders, 1958
of elbow injuries, 1813f
of facial trauma, 1717–1718
of forearm injuries, 1813f
of fractures, 1771
in gastroenteritis, 847
of hands, 293
of head injuries and concussion in children,
700
of head trauma, 1685–1687, 1686f, 1687t
in headache, 1108–1109, 1109t
of headaches in children, 886–887
in hematuria, 585
in hemoptysis, 434
in hepatic disorders, 518
in hepatitis, 517
of hip, 1895–1896
of hip injuries, 1844
in hypothermia, 1341
in hypothyroidism, 1449
in intracerebral hemorrhage, 1117, 1117f
in iron toxicity, 1291
of joint disorders, 1921
of kidney, 567–568, 568f
of knee, 1895–1896
of knee injuries, 1852
lactation after, 631
in nausea, 482
in obese patients, 1995–1996, 1996f
in pancreatitis, 510, 511f
in pediatric emergency care, 670
in pediatric seizures, 890
in pediatric trauma, 693–694
in pelvic inflammatory disease, 656
in pelvis injuries, 1837
in pregnancy, 631
in pulmonary hypertension, 410–411
radiography of, 1771–1773
in respiratory distress, 425–426
in seizures, 1155
in sepsis, 1000–1001
in shock, 59–60
in stroke, 1126–1127
in subarachnoid hemorrhage, 1115,
1115f–1116f
in thyroid storm, 1453
in trauma, 1675–1676
of trauma to extremities, 1773–1775
in urinary tract infections, 581, 872
in urologic stone disease, 600–601
in venous thromboembolism, 392–396
of wounds, 268
of wrist injuries, 1796–1797
Imipenem
in diverticulitis, 528t
in intra-abdominal infections, 480t
in pneumonia, 445t
in urinary tract infections, 583t
Imipramine, 1195t
Immersion cooling, 1348–1349
Imminent death, 2003
Immobilization
ankle stirrup, 1779, 1779f
arm sling, 1776, 1777f
clavicle strap, 1776
cock-up wrist splint, 1777
8/2/19 6:02 PM
 2070   Index
Immobilization (Cont.):
knee immobilizer, 1778, 1778f
long-arm gutter splint, 1777, 1777f
posterior ankle mold, 1778–1779, 1779f
short-arm gutter splint, 1777, 1777f
shoulder, 1776
splints in, 1776–1780
sugar-tong, 1777, 1777f
thumb spica splint, 1778, 1778f
Immune checkpoint inhibitor therapy,
1520–1521
Immune reconstitution inflammatory
syndrome, 1035
Immune reconstitution syndrome, 454
Immune thrombocytopenia, 955
Immunization
in children, 671t
of HIV patients, 1041, 1041t
for pertussis, 438
for tetanus, 1050–1051
Immunoglobulin, tetanus, 1049–1050
Immunosuppressives
adverse reactions to, 1986t
in Crohn’s disease, 490
in systemic rheumatic diseases, 1912–1914
Impaled objects, 1675
Imperforate hymen, 880, 880f
Impetigo, 933, 933f, 1566–1567, 1568t
Implantable cardioverter-defibrillators (ICDs),
222–223, 222t
Implants, breast, 662
Implosion, 30
Inapsine, 628
Inborn errors of metabolism, 735
in children, 967–970
clinical features of, 968–969
complications of, 970
diagnosis of, 968–969, 968f
blood gas analysis in, 969
glucose and urine ketone levels in,
968–969
plasma ammonia concentration in, 969
plasma lactate level, 969
history in, 968
laboratory testing in, 968t
pathophysiology of, 968
physical examination, 968
treatment of, 969–970
eliminating toxic metabolites in,
969–970
fluid resuscitation in, 969–970
specific therapies, 970t
Incapacitating agents, 40
Incarcerated hernia, 533f
Incident Command System, 14, 14f, 21
Incision, in fishhook removal, 317, 317f
Incisional hernia, 532
Incomplete abortion, 620t
Incomplete spinal cord syndromes, 1709
Incretin, 1424
Incretin analogues, 1430
Indinavir, 1042t
Indirect ophthalmoscope, 1529
Indomethacin, 234t
Induced abortion, 666, 666t
Induction agents, in rapid-sequence
intubation, 186
Industrial toxins, 1318–1323, 1319t
ammonia, 1320
chlorine, 1320
Tintinalli_Index_p2025-2116.indd 2070
cyanide, 1320
delayed toxicity, 1319t
hydrogen sulfide, 1322–1323
nitrogen dioxide, 1320
phosgene, 1319–1320
respiratory toxins, 1319–1320
skin absorption of, 1319t
Indwelling vascular devices, 1044
Indwelling venous catheters, in technology-
dependent children, 979
Inevitable abortion, 620t
Infants
abdominal pain in, 857–864
airway management in, 714–719
apparent life-threatening event in,
739–744
bacteremia in, 747
central venous access in, 721–723, 721t
cervical spine injuries in, 706–709
compression and ventilation in, 682
diarrhea in, 844
ear disorders in, 756–762
electroencephalography in, 841–842
eye disorders in, 763–771
amblyopia, 764
blepharitis, 765
cataracts, 771, 771f
conjunctivitis, 768–770
corneal abrasion, 767
dacryoadenitis, 765
dacryocele, 765
dacryocystitis, 765, 765f
dacryostenosis, 764–765
glaucoma, 770
leukocoria, 770–771
ophthalmia neonatorum, 767–768, 768t
orbital cellulitis, 766–767, 766f
periorbital cellulitis, 765–766
red eye, 767–770
retinal hemorrhages, 771
retinoblastoma, 771
strabismus, 764
fever in, 746–752
fluid and electrolyte therapy in, 851–856
gastrointestinal bleeding in, 864–870
causes of, 867–868
gynecologic problems in, 879–880
heart rate, normal, 841, 841t
intraosseous access in, 719–721
meningitis in, 747, 752–756
metabolic emergencies in, 965–971
mouth and throat disorders in, 775–782
aphthous ulcers, 776–777, 776f
group A b-hemolytic Streptococcus
pharyngitis, 779–780
hand, foot, and mouth disease, 777, 778f
herpangina, 777
herpes simplex gingivostomatitis,
777–778, 778f
pharyngitis, 778–780
stomatitis, 777
uvulitis, 780–781, 781f
neck masses in, 782–789
oral problems in, 781–782
pain assessment in, 724
pain management in, 723–727
peripheral venous access in, 721
pneumonia in, 811–819
rashes in, 925–944
seborrheic dermatitis in, 1629
FB:Cardiologia Siglo XXI
seizures in, 888–896
sepsis in, 747
sinusitis in, 747, 772–774
stridor in, 789–798
sudden death syndrome in, 745–746
umbilical vein access in, 722
urinary tract infection in, 747, 870–874
urologic disorders in, 874–879
vascular access in, 719–722
vomiting in, 842–843
wheezing in, 798–810
Infections, 997–1043
airborne precautions in, 1098
arboviral
clinical features of, 1031
diagnosis of, 1031–1032
epidemiology of, 1031
in North America, 1031t
pathophysiology of, 1031
treatment of, 1032
bacterial, 743
Bartonella henselae, 322–323
from bite wounds, 321–323
in blood transfusions, 1500
Bordetella pertussis, 436
in pneumonia, 811, 812t
Campylobacter, 1066t, 1067
gastroenteritis in, 846t
Candida
in groin and skinfolds, 1652–1653, 1653f
in HIV infection, 1040, 1040f
vaginitis, 649–650
Capnocytophaga canimorsus infections,
322
central nervous system, 1172–1176
of cerebrospinal fluid shunts, 1183
Chlamydia pneumoniae infections, 436
Chlamydia trachomatis, 1014–1017
clinical features, 1014
diagnosis of, 1014
with gonorrhea, 1014
in pneumonia, 811, 812t
premature rupture of membranes in, 634
in proctitis, 547
treatment of, 1014–1017, 1015t
in urinary tract infections, 582
Chlamydophila pneumoniae, in pneumonia,
440t, 441
Clostridium botulinum, 43t, 45t, 558, 1066t,
1159
in injection drug users, 1982
Clostridium difficile, 451
colitis in, 486–488
in diarrhea, 851
diarrhea in, 486–488
control of, 1093
Corynebacterium diphtheriae, 1595
Cryptococcus neoformans, 444
cutaneous, in HIV infection, 1040–1041
deep tissue, 319
disseminated intravascular coagulation in,
1472t
droplet precautions in, 1098
Eikenella corrodens, 323
endocarditis, 1043–1048
Entamoeba histolytica, 1068
in eye disorders, 1533–1544
of eyelids, 1539–1542
of face, 1566–1570
antibiotics for, 1568t
8/2/19 6:02 PM

differential diagnosis of, 1567t
masticator space infection, 1570
of salivary glands, 1567–1569
sialolithiasis, 1569
suppurative parotitis, 1569
facial space, 1582
foodborne illnesses, 1063–1070
Fusobacterium necrophorum, 1595
Gardnerella vaginalis, 636
Haemophilus aphrophilus, 1896
Haemophilus ducreyi, 1021
Haemophilus influenzae, 436
in bacterial meningitis, 1172–1174
in cellulitis, 1565
in children, 747, 751–752
in injection drug users, 1982
in otitis media, 1563
in pneumonia, 440t, 441
of hand, 1914–1918
from closed fist injuries, 1916, 1916f
deep space, 1916
felon, 1917, 1917f
herpetic whitlow, 1918
paronychia, 1916–1917, 1917f
in hemodialysis, 575
herpes simplex virus, 651–652, 652f, 652t
Histoplasma capsulatum, 444
human immunodeficiency virus,
1032–1043
human papillomavirus, 1022–1023
in injection drug users, 1982–1984
Klebsiella granulomatis, 1022
Klebsiella pneumoniae
in injection drug users, 1982
in pneumonia, 440t
in spontaneous bacterial peritonitis, 520
Legionella pneumophila
in pneumonia, 440t, 441, 443–444
in waterborne illnesses, 1068
Listeria monocytogenes, in bacterial
meningitis, 1172
Macacine herpesvirus, 324
malaria, 1057–1063
in marine trauma, 1363
methicillin-resistant Staphylococcus aureus,
1006t, 1007
Moraxella catarrhalis, 436
in pneumonia, 440t, 441
Mycobacterium marinum, 1070t, 1676–1677
Mycobacterium tuberculosis, 444, 451, 453
in bacterial meningitis, 1172
in lymphadenopathy, 786–787
pelvic inflammatory disease in, 655
in pneumonia, 811, 812t
in type II diabetes, 1426t
in waterborne illnesses, 1068
Mycobacterium ulcerans, 1657
Mycoplasma pneumoniae, 436
in hemolytic anemia, 1491
in pneumonia, 440t, 441, 812t
in natural disasters, 27
of neck, 1594–1598
bacterial pharyngitis, 1595–1596
epiglottitis, 1596–1597, 1597f
odontogenic abscess, 1598
peritonsillar abscess, 1596
retropharyngeal abscess, 1596f,
1597–1598
tonsillitis, 1594–1596
viral pharyngitis, 1594–1595
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2071
necrotizing soft tissue, 1010–1012
clinical features of, 1011, 1011f
diagnosis of, 1011–1012, 1012t
hyperbaric oxygen therapy in, 140
organisms in, 1010
pathophysiology of, 1010–1011
treatment of, 1012
Neisseria gonorrhoeae, 1017–1018. See also
Gonorrhea
in flexor tenosynovitis, 1916
pelvic inflammatory disease in, 654
in urinary tract infections, 582
Neisseria meningitidis, 1085, 1628
in bacterial meningitis, 752, 1172
in children, 752
in meningococcemia, 936–937
in shunts, 1183
occupational exposure, 1092–1099
opportunistic, 817–818
after pacemaker insertion, 221t
parasitic helminth, 1089–1090, 1090t
parasitic, in diarrhea, 851
in pediatric oncologic emergencies,
961–962
Plasmodium falciparum, 1057–1063
Pneumocystis jiroveci, 1035
in injection drug users, 1982
portals for exposure, 1093
postoperative, 558
precautions, 1096–1098
Proteus mirabilis, 1896
Pseudomonas
in corneal ulcer, 1543
in frostbite, 1356
Pseudomonas aeruginosa, 1070t
in empyema, 450
in otitis externa, 761
in otitis media, 1563
in pneumonia, 440t, 441, 443
in psoas abscess, 1896
in puncture wounds, 318
in type II diabetes, 1426t
in waterborne illnesses, 1068
rabies, 1051–1057
rashes in, 924–937, 928f–929f
bacterial, 933–937
fungal, 931–933
viral, 926–931
salivary gland, 1567–1569
sepsis, 997–1004
Serrata marcescens, 1896
sexually transmitted, 1013–1024
in sickle cell anemia, 1486–1487
in skin disorders, 1652–1653
skin, in natural disasters, 27
soft tissue, 1005–1013
anatomy in, 1005f
carbuncles, 1008–1010
cellulitis in, 1005–1008
cutaneous abscesses, 1008–1010
epidermoid cyst, 1012
erysipelas in, 1005–1008
folliculitis, 1012
furuncles, 1008–1010
in injection drug users, 1982
necrotizing, 1010–1012
pilar cyst, 1012
sporotrichosis, 1012–1013
spinal, 1177–1179, 1887–1888
Staphylococcus
Index   2071
in corneal ulcer, 1543
in foot and leg lacerations, 307
Staphylococcus aureus, 741, 1017–1021,
1066t
acute unilateral lymphadenopathy in,
785–786
in cellulitis, 1566
in corneal ulcer, 1543
in empyema, 450
in felon/paronychia, 1917–1918
in flexor tenosynovitis, 1916
of hand, 1914
in human bite wounds, 294
mastitis in, 660
in otitis externa, 761
in otitis media, 1563
in peritoneal dialysis, 578
in pneumonia, 439, 440t, 441
in psoas abscess, 1896
in puncture wounds, 318
in shunts, 1183
in spinal infections, 1888
in vascular access, 575
Staphylococcus epidermidis
in epidural abscess, 1178
in peritoneal dialysis, 578
in shunts, 1183
Staphylococcus pneumoniae, 812t
Streptococcal pneumoniae, in spontaneous
bacterial peritonitis, 520
Streptococcus
in epiglottitis, 1596–1597
in foot and leg lacerations, 307
in human bite wounds, 294
Streptococcus aureus, in necrotizing soft
tissue infections, 1010
Streptococcus pneumoniae, 436
in bacterial meningitis, 1172
in children, 747, 752
in injection drug users, 1982
in meningitis, 752
in otitis media, 1562
in pneumonia, 440, 440t, 443
in shunts, 1183
Streptococcus pyogenes, in cellulitis, 1566
in systemic rheumatic diseases, 1912
Taenia solium, 1157
tetanus, 1048–1051
tickborne, 1070–1075
anaplasmosis, 1073–1074
babesiosis, 1074–1075
Colorado tick fever, 1074
ehrlichiosis, 1073–1074
Lyme disease, 1072–1073
prevention of tick bites in, 1071
prophylactic treatment in, 1071
Rocky Mountain spotted fever,
1071–1072
tick paralysis, 1072
tick removal in, 1071
tickborne relapsing fever, 1074
tularemia, 1074
in transplantation, 1986–1987, 1987t
in cardiac transplantation, 1993
in corneal transplantation,
1993–1994
in kidney transplantation, 1989–1991
in liver transplantation, 1991
in lung transplantation, 1991–1993
in renal transplantation, 1989–1991
8/2/19 6:02 PM
 2072   Index

Infections, in transplantation (Cont.): Inferior vena cava, 569f fleas, 1357, 1649
in travelers, 1079–1092 Infestations flies, 1357
Trichomonas vaginalis, 650–651, 1008–1011 lice, 937–938, 938f, 1617 kissing bugs, 1357
complications of, 651 rashes in, 937–938 mosquitoes, 1057–1058, 1356
diagnosis of, 653, 1018 Inflammation, 58 spiders, 1351–1355, 1352t
in HIV patients, 651 Inflammatory bowel disease, 261t, 262 wasps, 1350–1351
pelvic inflammatory disease in, 654 abdominal pain in, 862 Insecticides, 1300–1305, 1300t
premature rupture of membranes in, in children, 862 amitraz, 1305
634 diarrhea in, 488–491 carbamates, 1303–1304
treatment of, 651, 651t, 1009t–1011t, Inflammatory breast cancer, 660 N,N-diethyl-3-methylbenzamide, 1305
1016t, 1018 Inflammatory cardiomyopathy, 381–383 neonicotinoids, 1304
tropical, 1083t–1084t Inflammatory myopathies, 1164 nereistoxin analogs, 1305
in type II diabetes, 1426t Influenza, 437–438 organochlorines, 1304
of upper respiratory tract, 436–439 clinical features of, 437, 1024 organophosphates, 1298–1301
common cold, 437 diagnosis of, 437–438, 438t, 1024 pyrethrin, 1304
influenza, 437–438 epidemiology of, 1024 pyrethroid, 1304
pertussis, 438–439 pathophysiology of, 437, 1024 Inspiratory positive airway pressure, 176
viral, 1024–1032 in pneumonia, 817 Insulin, 1430
arboviral, 1031–1032 risk factors for, 1024t in calcium channel blocker toxicity,
cytomegalovirus, 1030 risk for complications, 438t 1278–1279, 1278t
Ebola virus, 1032 treatment of, 438, 438t, 1024–1025 categories of, 1421t
Epstein-Barr, 1029–1030 Informed consent in diabetes mellitus, 1430
hemorrhagic fever, 1032 documentation of, 2015 categories of, 1421f
herpes simplex, 1025–1027 elements of, 2014–2015 comparison of preparations, 1420t
herpes zoster, 1027–1029 exceptions to, 2015 dosing and administration, 1419–1420
influenza, 1024–1025 failure to obtain, 2015–2016 glycemic complications, 1420–1422
measles, 1030–1031 free choice in, 2015 hyperglycemia, 1428
varicella, 1027–1029 information necessary for patient decision pumps, 1422–1423
waterborne illnesses, 1068–1070 making in, 2015 secretion, 1424
in wounds, 267, 268t–269t informed refusal in, 2016 in diabetes mellitus type I, 1419–1420
bite wounds, 321–324 patient capacity in, 2014–2015 in diabetes mellitus type II, resistance, 1424
risk factors for, 264t, 267, 269t Infraorbital nerve block, 244 in diabetic ketoacidosis, 973–974, 1434,
tetanus, 325, 325t Infrapatellar fat syndrome, 1901 1434f, 1438–1439
zoonotic, 1070–1079 Inguinal hernia, 532, 534f, 862 inhaled, 1420
anaplasmosis, 1073–1074 Inhalation anthrax, 1076, 1077t intravenous, 1438–1439
anthrax, 1076 Inhalation injury, 1388, 1399 in nonketotic hyperglycemic coma, 1447
babesiosis, 1074 Inhalational botulism, 41 overdose, 1422
bacterial skin infections, 1078 Inhaled insulin, 1420 prandial dosing, 1420
brucellosis, 1076 Inhibitor screens, 1468t subcutaneous, 1439
Colorado tick fever, 1074 Injection drug users, 1979–1984 Insulin pumps, 975
cutaneous anthrax, 1078 altered mental status in, 1981 complications, 1423
dermatologic, 1078 back pain in, 1981 hyperglycemia in patients using, 1423
ehrlichiosis, 1073–1074 bone and joint infections in, 1983 hypoglycemia in patients using, 1423
encephalitis, 1075 clinical features of, 1979–1981 ketoacidosis in patients using, 1423
hantavirus, 1078 dyspnea in, 1981 manufacturers of, 1423t
helminths (worms) in, 1078 endocarditis in, 1043–1044, 1981–1982 Integrase inhibitors, 1043t
household pets in, 1078, 1079t epidemiology of, 1979 Intellectual disability, 980
in immunocompromised persons, evaluation of, 1980t Intercondylar fractures, 1817–1818
1079, 1079t fever in, 1035, 1979 Intercostal nerve block, 245–246, 246f
lower respiratory, 1076–1078 hepatic disorders in, 1983–1984 Interferon-gamma release assays, 453
Lyme disease, 1072–1073 HIV infection in, 1981 Internal defibrillation, 152
meningitis, 1075 infections in, 1982–1984 Interosseous muscles, 1784
pasteurellosis, 1076 neurologic abnormalities in, 1981 Interstitial cystitis, 262, 262t, 264t
plague, 1076–1078 ophthalmologic infections in, 1984 Interstitial fluids, 81, 83f
protozoa in, 1079 pathophysiology of, 1979 Interstitial lung disease, 1908
psittacosis, 1076 pulmonary infections in, 1982 Intertrigo, 1652t, 1654–1655, 1654f
pulmonic plague, 1076–1078 skin and soft tissue infections in, 1982 Intertrochanteric fracture, 1845
Q fever, 1076 vascular infections in, 1983 Interventricular septum rupture, 350
Rocky Mountain spotted fever, Inner cup ligament, 299 Intestinal pseudo-obstruction (Ogilvie’s
1071–1072 Innominate artery aneurysm, 419 syndrome), 494
tick paralysis, 1072 Inotropes, 91t, 137 Intimate partner violence and abuse,
tickborne, 1070–1075 in cardiogenic shock, 355–356, 356t 1971–1974. See also Physical abuse
tickborne relapsing fever, 1074 Inotropy, 820 assessment of, 1972
treatment of, 1075t Insect bite and stings, 1350–1358, 1649–1650, clinical features of, 1971–1972
tularemia, 1074 1650f consequences of, 1972
upper respiratory, 1076 ants, 1351 definition of, 1971
viral skin infections, 1078 bed bugs, 1357, 1649 documentation of, 1973–1974
Infectious diseases, in natural disasters, 27 bees, 1350–1351 epidemiology of, 1971
Inferior alveolar nerve block, 1590–1591, botflies, 1649–1650 hotlines for patients, 1974t
1593f epidemiology of, 1350 in immigrants, 1974

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2072 8/2/19 6:02 PM


legal considerations in, 1974
in pregnancy, 629, 1974–1975
risk assessment in, 1972–1973
screening for, 1972, 1973t
signs of, 1972t
Intoxication syndromes, 1957–1958
Intra-abdominal abscess, 559
Intra-aortic balloon pump, 351
Intra-aortic balloon pump counterpulsation,
356
Intracardiac missiles, 1744
Intracavernosal injections, 606
Intracellular fluids, 81, 83f
Intracellular second messenger, 1270
Intracerebral hemorrhage, 404, 404t, 627,
1117–1118, 1126. See also Neurologic
disorders
clinical features of, 1117
diagnosis of, 1117
epidemiology of, 1117
headache in, 1110
imaging in, 1117, 1117f
pathophysiology of, 1117
reverse coagulopathy in, 1118
treatment of, 1118, 1118t
Intracerebral stroke, 1121t
Intracranial hemorrhage, 735
Intracranial hypotension, headache in, 1112
Intracranial pressure (ICP)
in children, 964
in coma, 1142
ketamine emergence reactions, 253–254
measurement of, 1559–1560
Intradermal anesthesia, 238
Intraocular pressure, 1529–1530
Intraoral mucosal lacerations, 290–291
Intraosseous access, 2009–2010
cannulation devices, 719–721
in children, 719–721
complications of placement in, 721
contraindications to, 719t
devices, 6
laboratory testing of bone marrow aspirate
in, 719
medications and fluids in, 719
placement and insertion of needles in,
719–721, 720f
removal in, 721
Intraosseous access devices, 6
Intrascrotal tumors, 876
Intrathecal baclofen, 1184–1185, 1184f, 1185t
Intraurethral injections, 606
Intrauterine devices, 666
Intravenous fluids
in gastroenteritis, 848
in military medicine, 2009–2010
in myasthenia gravis, 1166t
Intravenous lipid emulsion, 1188t
in beta-blocker toxicity, 1276
in calcium channel blocker toxicity, 1279
in cyclic antidepressant toxicity, 1199
in resuscitation of poisoned patient, 1188,
1188t, 1189
Intrinsic sympathomimetic activity, 1271
Intrusive luxation, 1587–1588
Intubation, 179–190
in asthma, 807, 807t
blind nasotracheal, 189
cardiac arrest in, 1742
in children, 710–718
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2073
anatomy in, 710–711, 711t
bag-mask ventilation, 711–712
equipment in, 712–713, 713t
external laryngeal manipulation, 714
foreign body obstruction in, 717
noninvasive ventilation in, 712
physiology in, 710
postintubation management, 715–716
preparation for, 714
rapid-sequence, 715
tracheal, 714
difficult, 180
endotracheal, 5–6, 676
in children, 712–713
complications of, 185, 185t
converting supraglottic airway to,
178–179
equipment in, 712–713, 713t
location of, 183–185
in head trauma, 1688t
in neonates, 676
orotracheal, 181–185
complications of, 185
endotracheal tube location in, 183–185
equipment in, 182–185
patient positioning in, 182
preoxygenation in, 181
procedure in, 182–183
Sellick or cricoid maneuver in, 182
in pregnancy, 167
preparation for, 714
rapid-sequence, 6, 185–187, 715
in children, 715
induction agents in, 186, 186t
medications in, 715t
paralytic agents in, 186–187
pretreatment agents in, 186, 186t
steps in, 186t
in systemic rheumatic diseases, 1908
tracheal, 179–190, 714
airway assessment in, 180–181
anticipated intubation difficulty, 189
blind nasotracheal intubation, 189
flexible fiberoptic laryngoscopy,
188–189
orotracheal, 181–185
preparation of, 179, 180f
rapid-sequence intubation, 185–187
steps of, 182t
unanticipated intubation difficulty,
189–190
video laryngoscopy, 187, 188f
Intussusception, 844, 859, 860f, 868
Invasive cooling, 1349
Inversion stress test, 1863
Involuntary horizontal nystagmus, 1525–1526
IO vascular access, 208–209, 209f, 209t
Ion channel disease, 54–55
Iopanoic acid, in thyroid storm, 1455
Ipecac, 1277
Ipodate, 1455
Ipomoea species, 1247t, 1248
Ipratropium bromide
in anaphylaxis, 70t
in asthma, 464t
dosages of, 806t
Irbesartan, 1282
Iridodialysis, 1528
Iris, prolapse of, 1527f
Iritis, 1544, 1544t
Index   2073
Iron, 1289–1292
chelating agents, 1289–1290
elemental, 1290t
formulations, 1290t
pathophysiology of, 1289–1290
pharmacology of, 1289–1290
toxicity of, 1287–1290, 1290t, 1291–1292
clinical features of, 1290
deferoxamine in, 1291–1292
diagnosis of, 1290–1291
gastrointestinal decontamination in,
1288–1289
imaging of, 1291
laboratory testing in, 1290–1291
stages of, 1290
treatment of, 1291–1292, 1292f
Iron deficiency anemia, 954, 1464t
Iron overload, 949
Irrigation, in wound preparation, 270–271
Irritable bowel syndrome (IBS), 261t, 262, 264t
Irritant agents, 40
Irritant dermatitis, 1414
Irukandji syndrome, 1367–1368
Ischemia
critical limb, 420
recurrent, 351–352
refractory, 351–352
upper extremity, 423
Ischemia-reperfusion injury, 169–170, 169f
Ischemic colitis, lower gastrointestinal
bleeding in, 498
Ischemic injury, 563
Ischemic priapism, 594
Ischemic stroke, 404, 1121t, 1122–1126
anterior cerebral artery infarction in, 1122
antiplatelet therapy for, 1129
basilar artery occlusion in, 1124–1125
carotid and vertebral artery dissection in,
1125–1126
cerebral infarction in, 1125
fever in, 1128
hyperglycemia in, 1128–1129
in hypertension, 400t, 404t
lacunar infarction in, 1125
middle cerebral artery infarction in,
1122–1124
posterior cerebral artery infarction in, 1124
time recommendations for, 1127t
treatment of, 1128–1130
vertebrobasilar infarction in, 1125
Ischemic tubular necrosis, 563
Ischial bursitis, 1898
Ischiogluteal bursitis, 1898
Islet cell transplantation, 1424
Isocarboxazid, 1205t
Isolated ulna fracture, 915, 1820
Isolation, 1098
Isoniazid
in HIV-related infections, 1036t
toxicity of, 1329
in tuberculosis, 455t
Iso-osmolar hyponatremia, 83–84
Isopropanol, 1225–1226
metabolism of, 1227f
pathophysiology of, 1227
structure of, 1222f
toxicity of, 1225–1226
clinical features of, 1227
diagnosis of, 1227
treatment of, 1227
8/2/19 6:02 PM
 2074   Index
Isoproterenol, 131
in resuscitation of children, 683t
in shock, 61t
Isotonic crystalloids, 65–66
Isradipine, 886t, 1276t
in hypertension, 408t
for hypertensive pediatric patients, 408t
Itraconazole, 1013
Ivermectin, 1091, 1643, 1653
J in acute pediatric pain, 725
Jamaican vomiting sickness, 1413
Japanese encephalitis, 1086
Jarisch-Herxheimer reaction, 1019
Jaundice, 516, 833
in neonates, 738–739, 738t
Jaw thrust maneuver, 145–146, 145f
Jefferson burst fracture of atlas, 1701f
Jellyfish stings, 1367–1368, 1368f
Jervell and Lange-Nielsen syndrome, 55
Jet ventilation, 198–199
complications, 199
equipment in, 198–199, 199f, 199t
indication and contraindications, 198
procedure, 199, 200t
Jimsonweed, 1248, 1412
Jock itch, 1652
Joint disorders, 1920–1927
arthrocentesis, 1921–1925
clinical approach to, 1920–1921
gout, 1926
hemarthrosis in, 1927
imaging of, 1921
Lyme disease in, 1927
osteoarthritis, 1927
pseudogout, 1926
reactive arthritis, 1927
rheumatoid arthritis, 1927
septic arthritis, 1925–1926
serum laboratory studies for, 1920–1921
viral arthritis, 1926
Joints, 1767
Jones fracture, 1874, 1874f
Jugular vein
central venous access in, 203–206, 205f,
721–722
external, 203
internal, 203–206, 205f, 205t, 206f,
721–722
posterior approach to, 204–205
pulsation of, 214, 214f
US-guided localization of, 205f
Jumper’s knee, 1901, 1901f
Jumping spiders, 1355
Junctional rhythm, 105–106, 105f
Juniper, 1326t
Juvenile idiopathic arthritis, 923
K acute failure of, 563–570
K2 (synthetic cannabinoids), 1244t,
1246–1247
Kaolin, 270
Kaposi’s sarcoma, 1041, 1651, 1651f
Kappa-opioid receptor, 229
Kava, 519t, 1325t–1326t
Kava lactones, 1411t
Kawasaki’s disease, 770, 831–832
in children, 751, 942–943, 943t
clinical features of, 830t, 831–832
complications of, 832t
Tintinalli_Index_p2025-2116.indd 2074
criteria for, 939t
diagnostic criteria for, 831t
rashes in, 942–943, 943t
treatment of, 832
Keloid, 267, 273
Kendrick Extrication Device, 6, 7f
Keratoconjunctivitis, 768
Keraunoparalysis, 1402
Kernig sign, 750, 754
Ketamine, 257
in agitation, 1938–1939
in asthma, 466, 807
dosages of, 806t
dosing and administration, 234t
emergence reactions of, 253
hallucinogenic properties of, 1247t, 1248
in migraine, 1112t
in pain management, 233, 2012
in pediatric seizures, 894
in pregnancy, 253–254
in rapid-sequence intubation, 186, 186t,
715t
in refractory status epilepticus, 1158–1159
in sedation, 251t, 253–254, 729
in sexual abuse and assault, 1969
in vaso-occlusive crisis, 948
Ketoacidosis
anions in, 74t
diabetic, 1433–1441
insulin pump complications and, 1423
Ketoacidotic syndromes, 1441–1443
alcoholic ketoacidosis, 1441
differential diagnosis of, 1442t, 1443
disposition and follow-up in, 1443
formation and metabolism of ketone
bodies, 1442f
inborn errors of metabolism in, 1443
ketogenic diet, 1443
nutritional ketosis, 1442–1443
pathophysiology of, 1441
starvation ketosis, 1442
toxic ingestions, 1443
treatment of, 1443
Ketoconazole, 932t, 1013, 1630t, 1653t
Ketofol, 254
Ketogenic diet, 1443
Ketolides, 1328
Ketone bodies, 1436, 1442f
Ketoprofen, 235t
Ketorolac
in acute pediatric pain, 726
dosing and administration, 234t
for headache in children, 901
in migraine, 1112t
in vaso-occlusive crisis, 947t, 948
Ketosis, 1225
Kidney
AKIN criteria, 563, 564t
angiotensin-converting enzyme
inhibitors in, 564
causes of, 563, 566t
clinical features, 563–564
community-acquired, 563
crystal-induced nephropathy, 564
diagnosis of, 564–568
epidemiology of, 563
history and comorbidities, 563
hospital-acquired, 563
FB:Cardiologia Siglo XXI
intrinsic, 563
ischemic, 563
nonsteroidal anti-inflammatory drugs
for, 564–566
pathophysiology of, 563
physical examination in, 563–564
pigments nephropathy, 566
postobstructive, 563
postrenal, 563
prerenal, 563–564
RIFLE criteria, 563, 564t
treatment of, 568–569
complications of urologic procedures and
devices, 602–606
disorders of
acute kidney injury, 563–570
acute urinary retention, 586–590
analgesics and, 235
cardiac troponins in, 329t
in children, 881–888
chronic kidney disease, 567t
coagulation disorders in, 1472
cocaine in, 1237
end-stage renal disease, 573–578
in heat emergencies, 1350
hematuria, 583–585
in HIV infection, 1039
hydrocarbon toxicity in, 1295
in mushroom poisoning, 1409
nephrolithiasis in, 598–602
in nonsteroidal anti-inflammatory drugs,
1260–1261
rhabdomyolysis in, 570–572
risk factors for, 566t
in shock, 60t
in systemic rheumatic diseases,
1910–1911
in type II diabetes, 1426t
end-stage disease of, 573–578
injuries of, in children, 698
injuries to, 1758–1759, 1759t
ischemia of, 563
laboratory evaluation of, 565–567, 566t
transplantation of
diagnosis in, 1989–1990, 1991t
dysfunctions and failure in, 1991t
imaging in, 1990–1991
infections, 1989–1991
tubular necrosis of, acute, 563, 565f
urinary tract infections, 578–583
urologic stone disease, 598–602
Killer bees, 1350
King Laryngeal Tube, 177
King LTS-D®, 5t
Kissing bugs, 1357
Klebsiella granulomatis infections, 1022
Klebsiella pneumoniae infections
in injection drug users, 1982
in pneumonia, 440t, 441
in spontaneous bacterial peritonitis, 520
Knee
anatomy of, 1850–1851, 1852f, 1894, 1895f
arthrocentesis of, 1923–1924, 1924f
bursal syndromes of, 1898–1899
bursitis, 1896t
dislocation of, 1856–1857, 1856f
in children, 918
patellar, 918
disorders of, 1896–1905
effusion of, 1855
8/2/19 6:02 PM

foreign bodies in, 1858
fractures of, 1852–1853
in children, 918–919
distal femoral physeal, 918
femoral condyle, 1852
patella, 1852
patellar, 918–919
tibial plateau, 1853
tibial spine, 1852–1853
tuberosity, 1852–1853
hemarthrosis of, 1855
imaging of, 1895–1896
immobilization of, 1778, 1778f
injuries of, 1850–1858
anterior cruciate ligament, 1854–1855
clinical features of, 1851
diagnosis of, 1852, 1852t
imaging of, 1852
lateral collateral ligament, 1853–1854
ligamentous, 1853, 1855
mechanisms of, 1853t
medial collateral ligament, 1853–1854
meniscal, 1853, 1856
neurovascular, 1851
postarthroplasty problems, 1857
postarthroscopy problems, 1857
posterior cruciate ligament, 1855
posterolateral, 1855
treatment of, 1855–1858
joint aspiration of, 1923–1924, 1924f
lacerations, 303
locked, 1856
motion and strength exercises for, 1778
overuse syndromes, 1896t, 1899–1901
pain in, 1894–1902. See also
Musculoskeletal disorders
anterior, 1900
anterior inferior, 1901
anterior medial, 1900–1901
anterior superior, 1901, 1901f
diagnosis of, 1896t
lateral, 1901, 1901f
posterior lateral, 1901
posteroinferior, 1901–1902, 1902f
postmedial, 1901
referred, 1895
patellar dislocation of, 1857
patellar tendinitis of, 1857–1858
penetrating injuries of, 1858
quadriceps or patellar tendon rupture, 1857
Knee immobilizer, 1778
Knock-out drops, 1220
Kocher’s technique, 1829, 1829f
Koebner phenomenon, 1653
Kombucha, 519t
Koplik spots, 927, 929f, 1030
Korsakoff ’s psychosis, 1324
Kratom, 1236
Krokodil, 1236, 1982
Kupffer cells, 1489
L in digoxin toxicity, 1268–1269
Labetalol, 887t
actions of, 125t, 126
in acute ischemic stroke, 404t
adverse effects of, 125t
in aortic dissection, 403t, 415
dosing and administration, 125t, 126
in emergency delivery, 638t
in gestational hypertension, 632
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in hypertension, 407t, 408t in hemolytic-uremic syndrome, 884
in hypertensive encephalopathy, 403t in hepatitis, 517–518
for hypertensive pediatric patients, 408t in hypothermia, 1341
indications for, 125t, 126 in hypothyroidism, 1449
in intracerebral hemorrhage, 404t in iron toxicity, 1290–1291
in ischemic stroke, 1128t in lower gastrointestinal bleeding, 499
in myocardial infarction, 403t in nausea, 482
in preeclampsia and eclampsia, 633t in nephrotic syndrome, 883
in subarachnoid hemorrhage, 403t, 1116 in pancreatitis, 509–510
Labial adhesions, 879–880, 880f in pediatric seizures, 890
Labor and delivery, 637–647. See also in pediatric trauma, 693
Pregnancy in pelvic inflammatory disease, 656
amniotic fluid embolus in, 646 in psychosocial disorders, 1935
breech presentation in, 647, 648f in pulmonary hypertension, 410
cervical dilatation in, 637 in respiratory distress, 425–426
clamping the umbilical cord in, 640–641 in seizures, 1155
clinical evaluation in, 638–640 in sepsis, 1000–1001
completion of delivery in, 640 in sexual abuse and assault, 1969
complications in, 642–644 in shock, 59
delivery of placenta in, 641–642 in syncope, 365, 836–837
epidemiology of, 637, 637t in trauma, 1675–1676
episiotomy in, 640 in urologic stone disease, 599, 600t
fetal distress in, 639f, 642t Labyrinthitis, 1146
gestational age in, 642 Lacerations
history in, 642 adhesive tapes in repair of, 282f–284f
medications for, 638t of ankle, 305–306
normal delivery, 641f of arm and hand, 292–299
out-of-hospital, 637 of cheeks, 291
pelvic examination in, 640 of cornea, 1546
physical examination in, 642 disposition and follow-up in, 292
postpartum endometritis in, 636, 636t dressings in, 290f, 293–294
postpartum hemorrhage in, 644, 646f, 646t of ears, 289–290, 290f
preterm delivery, 647–649 elbow, 294
rupture of membranes in, 637 of extensor tendons, 294–295
shoulder dystocia in, 642–643, 642t of eye
stages of labor in, 638, 638t corneal laceration, 1546
true vs. false labor in, 638, 638t lid lacerations, 1547
umbilical cord prolapse in, 642, 642t of eyebrow, 286
Laboratory Response Network, 21t of eyelids, 287–288, 287f, 1547
Laboratory testing of face, 285–292
in abdominal pain, 475–476, 476t pathophysiology of, 285
in abnormal uterine bleeding, 610 skin tension lines in, 286f
in acute kidney injury, 881–882 suturing guidelines for, 287t
in adrenal insufficiency, 1459 of fingers, 296
in appendicitis, 524 of flexor tendons, 296
in arterial gas embolism, 1373 of foot, 299–307
in arterial occlusion, 423 digital, 306
in bacterial meningitis, 1172–1173 dorsal, 305–306
in behavioral disorders in children, 983 hair-thread tourniquet syndrome, 306
in bowel obstruction, 531 interdigital, 306
in cardiogenic shock, 354 physical examination of, 300–301
in caustic ingestions, 1298 plantar, 306
in cervical spine injuries, 707 treatment of, 302–303
in child abuse and neglect, 992 of foot and leg
in child neglect, 989 amputation in, 306
in cholecystitis, 514 anesthesia in, 302–303
in compartment syndrome, 1879 antibiotics in, 307
in decompression sickness, 1373 in children, 306
in delirium, 1942 radiographic evaluation of, 303–304
in diabetic ketoacidosis, 972–973, 973t, of forehead, 285–286
1436 of frenulum, 1589
of hand
in disseminated intravascular coagulation, antibiotics in, 293
1473t extensor tendon lacerations, 294–295
in eating disorders, 1958 finger lacerations, 296
in gastroenteritis, 845–846 flexor tendon lacerations, 296
in headache, 1108 lacerations, 292–299
in headaches, 900 palm lacerations, 296–297
in hematuria, 585 high-tension, 273
in hemolytic anemia, 1490t intraoral mucosal, 290–291
8/2/19 6:02 PM
 2076   Index

Lacerations (Cont.): stents in, 1604 upper, nerves of, 1895

of knee, 303 tubes, 1603 venous ulcers of, 1655–1656
of leg, 299–307 Laryngomalacia, 790 Legal issues, 2014–2024
knee, 303 Laryngoscopy in care of minors, 2016–2017
physical examination of, 300–301 blades, 713, 714f confidentiality, 2017–2018
pretibial, 303–305 in children, 714 in departure against medical advice, 2016
radiographs of, 302 difficult, 180 duty to third parties, 2023
treatment of, 302–303 in esophageal foreign bodies, 504 in elopement, 2016
linear, 273 flexible fiberoptic, 188–189 in emancipated minors, 2016–2017
of lips, 290, 291f video, 187 EMTALA, 2019–2022
sutures in, 290, 291f Laryngospasm, 174 HIPAA, 2018–2019, 2019t
low-tension, irregular, 273 Lassa fever, 1032, 1086 informed consent in, 2014–2016
nasal, 288–289, 289f Latent phase, 49 negligence standards, 2023–2024
of nose, 288–289 Lateral canthotomy, 1550 in newborns left at the ED, 2023
of oral cavity, 1589 Lateral collateral ligament, 1853–1854 privacy, 2017–2018
frenulum lacerations in, 1589 Lateral compression fracture, 1838, 1838f protected health information, 2018–2019
mucosal lacerations of, 1589 Lateral condyle fractures, 910, 912f risk management in, 2022–2023
tongue lacerations in, 1589 Lateral femoral cutaneous nerve entrap, Legal name, 1998t
of palm, 296–297 1896–1897 Legal X (drug), 1247
of scalp, 285–292, 1689 Lateral luxation, 1587 Legg-Calvé-Perthes disease, 923–924
anatomy of, 285 Lateral mass fracture, 1700f Legionella pneumophila infections
repair of lacerations, 286 Lateral sinus thrombosis, 1564 in pneumonia, 440t, 441, 443–444
suture size based on location of, 274t Lateral ventral hernias, 532–535 in waterborne illnesses, 1068
of tendon, 1931 Latex allergy, 1099 Legs, compartments of, 1877f
of tongue, 1589 Laundry detergent pods, 1300 Leiomyomas, 608–609
upper arm, 294 Laurel, 1410–1412 Leishmaniasis, 1087
of volar forearm, 295–296 Laxatives, 494t cutaneous, 1091, 1658, 1658f
of wrist, 294–296 Le Fort fractures, 1720, 1721f, 1730f Lemierre’s syndrome, 1595
Lacosamide, 1288 Lead poisoning, 1312–1314. See also Poisoning LEMON airway assessment, 194t
in status epilepticus, 1158 chelation therapy in, 1312t Lenègre’s disease, 54
Lacrimators, 1396 clinical features of, 1313, 1313t Lepirudin, 1508
Lactase, secondary deficiency in, 851 diagnosis of, 1313–1314 Leptospira, 1071t
Lactate, 216 epidemiology of, 1312 Leptospirosis, 1077t, 1084
Lactate clearance, 998, 1002 lead lines in, 1313 treatment of, 1075t
Lactate dehydrogenase, 517 pathophysiology of, 1313 Lesbian patients
Lactated ringer’s, 62t pharmacology of, 1313 intimate partner violence in, 1974
Lactation treatment of, 1314 sexual abuse and assault of, 1971
abnormal, 659 Left ventricular assist devices, 382, 382f Lesbian patients, sexual assault of, 1971
complications of, 659–660 Left-hemisphere dominant, 1101 Leucovorin, 1036t
after imaging, 631 Leg Leukemia
medications in, 629–630, 630t Achilles tendon rupture in, 1861–1862 blood products in, 956–957
thyrotoxicosis and, 1456 anatomy of, 299, 1859, 1859t, 1860f in children, 956–957
Lactic acid, in shock, 58 bone, 1859 clinical features of, 956
Lactic acidosis, 74t, 216 common peroneal nerve of, 302f complications of, 956–957
Lactobacillus rhamnosus, 849 compartments of, 1859 diagnosis of, 956
Lactulose, 494t, 520 fractures of, 1859–1861 disseminated intravascular coagulation in,
Lacunar infarction, 1125 midshaft fibula, 1861 957, 1472t
Lai tai, 55 pilon, 1860–1861 epidemiology of, 956
Lambert-Eaton myasthenic syndrome, proximal fibula (Maisonneuve’s fracture), thrombocytopenia in, 956
1169 1861 treatment of, 956
Laminar fracture, 1703f stress, 1861 Leukemic infiltrates, in pulmonary infiltrates,
Lamivudine, 1042t, 1096t tibial shaft, 1859–1860, 1860t 448t
Lamotrigine, 1288 injuries of, 1859–1870 Leukocoria, 770–771, 771t, 959
in bipolar disorder, 1950t clinical features of, 1858 Leukocyte reaction by dipstick test, 581
in seizure disorders, 628 complications of, 1859 Leukocytosis, 957
Landiolol, 1454 diagnosis of, 1859 Leukopenia, 1912
Lantus, 622 treatment of, 1859 Leukoplakia, 1585
Laparoscopic adjustable gastric banding, lacerations, 299–307 Leukostasis, 957
480t knee, 303 Leukotrienes, 466
Laparoscopy physical examination of, 300–301 Levalbuterol, in asthma, 464t
complications of, 560–561, 561t, 663–664, pretibial, 303–305, 305t Levemir, 622
664t radiographs of, 302 Levetiracetam, 628, 1288
in ectopic pregnancy, 618 treatment of, 302–303 in seizures, 892
indications for, 663t major arteries of, 303f in status epilepticus, 1158
Laparotomy, 1754, 1754t medial gastrocnemius muscle strain in, Levobupivacaine, 236, 237t
Larkspur, 1410–1412 1862 Levofloxacin
Laryngeal Mask Airway, 177 muscles of, 301f in chlamydial infections, 1015t
Laryngectomy sensory distribution of, 302f in diverticulitis, 528t
complications of, 1603–1604 shin splints (exertional compartment in intra-abdominal infections, 480t
speech devices in, 1604–1605 syndrome) in, 1862 in pelvic inflammatory disease, 657t

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 Index   2077

in pneumonia, 444t flashover in, 1401 complications, 1992t

in urinary tract infections, 582t
Levomilnacipran, 1202
Levonorgestrel, 1970t
Levothyroxine, 1449–1450
Lev’s disease, 54
Lewisite, 41
Lewy body dementia, 1944
LGBTQ persons. See also Transgender patients
intimate partner violence in, 1974
sexual abuse and assault of, 1971
Lhermitte’s sign, 1881
Lice infestation, 938, 938f, 1617
Lichen planus, 1636t–1637t, 1641–1642,
1641f
Lichen simplex chronicus, 1658t, 1662–1663,
1663t, 1676f
Lichen tropicus, 1347
Lichtenberg figures, 1403, 1403f
Licorice, 1326t
Lidocaine, 236, 727
adverse effects of, 124
in cardiac arrest, 158–159
dosing and administration, 124t, 234t, 237t
in emergency delivery, 638t
indications for, 124
in neuropathic pain, 264t
pharmacokinetics of, 124t
in pregnancy, 168t
in rapid-sequence intubation, 186t
in resuscitation of children, 683t
in tachydysrhythmias, 101t
in urologic stone disease, 601
Life support, cardiac, 152–159
algorithms for, 154f, 159–162
asystole/pulseless electrical activity,
160–161, 161f
ventricular fibrillation/ventricular
tachycardia, 159–160, 161f
capnography in, 158
chain of survival in, 152, 153f
complications in, 158–159
differential diagnoses for cardiac arrest in,
158
drugs used in, 158–159
amiodarone, 159
atropine, 159
beta-blockers, 159
calcium, 159
epinephrine, 158
lidocaine, 158–159
lignocaine, 158–159
magnesium, 159
sodium bicarbonate, 159
vasopressin, 159
Primary ABCD Survey, 155–157, 155f
Secondary ABCD Survey, 157, 157t
vascular access, 157
Life-sustaining treatment, withdrawal of,
2006–2007
Ligaments, 1767
Lightning injuries, 1401–1403. See also
Electrical injuries; Environmental
injuries
auditory injuries in, 1403
cardiac effects in, 1402
cutaneous injuries in, 1403
diagnosis of, 1402–1403
electrical injuries, comparison with, 1401t
epidemiology of, 1401
musculoskeletal injuries in, 1403
neurologic injury in, 1402
ocular injuries in, 1402–1403
pathophysiology of, 1401–1402
scene care in, 1402
stunning (keraunoparalysis) in,
1401–1402
treatment of, 1402–1403
types of lightning strikes in, 1402
vascular effects in, 1402
Lignocaine, 158–159
Lily of the valley, 1412
Lime, 1394
Linamarin, 1320, 1413
Lincosamide, in pneumonia, 445t
Lindane, 937, 1653
Linear burns, 1403
Linezolid, 1328
in bacterial infections, 933t
in pneumonia, 445t
Lingual nerve block, 1592, 1593f
Lingual thyroid, 1585
Liothyronine, 1449–1450
Lipase, 510
Lipid emulsion, intravenous
in beta-blocker toxicity, 1274
in calcium channel blocker toxicity, 1279
in cyclic antidepressant toxicity, 1199
in resuscitation of poisoned patient,
1188t, 1189
Lips
electrical injuries of, 1400, 1401f
lacerations of, 290
Liquefaction necrosis, 1297
Liquid nicotine, 1265
Liquids, properties of, 35
Liraglutide, 1430
Lisfranc injury, 1872–1873, 1873f
Lisfranc joint, 1870
Lisinopril, 133t
Listeria monocytogenes infections, 1066t
in bacterial meningitis, 1172–1173
Lithium, 1212–1214
adverse effects of, 1213
in bipolar disorder, 1950t
clinical features of, 1951–1952
overdose and toxicity of, 1212–1214,
1213t
diagnosis of, 1212
treatment of, 1212, 1213t, 1215t
pharmacokinetics of, 1212
pharmacology of, 1212
in thyroid storm, 1455
toxicity of, 1281
Lithotripsy, 604
Liver
disorders of
cirrhosis, 519–520
coagulation disorders in, 1471–1472
Gilbert’s syndrome, 520
in heat emergencies, 1349
hepatic, 516–522
hepatic vein thrombosis, 521
hepatorenal syndrome, 520
nonalcoholic fatty liver disease, 521
in travel, 522
failure of, 518, 520
synthetic functions of, 516
transplantation of, 523
infections in, 1991
LMA®, 5t
Loa loa, 1091
Lobelia, 1326t
Local anesthesia, 236–238
in children, 727
general principles, 237–238
pharmacology, 236
systemic toxicity of, 236
Local arterial trauma, 421t
Locked knee, 1856–1857
Löffler’s syndrome, in pulmonary infiltrates,
448t
Long QT syndrome, 122
in children, 840–841
clinical features of, 122
diagnostic score of, 122t
electrocardiogram of, 122f
in sudden cardiac death, 55–56
syncope and, 363
treatment of, 122
Long-arm gutter splint, 1776, 1777f
Long-term memory, 1101
Loop diuretics, 371, 1281
Loperamide, 486t, 1236–1237
Lopinavir, 1043t, 1096t
Loratadine, 1622t
Lorazepam
in agitation, pediatric dosing of, 987t
in chemotherapy-induced vomiting,
1519t
in nausea and vomiting, 484t
in rapid-sequence intubation, 715t
in status epilepticus, 1153–1154
Losartan, 132, 133t, 1282
in hypertension, 407t, 408t
for hypertensive pediatric patients,
408t
Lotaustralin, 1320, 1413
Low molecular weight heparins, 347, 1507,
1507t
in deep venous thrombosis, 397t
in pulmonary embolism, 397t
Lower extremity
injuries of, 909–918
muscles, 1105t
Lower gastrointestinal bleeding, 498–500.
See also Gastrointestinal disorders;
Upper gastrointestinal bleeding
diagnosis of, 499
in diverticulosis, 498
endoscopy in, 500
epidemiology of, 498
history in, 499
imaging in, 499–500
in ischemic colitis, 498
laboratory testing in, 499
in Meckel’s diverticulum, 498–499
in mesenteric ischemia, 498
pathophysiology of, 498
physical examination, 499
surgery in, 500
treatment of, 500
in vascular ectasia, 498
Low-molecular-weight heparin, in
intracerebral hemorrhage, 1118t
Low-probability acute coronary syndrome,
357–362. See also Acute coronary
syndromes

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 2078   Index

Low-probability acute coronary syndrome tuberculosis, 451–457 in ankle injuries, 1864

(Cont.):
cardiac testing in, 360–361
CT coronary angiography, 361
echocardiography, 360–361
exercise treadmill, 360, 360t
MRI, 361
nuclear medicine imaging, 361
clinical features of, 357–358
comorbidities in, 357
diagnosis of, 357–360, 358f
cardiac markers in, 355–356
ED observation and testing, 362
pathways to, 362
primary evaluation in, 357–359
risk assessment in, 358–359, 358t–359t
secondary evaluation in, 359–360
serial marker approach in, 360
epidemiology of, 357
history in, 357
pathophysiology of, 357
physical examination in, 357
in special populations, 362
treatment of, 362
Loxosceles spiders, 1352–1353, 1352f–1353f
Lubiprostone, 494t
Ludwig’s angina, 797, 797f, 1581, 1598
Lumbar puncture, 1179–1180
anatomy in, 1180f
in bacterial meningitis, 1172
in children, 751–752
complications of, 1180
contraindications to, 1179t
in headache, 1109
needles for, 1180f
in seizures, 1155
in subarachnoid hemorrhage, 1115–1116
technique, 1179–1180
Lumbosacral plexopathy, 1162–1163
Lumbrical muscles, 1784
Lunate dislocation, 1799–1801, 1801f
Lunate fractures, 1802t
Lund University Cardiac Arrest System, 148
Lung
abscess in, 450–451. See also Pulmonary
emergencies
cavity lung lesions in, 450t
clinical features of, 450
diagnosis of, 450–451
pathophysiology of, 450
treatment of, 451, 451t
burst lung syndrome in, 1370
disorders of, 425–471
acute bronchitis, 436–439
asthma, 461–466
in children with special healthcare needs,
978
chronic obstructive pulmonary disease,
467–471
empyema, 449–450
hemoptysis, 432–436
in hydrocarbon toxicity, 1291–1292
from industrial toxins, 1317–1318,
1319t
lung abscess, 450–451
in natural disasters, 27
pneumonia, 439–449
respiratory distress, 425–432
in shock, 60t
in systemic rheumatic diseases, 1908
in volatile substance toxicity, 1291–1292
transplantation of, 1991–1993
complications of, 1992, 1992t
infections in, 1991–1993
Lung fluke disease, 1092
Lupus, 1914t
Lupus anticoagulant, 1477
Luxatio erecta, 1830, 1833f
Lychee fruit, 1413
Lyes, 1394–1395
Lyme disease, 1072–1073, 1645–1646
acute neuropathies of, 1161–1162
arthritis in, 1927
clinical features of, 1072t, 1073
diagnosis of, 1073
stages of, 1073
treatment of, 1073, 1073t
Lymphadenopathy, 785–787
bilateral, 785
subacute/chronic, 786–787
suppurative, 785f
unilateral, 785–786
Lymphangiomas, 788
Lymphatic filariasis, 1091
Lymphocytes, 1034
Lymphocytic interstitial pneumonia, 1039
Lymphogranuloma venereum, 1021–1022
clinical features of, 1018t, 1021–1022,
1021f–1022f
diagnosis of, 1022
treatment of, 1016t, 1022
Lymphoma, 789
disseminated intravascular coagulation in,
1472t
Lysergic acid diethylamide, 402, 1243, 1244t
M travel-related, 1081
Ma huang, 519t
Macacine herpesvirus infections, 324
Mace (riot control agent), 40
Macintosh blade, 182, 183f
Macrocytic anemia, 1462f
Macrolides, 325t, 1328
in pneumonia, 444t–445t
toxicity of, 1328
Macrophage activating syndrome, 923
Macrovascular hemolysis, 1494
Maculae caerulea, 1654
Macule, 1609f, 1609t
diagnosis of, 1615f, 1615t
Magnesium
in acute coronary syndrome, 348
in asthma, 807
in cardiac arrest, 159
in constipation, 494t
disorders of, 856
hypermagnesemia, 94, 856
hypomagnesemia, 93–94, 856
and fluids, 91–94
Magnesium sulfate, 131, 1112t
in anaphylaxis, 70t
for antipsychotics overdose, 1210
in asthma, 465
dosages of, 806t
in emergency delivery, 638t
in pregnancy, 168t
in tachydysrhythmias, 101t
Magnetic resonance angiography, 1109
Magnetic resonance imaging
in anorectal abscess, 545f
in appendicitis, 526
in back pain, 1885
of cervical spine, 1711
of cervical spine injuries, 708
in cholecystitis, 514
in ectopic pregnancy, 618
in epidural compression, 1887
in headache, 1109t
of headache in children, 901
in low-probability acute coronary
syndrome, 361
in pregnancy, 631
in soft tissue foreign bodies, 312
of thoracic great vessels, 1750
in venous thromboembolism, 395
of wounds, 268
Magnetic resonance imaging angiography,
1725
Maisonneuve’s fracture, 1861, 1863
Makkah cooling unit, 1348
Malaria, 1057–1063
clinical features of, 1059
diagnosis of, 1059–1060
disposition and follow-up in, 1062
drug therapy for, 1061t
epidemiology of, 1057
fever in, 1081
incubation period, 1057
parasite clearance rate in, 1062
pathophysiology of, 1057–1058
in pregnancy, 1062
prevention of, 1063
severe (complicated), 1059, 1062
thick blood film in, 1060, 1060f
thin blood film in, 1060, 1060f
treatment of, 1060–1062
uncomplicated, 1059, 1061
Male genital problems, 591–598
anatomy, 591–592
balanitis, 593
balanoposthitis, 593
epididymitis, 595
Fournier’s gangrene, 592–593, 592f
hematospermia, 598
orchitis, 597
paraphimosis, 593f
Peyronie’s disease, 594
phimosis, 593, 593f
physical examination of, 592
posthitis, 593
priapism, 594–595
prostatitis, 595–596
scrotal abscess, 592
Malignancy
airway obstruction in, 1513
clotting disorders in, 1476
emergency complications of, 1513–1521,
1513t
febrile neutropenia in, 1517–1518
hyperviscosity syndrome in, 1518
pericardial effusion with tamponade,
1514–1515
spinal cord compression, 1514, 1514t
Malignant hypertension, 1915
Malignant neoplasms, 789
Malignant otitis externa, 1426t
Mallampati Class III airways, 167

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 Index   2079

Mallampati criteria, 181, 181f special situations, 17 Media center, in disasters, 22

Mallet finger, 295, 295f, 1791f training, 15 Medial collateral ligament, 1853–1854
Mallory-Weiss syndrome, upper treatment facilities, 15 Medial epicondyle fractures, 913f
gastrointestinal bleeding in, 495 Massive hemothorax, 1733, 1733f Medial gastrocnemius, 1862
Malnutrition Massive transfusion, 66–68, 1496 Medial plica syndrome, 1900
in binge eating disorder, 1956 adjuncts, 67–68 Medial thigh/groin pain, 1897
in Crohn’s disease, 489t calcium in, 67 Median mononeuropathy, 1161–1162
Malrotation, 844, 858–859, 868 defined, 66 Median nerve block, 240–241
Mammalian meat allergy, 72 protocol, 67, 67f Medical clearance, 1933
Manchester Triage System, 1934 tranexamic acid in, 67 Medical examiner cases, 2006
Mandible, fractures of, 1731–1732 viscoelastic hemostatic assays, 68 Medical expulsion therapy, 602
Mania, in HIV infection, 1037 Mast cell modifiers, 466 Medical records
Manic-depressive disorder. See Bipolar Mast cell stabilizers, 1535t electronic, 4
disorder Mastalgia, 660–661 in emergency medical services, 2
Manipulative therapy, 1886 Masticator space infection, 1570 Medical screening, 2
Mannitol, 1142 antibiotics for, 1568t Medicare, 2
Mantoux test, 452–453 Mastitis, 660, 660f, 661t Medication overuse headaches, 259–260
Manual defibrillators, 149 nonpuerperal, 661t Medroxyprogesterone acetate, 610t
Maprotiline, 1194, 1195t periductal, 661t Mees lines, 1315
Marantic endocarditis, 1044 puerperal, 659–660, 661t Mefloquine, 1063t, 1328
Maraviroc, 1043t Mastodynia, 660–661 Melanoma, 1661, 1662f
Marboxil, 438t Mastoiditis, 761–762 Melatonin, 1220t, 1221
Marburg virus, 1085 clinical features of, 761–762 Melioidosis, 43t
Marcus-Gunn pupil, 1168, 1527, 1528f diagnosis of, 762 Melittin, 1350
Marijuana, 1244t, 1246 microbiology of, 751 Men
Marine envenomations, 1364–1368 in otitis media, 1563–1564 eating disorders in, 1959
bristleworms, 1367 pathophysiology of, 761 genital problems of, 591–598
cone snail injuries, 1365–1366 treatment of, 762 anatomy, 589–590
fire coral, 1367 Mature minor exception, 2017 balanitis, 593
fireworms, 1367 Mayapple, 1412–1413 balanoposthitis, 593
hydroids, 1367 McBurney’s point, 523 epididymitis, 596
jellyfish, 1367–1368, 1368f McMahon score, 572t Fournier’s gangrene, 592–593, 592f
octopus injuries, 1365, 1366f McRoberts maneuver, 642, 643f hematospermia, 598
sea snakes, 1364–1365 Mean arterial pressure (MAP), 212 orchitis, 597
sea urchins, 1366, 1366f Measles, 785, 926–927, 928f, 1030–1031 paraphimosis, 593f
starfish, 1366 Mebendazole Peyronie’s disease, 594
stingrays, 1364 for pinworms, 654t phimosis, 593, 593f
treatment of, 1365t in trichomoniasis, 656t physical examination of, 592
venomous fish stings, 1364 Mechanical ventilation, 190–193. See also posthitis, 593
Marine trauma, 1362–1363. See also Trauma priapism, 594–595
Drowning; Environmental injuries in acute respiratory distress syndrome, prostatitis, 595–596
epidemiology of, 1362–1363 192, 193f scrotal abscess, 592
soft tissue infections in, 1363 in asthma, 466 sexual abuse and assault of, 1969–1971
Masculinizing hormones, 1999 cardiac output monitoring in, 215 Ménière’s syndrome, 1151
Masks, 1098 in chronic obstructive pulmonary disease, Meningismus, 1108
Mass casualty incident, 18 470 Meningitis
Mass casualty triage, 2013 hyperoxia, 191 antibiotics in, 755
cardiopulmonary resuscitation in, 2013 in hypoxemia, 192 bacterial, 1172–1175
individual casualty assessment, 2013 in hypoxia, 192 carcinomatous, 1113
three-tier prioritization in, 2013 in obstructed lung disease, 192, 192t cerebrospinal fluid in, 1173t
Mass gatherings, 13–18 positive end-expiratory pressure, 191, 192f in children, 747, 752–756
access to care, 16 pressured targeted, 191 clinical features of, 753–754
cardiac arrests in, 17 respiratory rate, 191 cochlear implant in, 756
command and control, 14 sedation of intubated patient in, 191–192 CSF leak in, 756
communication system, 16–17 settings, 190–191 diagnosis of, 754
continuous quality improvement in, 17 synchronous intermittent mandatory febrile seizure, 756
documentation, 17, 17t ventilation, 191 history in, 753
epidemiology, 13 in technology-dependent children, 979, laboratory testing in, 754–755
equipment, 15, 16t 979t pathophysiology of, 753
event negotiations, 14–15 in tracheostomy, 1602–1603 penetrating head trauma in, 756
event reconnaissance, 14–15 in trauma, 192 physical examination in, 754
force protection medical support, 14 ventilator care bundle, 192, 193f pretreatment with antibiotics in, 756
human resources, 15 volume targeted, 190 signs and symptoms of, 753–754
level of care, 15 Meckel’s diverticulitis, 529 treatment of, 755
liability, 17 Meckel’s diverticulum, 868 unvaccinated child in, 755–756
mass casualty incident, 18 lower gastrointestinal bleeding in, 498–499 ventriculoperitoneal shunt in, 755
medical action plan in, 13–17 Meclizine complications of, 755
patient encounter form, 18f in emergency contraception, 1969 cryptococcal, 1037
physician medical oversight, 14 in nausea and vomiting, 484t epidemiology of, 752–753
public health, 16, 16t in vertigo, 1152t fungal, 753

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 2080   Index
Meningitis (Cont.):
headache in, 1109–1110
pathophysiology of, 753
steroids in, 755
viral, 752, 1175
zoonotic, 1075
Meningococcemia, 1624t, 1628, 1628f
in children, 936–937
rashes in, 936–937
treatment of, 936–937
Meningoencephalitis, 752
Menopausal women, chest pain in, 330
Menstrual cycle, 607, 608f
Mental health disorders
in children, 982–988
aggression in, 987, 987t
altered mental status, 902–904
anxiety in, 988
causes of, 983t
child abuse and neglect in, 985
clinical assessment of, 983–984
depression in, 988
epidemiology of, 982–983
history in, 983
imaging in, 983
laboratory testing in, 983
non-suicidal self-injury in, 987
physical examination in, 983
psychosis in, 988, 988t
substance misuse and withdrawal in,
988
suicidal ideations and attempts in,
984t, 985–987, 985f, 985t, 986f
in elderly, 1940–1946
bipolar disorder, 1945–1946
delirium, 1941–1943
dementia, 1943–1944
depression, 1945
eating disorder, 1946
psychosis, 1946
schizophrenia, 1946
substance abuse, 1945
suicide, 1945
HEARTSMAP Structured Mental Health
Screening Tool, 984t
in natural disasters, 27
in transgender patients, 2000, 2000t
treatment of emancipated minors, 2017
Mental health services, in disasters, 23
Mental nerve block, 244–245, 245f
Meperidine, 948
dose of, 231, 232t
Mephedrone, 1239
Mepivacaine, 236, 237t
Meprobamate, 1219–1220, 1220t
Meralgia paresthesia, 1896–1897
Meralgia paresthetica, 1162
Mercury poisoning, 1316–1318
chelation therapy in, 1317t
diagnosis of, 1317
elemental mercury in, 1316–1317
epidemiology of, 1316
inorganic mercury in, 1316–1317
organic mercury in, 1317
pathophysiology of, 1316
pharmacology of, 1316
treatment of, 1317
Meropenem
in diverticulitis, 528t
in intra-abdominal infections, 480t
Tintinalli_Index_p2025-2116.indd 2080
in pneumonia, 445t hemodialysis for, 1231–1232
in urinary tract infections, 583t metabolic blockade in, 1231–1232,
Mersilene®, 273t 1231t
Mescaline, 1244–1245, 1244t osmolar gap in, 1230, 1230t
Mesenteric arterial occlusion, 478t treatment of, 1226t, 1231–1232
Mesenteric ischemia, 478t vitamin therapy for, 1232
lower gastrointestinal bleeding in, 498 structure of, 1222f
Mesenteric venous thrombosis, 478t Methaqualone, 1222
Metabolic acidosis, 74–77, 569, 969–970 Methemoglobin, 39, 1330, 1330f
anion gap, 76 Methemoglobinemia, 39, 1329–1332
bicarbonate therapy in, 76–77, 77t acquired, 1330–1331
causes of, 76 clinical features of, 1331
clinical approach to, 75 cyanide poisoning and, 1322
differential diagnosis of, 76 diagnosis of, 1331–1332
hyperchloremic, 76 drugs causing, 1330t
with large-volume normal saline hereditary, 1331
resuscitation, 76 pathophysiology of, 1329–1330
osmolal gap, 76 treatment of, 1332, 1332t
treatment of, 76–77 Methicillin-resistant Staphylococcus aureus
Metabolic alkalosis skin infections, 754, 1002, 1006t,
causes of, 77 1007
clinical approach to, 75 Methimazole, in thyroid storm, 1455
treatment of, 77 Methohexital, 252t, 256–257
Metabolic disorders Methotrexate, in ectopic pregnancy,
in children with special healthcare needs, 619–620, 619t
978 5-Methoxy-dimethyltryptamine, 1248
in methylxanthines, 1264 Methsuximide, 1287
in nonsteroidal anti-inflammatory drugs, Methyl salicylate, 235t
1261 4-Methylcyclohexane, 35
in shock, 60t Methyldopa, 633, 1281–1282
Metacarpal base fractures, 1793 Methylene blue
Metacarpal fractures, 1793 in resuscitation of poisoned patient, 1188t
Metacarpal head fractures, 1793 in treatment of methemoglobinemia, 39
Metacarpal neck fractures, 1793 Methylenedioxymethamphetamine, 1244t,
Metacarpal shaft fractures, 1793 1245
Metal and metalloid poisoning, 1312–1318 Methylenedioxypyrovalerone, 1239
arsenic in, 1314–1316 Methylergonovine, in emergency delivery,
bismuth, 1318t 638t, 653t
cadmium, 1318t Methylone, 1239
chromium, 1318t Methylphenidate, 1239
cobalt, 1318t Methylprednisolone, 1112t
copper, 1318t in anaphylaxis, 70t
lead in, 1312–1314 in asthma, 464t
mercury in, 1316–1318 dosages of, 806t
silver, 1318t in vertigo, 1152t
sources of, 1312t Methylxanthines, 466, 1262–1265
thallium, 1318t in asthma, 807
zinc, 1318t in chronic obstructive pulmonary
Metal burns, 1395 disease, 470
Metal fume fever, 1318 epidemiology of, 1262–1263
Metallic needles, removal of, 314–315, mechanisms of action of, 1264t
314f–315f pharmacokinetics of, 1263t
Metaphyseal fractures, 915 pharmacology of, 1263
in child abuse, 991, 992f toxicity of, 1260–1263
Metaphysis, 905 classification of, 1265t
Metastatic calcification, 575 clinical features of, 1263–1264
Metastatic disease, 789 clinical manifestations of, 1264t
Metatarsophalangeal fractures, 1875 treatment of, 1264–1265
Metformin, 570, 622, 1428–1429 Metoclopramide, 233t, 483, 622t, 628,
Methacrylic acid, 1394 901, 1519t
Methadone, 1235–1236, 1963 in emergency contraception, 1969
Methamphetamine, 1108 in hiccups, 428t
Methanol, 1227–1232 in nausea and vomiting, 484t
metabolism of, 1228f in vertigo, 1144, 1152t
pathophysiology of, 1228 Metoprolol, 126
poisoning, 1229–1232 actions of, 126
acidosis in, 1231 adverse effects of, 125t
anion gap in, 1230, 1230f in atrial fibrillation/flutter, 109, 109t–110t
clinical features of, 1229 in atrioventricular blocks, 101t
diagnosis of, 1229–1230 dosing and administration, 125t
FB:Cardiologia Siglo XXI
8/2/19 6:02 PM

in hypertension, 406
indications for, 125t
in myocardial infarction, 403t
in NSTEMI, 345t
in STEMI, 344t
in tachycardia, 102
in vertigo, 1152t
Metronidazole
in animal bites, 1915t
in bacterial vaginosis, 1015t
in balanoposthitis, 593
in diarrhea, 487t
in diverticulitis, 528t
in facial infections, 1568t
in intra-abdominal infections, 480t
in pelvic inflammatory disease, 657t
for sexual infection prophylaxis, 1970t
in Trichomonas infections, 1018
in trichomoniasis, 1016t
Metropolitan Medical Response System,
21t
Miami J® collar, 6, 7f
Michaelis-Menten kinetics, 1263
Mickey Finn, 1220
Miconazole, 932t, 1037t, 1653t
in Candida vaginitis, 650t
Microangiopathic hemolytic anemia,
1492–1493
Microcytic anemia, 1463f
Microhyphema, 1548
Midazolam, 186, 252t, 254, 728t, 1519t
in pediatric seizures, 894
in rapid-sequence intubation, 715t
in refractory status epilepticus, 1158
in sedation, 729–731
in status epilepticus, 1158
Middle Class Tax Relief and Job Creation
Act of 2012, 4
Middle East respiratory syndrome
coronavirus, 1092
Middle phalanx fractures, 1793
Midfoot injuries, 1872–1873
Midshaft fibula fractures, 1861
Mifepristone, 1970t
Miglitol, 1430
Migraine
with aura, 897t
in children, 898
clinical features of, 1108t
headache in, 1111
in pregnancy, 627–628
probable, 897t
prophylaxis for, 902t
treatment of, 1112t
vestibular, 1151, 1152t
vs. seizures, 1155
without aura, 897t
Milch technique, 1829, 1830f
Mild traumatic brain injury (mTBI),
1692–1695
biomarkers for, 1694
diagnosis of, 1694
electroencephalogram of, 1695
neuroimaging in, 1695
pathophysiology of, 1693
physical examination in, 1694
recurrent, 1695
second impact syndrome in, 1695
signs and symptoms of, 1694t
treatment of, 1695
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2081
Miliaria crystallina, 1650
Miliaria rubra, 1347, 1650
Miliary tuberculosis, 456
Military antishock trousers, 1769
Military medicine, 2007–2014
airway management in, 2009
amputation in, 2012–2013
care under fire in, 2007–2009
circulation management in, 2009–2010
equipment in, 2007, 2008t
hemorrhage in, 2009
mass casualty triage in, 2013
respiratory/breathing in, 2009
roles of, 2007t
secondary survey in, 2011–2012
specific injuries in, 2012–2013
abdominal trauma, 2012
blast injuries, 2012
burns, 2012
cervical spine injuries, 2012
tactical combat casualty care in,
2007–2014
tactical field care in, 2009
tourniquet in, 2008
trauma pack in, 2008t
Milk protein allergy, 867
Milkweed, 1412
Miller-Fisher syndrome, 1160
Milrinone, 828
actions of, 137
adverse effects of, 137
in cardiogenic shock, 356, 356t
cardiovascular effects of, 134t
contraindications, 134t
dosing and administration, 134t
indications for, 137
pharmacokinetics of, 137t
in pulmonary hypertension, 411t
Mineralocorticoids, 1281, 1457, 1458
Mini-Cog Screening Test, 1944, 1944f
Minnesota tube, 497
Minocycline, 1568t
Minoxidil, 1283
in hypertension, 408t
for hypertensive pediatric patients, 408t
Minute ventilation, 78
Mirtazapine, 1200, 1948–1949
Misoprostol, 507
in emergency delivery, 638t, 653t
Missed abortion, 620t
Mistletoe, 519t
Mitoxantrone, 1169
Mitragyna speciosa, 1236
Mitral regurgitation, 374–376
acute, 375
clinical features of, 375
diagnosis of, 375–376
epidemiology of, 374–375
treatment of, 375–376
Mitral regurgitation, acute, 353
Mitral stenosis, 374
clinical features of, 374
diagnosis of, 374
epidemiology of, 374
new murmurs in, 375f
pathophysiology of, 374
treatment of, 374
Mitral valve prolapse, 376–377, 838, 1043
bedside interventions in, 383t
chest pain in, 332
Index   2081
clinical features of, 376–377
diagnosis of, 377
epidemiology of, 376
in mitral regurgitation, 375
pathophysiology of, 376
treatment of, 377
Mittelschmerz, 613
Mixed acid-base disorder, 75
Moclobemide, 1205t
Modified Hippocratic technique, 1828, 1828f
Modified Valsalva maneuver, 102t
Moexipril, 1282
Mole, definition of, 82t
Molecular Adsorbent Recirculation System,
1408–1409
Molluscum bodies, 1619f
Molluscum contagiosum, 1024, 1650, 1650f
Mondor’s disease, 661–662
Monge’s disease, 1383
Monkshood, 1410–1412
Monoamine oxidase inhibitors, 402,
1204–1208
in depression, 1949
dosage of, 1205t
drug interactions with, 1205–1206,
1206t
isoenzymes, 1204–1205
overdose and toxicity of, 1204
clinical features of, 1206
diagnosis of, 1206–1207, 1207t
dysrhythmias in, 1207
hypertension in, 1207
hyperthermia in, 1207
hypotension in, 1207
seizures in, 1207
pharmacokinetics of, 1205
pharmacology of, 1204–1206
serotonin syndrome in, 1206
tyramine reaction in, 1208
Monobactam, in pneumonia, 445t
Monoclonal antibodies, 1519–1520, 1520t
Monocryl®, 274t
Monocular diplopia, 1527, 1527f
Mononeuropathies, 1426t
Mononucleosis, 751, 785, 785f
Monsel solution, 667
Monteggia fracture-dislocations, 1820–1821
Monteggia fractures, 910, 913f, 915
Mood, 705
Mood disorders
bipolar disorder, 1949–1951
depression, 1946–1949
Moraxella catarrhalis infections, 436
in pneumonia, 440t, 441
Morbilliform exanthem, 1646
Morgue facilities, 23
Moricizine, 56
Morning glory seeds, 1248
Morphine, 1232
in acute pediatric pain, 725
dose of, 232t
in heart failure, 372
in rapid-sequence intubation, 715t
in STEMI, 344t
in vaso-occlusive crisis, 947t, 948
Morton’s neuroma, 1931
Mosquitoes, 1356
Moths, 1357
Motor ataxia, 1143
Motor examination, 1103–1105
8/2/19 6:02 PM
 2082   Index
Mountain sickness, 1378–1381. See also
High-altitude disorders
chronic, 1383
clinical features of, 1379
medical therapy in, 1379–1380
oxygen in, 1379
pathophysiology of, 1378–1379
preacclimatization in, 1391
prevention of, 1380–1381
self-questionnaire in, 1378t
treatment of, 1379–1380, 1379t
Mouth, 1579–1594
aphthous stomatitis, 1584, 1584f
cancer of, 1585
electrical injuries of, 1400, 1401f
erythroplakia in, 1585
frenulum lacerations in, 1589
gingival abscess of, 1583
gingivitis of, 1583
herpes zoster infection of, 1583
leukoplakia in, 1585
medication-related abnormalities of,
1584–1585
mucosal lacerations of, 1589
neurogenic and neurophysiologic
syndromes of, 1583
odontogenic pain in, 1580–1581
peri-implantitis of, 1584
periodontal abscess of, 1583
periodontal disease of, 1583
soft tissue lesions of, 1584–1585
soft tissue trauma of, 1589
teeth in. See Teeth
tongue lacerations in, 1589
tongue lesions in, 1585
ulcers of, 1584
Mouth-to-mask ventilation, 147, 147f
Mouth-to-mouth ventilation, 146, 146f
in children, 682
Mouth-to-nose ventilation, 146
Mouth-to-stoma or tracheotomy
ventilation, 146
Movement disorders, 1155
Moxifloxacin
in animal bites, 1915t
in pneumonia, 444t–445t
Mucocele, 776
Mucosal prolapse, 561
Mucous membrane exposure, 1093
Multidrug-resistant tuberculosis, 456
Multifocal atrial tachycardia, 110, 111f,
111t
Multiorgan failure syndrome, 1487
Multiple sclerosis, 1168–1169
clinical features of, 1168
diagnosis of, 1168
disposition in, 1169
pathophysiology of, 1168
treatment of, 1168
vertigo in, 1153
Mumps, 1568–1569
Munchausen syndrome by proxy, 994–995
Mu-opioid receptor, 229, 494t
Mupirocin, 933t, 1630t
Mural thrombus, 420
Murmurs
in congenital heart disease, 817, 821t
in endocarditis, 1045
grading system for, 375t
in valvular heart disorders, 373, 375t
Tintinalli_Index_p2025-2116.indd 2082
Muscarin, 1407
Muscarinic receptors, 1310t
Muscle relaxants
in back pain, 1886
in tetanus, 1050
Muscles
electrical injuries of, 1398–1399
of eye, 1527f
innervation, 1105t
lightning injuries of, 1403
stretch reflexes, 1105
Musculoskeletal disorders, 1881–1931
back pain, 1884–1888
bursitis, 1927–1928
in children, 921–925
avascular necrosis, 923
Legg-Calvé-Perthes disease, 923–924
Osgood-Schlatter disease, 924
poststreptococcal reactive arthritis, 925
rheumatic fever, 924–925
septic arthritis in, 921–922
transient synovitis of the hip, 922–923
in children with special healthcare needs,
979
hip pain, 1894–1905
joint pains, 1920–1927
knee pain, 1894–1905
neck pain, 1881–1883
nontraumatic hand disorders in,
1914–1919
shoulder pain, 1888–1894
soft tissue problems of foot, 1929–1931
systemic rheumatic diseases in,
1905–1914
Mushroom poisoning, 519, 1404–1409.
See also Poisoning
clinical features of, 1404, 1407, 1409
epidemiology of, 1404
pathophysiology of, 1404, 1406–1407, 1409
shiitake dermatitis in, 1409
signs and symptoms of, 1405t
delayed onset, 1409
disulfiram reaction, 1409
early-onset, 1406–1407
gastrointestinal, 1407–1409
muscarinic, 1407
neurologic, 1406–1407
renal failure, 1409
toxicity of, 1405t
treatment of, 1404–1406, 1405t, 1407, 1409
Mustard agents, 41
Myasthenia gravis, 1165–1168
clinical features of, 1169–1170
diagnosis of, 1170
drugs to avoid in, 1166t
edrophonium testing in, 1167f, 1167t
pathophysiology of, 1165–1166
TRAP symptoms, 1169–1170
treatment of, 1166–1167
Mycobacterial lymphadenitis, 786–787
Mycobacterium avium infections, 1035, 1036t
Mycobacterium fortuitum, 447
Mycobacterium marinum infections, 1070t
Mycobacterium tuberculosis infections, 444,
451, 453, 812t, 1035
in bacterial meningitis, 1172–1173
drugs for, 1036t
in lymphadenopathy, 786–787
pelvic inflammatory disease in, 654
in pneumonia, 811
FB:Cardiologia Siglo XXI
in type II diabetes, 1426t
in waterborne illnesses, 1068
Mycobacterium ulcerans infections, 1657
Mycoplasma pneumoniae infections, 436
in hemolytic anemia, 1491
in pneumonia, 440t, 441, 812t
Mydriatic-cycloplegic drugs, 1534t
Myelitis, transverse, 1887, 1910
Myocardial infarction, 1747
in hypertension, 400t, 402, 403t
signs and symptoms of, 340f, 341f, 400t
in stroke, 1136
Myocardial ischemia, 478t
Myocarditis, 381–383
causes of, 381t
clinical features of, 383, 830
diagnosis of, 383, 830
pathophysiology of, 381
treatment of, 383, 830
Myoclonic seizures, 889
Myofascial pain syndrome, cervical, 1883
Myofascial syndromes, hip, 1899
Myoglobin, 330
in acute kidney failure, 566
in rhabdomyolysis, 571
Myoglobinuria, 567, 571, 1400
Myopathies
inflammatory, 1164
statin-related, 570
Myopericarditis, 383
Myositis ossificans, 1905, 1905f
Myristicin, 1247t, 1248
Myxedema crisis, 1447–1450
clinical features of, 1447–1448
disposition and follow-up in, 1450
supportive management of, 1450
thyroid hormone replacement in,
1449–1450
treatment of, 1449–1450, 1449t
N
N,N-diethyl-3-methylbenzamide, 1305
Nafcillin, 933t
in facial infections, 1568t
Nail bed injuries, 298, 298f
Nalbuphine, 233t, 1235
Nalmefene, 1235
Naloxegol, 494t
Naloxone, 257, 1234t, 1235, 1282, 1964, 1965t
in emergency delivery, 638t
in resuscitation of children, 683t
in resuscitation of poisoned patient, 1188t,
1189
Naltrexone, 1235, 1962–1963
Naproxen, 234t
Narcotic bowel syndrome, 261t, 262, 264t
Narcotics, 1232
Narrow-complex tachycardia, 100, 102
multifocal atrial tachycardia, 111t
treatment of, 103f
Nasal airway, in prehospital care, 5
Nasogastric aspiration, 551–552, 551t–552t
Nasogastric catheters, 475
Nasopharyngeal airway, 175
Nateglinide, 1430
National Association of EMS Physi­cians, 9–10
National Athletic Trainer’s Association, 7
National Disaster Medical System, 21t, 29
National Highway Traffic Safety
Administration, 1
8/2/19 6:02 PM

National Notifiable Diseases Surveillance
System, 21t
National Triage Scale, 1934
Natriuretic peptide
in end-stage renal disease, 574
in heart failure, 368
Natriuretic peptides
B-type, 333, 354, 426
in cardiogenic shock, 354
in chest pain, 333
in heart failure, 367–368
Natural disasters, 25–30. See also Disaster
situations
blizzards and snow disasters, 29
chronic medical conditions in, 27
earthquakes, 28
epidemiology of, 25–26
floods, 29
handling of bodies in, 27–28
hurricanes, 28
infectious diseases in, 27
loss of resources in, 26
mental health conditions in, 27
relief efforts in, 29–30
timing of disease presentation in, 26t
tornadoes, 28–29
trauma in, 26
tsunamis, 29
Nausea, 481–484. See also Gastrointestinal
disorders
ancillary testing in, 482
in chemotherapy, 1518–1519
clinical features, 481–482
differential diagnosis of, 483t
epidemiology of, 481
history, 481–482
imaging in, 482
laboratory testing in, 482
in palliative care, 2003
pathophysiology of, 481
physical examination in, 482, 483t
in pregnancy, 621
treatment of, 483, 484t
in urologic stone disease, 601
Navicular fractures, 1873–1874
Near card (Rosenbaum chart), 1525
Nec Loc®, 6
Neck
anatomy of, 1722, 1722f, 1722t
blunt neck injury in, 1726–1727
carotid and vertebral dissection in,
1726–1727, 1727t
examination of, 1108
fascial layers of, 1723f
headache and, 1108
infections of, 1594–1598
bacterial pharyngitis, 1595–1596
epiglottitis, 1596–1597, 1597f
odontogenic abscess, 1598
peritonsillar abscess, 1596
retropharyngeal abscess, 1597–1598,
1597f
tonsillitis, 1594–1596
viral pharyngitis, 1594–1595
masses, 782–789, 1598–1599, 1599t–1600t
acute bilateral lymphadenopathy, 785
clinical features of, 783, 783t
congenital, 787–788
epidemiology of, 782
in infants and children, 782–789
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2083
inflammatory, 783–785
neoplastic, 788–789
mechanical disorders of, 1882
pain in, 1881–1883. See also
Musculoskeletal disorders
clinical features of, 1881–1882
diagnosis of, 1882–1883
history in patients with, 1881
physical examination of, 1881–1882
risk factors for, 1881, 1882t
treatment of, 1889–1890
uncomplicated, 1883
penetrating injury in, 1725–1726
laryngotracheal injuries in, 1727–1728,
1728t
pharyngoesophageal injuries in, 1728
treatment of, 1725, 1726f
vascular injuries in, 1725
posttonsillectomy bleeding of, 1599
as source of shoulder pain, 1894
strangulation of, 1728
trauma of, 1722–1729
airway management in, 1722–1723,
1723t
breathing in, 1723
in children, 696f, 1729
circulation in, 1723–1724
diagnosis of, 1724
disability in, 1724
in massively bleeding patients, 1729
penetrating injury in, 1726f
radiography in, 1724, 1724t
vascular anatomy of, 203f
Necrosis
coagulation, 1297
liquefaction, 1297
warfarin-induced, 1476–1477
Necrotizing enterocolitis, 858, 868
Necrotizing fasciitis, 1598
imaging in, 1012t
laboratory testing in, 1012t
postoperative, 558
in type II diabetes, 1426t
Necrotizing soft tissue infections, 1010–1012
clinical features of, 1007t, 1011, 1011f
definition of, 1005
diagnosis of, 1011–1012, 1012t
hyperbaric oxygen therapy in, 140
organisms in, 1010
pathophysiology of, 1010–1011
treatment of, 1012
Needle compression, 1741f
Needle decompression, 1740–1741
Needle-cover technique, in fishhook removal,
315, 316f
Needle-stick injuries, in puncture wounds,
320
Nefazodone, 1200
Neglect of children, 989
history in, 989
imaging in, 989
laboratory testing in, 989
physical examination of, 989
treatment of, 989
types of, 989t
Negligence, 2023–2024
Neisseria gonorrhoeae infections, 1017–1018.
See also Gonorrhea
in epididymitis, 876
in flexor tenosynovitis, 1916
Index   2083
in gonococcal pharyngitis, 780
pelvic inflammatory disease in, 654
in urinary tract infections, 581–582
Neisseria meningitidis infections, 1085, 1628
in bacterial meningitis, 752, 1172–1174
in children, 752
in meningococcemia, 936–937
in shunts, 1183
Nelfinavir, 1042t
Neonatal seizures, 895
Neonates, 669, 731–744
abdominal catastrophe in, 735
abdominal distention in, 737
abnormal movements and seizures in, 739
air leak syndromes in, 735
airway management in, 714–719
anatomic airway lesions, 735
apnea in, 736
blood in the diaper of, 737
breathing patterns in, 732
bronchiolitis in, 734
cardiac physiology of, 820
colic in, 735
congenital adrenal hyperplasia in, 735
congenital diaphragmatic hernia in, 678
congenital heart disease in, 733
constipation in, 737–738
cough and nasal congestion in, 735–736
critically ill, 732–735, 732t
crying in, 732, 732t
cyanosis in, 676–677, 677t
dehydration in, 737
diarrhea in, 737
eye complaints in, 739
feeding difficulties in, 736
feeding patterns in, 732
fever in, 748–751
gastroesophageal reflux in, 736–737
gastrointestinal bleeding in, 867–868
gastrointestinal concerns in, 736–738
gastroschisis in, 678
history in, 674
hypoglycemia in, 672
hypothermia in, 672
inborn errors of metabolism in, 735
intracranial hemorrhage in, 735
irritability in, 735
jaundice in, 738–739, 738t
left at ED, 2023
meningitis in, 752–756
neuromuscular disorders in, 735
noisy breathing in, 736
omphalocele in, 678
pathophysiology of, 674
physical examination of, 674
pneumonia in, 734, 734t, 811
antibiotics for, 815–816
pneumothorax in, 677–678
positive-pressure ventilation in, 675–676
rashes in, 938–941
red eye in, 739
regurgitation in, 736–737
resuscitation of, 673–679
epidemiology of, 673–674
equipment, 674, 674t
steps in, 675–676, 675t
withholding and discontinuing, 676
routine care of, 675
sepsis in, 733, 733t
sleeping patterns of, 732
8/2/19 6:02 PM
 2084   Index
Neonates (Cont.):
stool patterns in, 722t, 732
stridor in, 736
sudden infant death syndrome in,
745–746
tracheoesophageal fistula in, 678–679
transportation of, 671–673
umbilical cord clamping in, 674
umbilical vein access in, 722
upper airway complaints in, 735–736
vascular access in, 676
vegetative functions in, 732
vomiting in, 737
watery eyes in, 728
weight gain in, 732
Neonicotinoids, 1304
Neoplasms, in HIV infection, 1035
Neostigmine, 1221
Nephritis, 563
Nephroblastoma, 959, 959f
Nephrolithiasis, 563, 598–602
in children, 602
clinical features in, 598
in Crohn’s disease, 489t
diagnosis of, 599–600
differential diagnosis of, 599
epidemiology of, 598
imaging in, 600–601
indications for admission in, 602t
laboratory testing in, 599–600, 600t
medical expulsion therapy in, 602
pathophysiology of, 598–599
in pregnancy, 602
risk factors for, 598t–599t
treatment of, 601–602
Nephropathy
crystal-induced, 563–564
pigment, 569
Nephrostomy, complications of, 604
Nephrotic syndrome, 882–883, 1477–1478
in children, 882–883
clinical features of, 882
complications of, 882
diagnosis of, 883
history in, 882
laboratory testing in, 883
pathophysiology of, 882
physical examination of, 882
Nereistoxin analogs, 1305
Nerve agents, 40
Nerve entrapment, 1896t
deep peroneal, 1930
regional nerve entrapment syndromes,
1896–1897
tarsal tunnel syndrome, 1930
Nesiritide
in hypertension, 402
in hypertensive pulmonary edema, 403t
Netupitant, 1519t
Neural tube defects, 981–982, 981t
Neuralgia
craniofacial, 1584
occipital, 1111
postherpetic, 255, 264t
trigeminal, 264t, 1584
Neuraminidase inhibitors, 438, 438t, 1025
Neuroblastoma, 789, 958–959
Neurocardiogenic syncope, 835, 837
Neurocognitive disorders, HIV-associated,
1035
Tintinalli_Index_p2025-2116.indd 2084
Neurocysticercosis, 1156
Neurofibromas, 789
Neurogenic claudication, 1887
Neurogenic orthostatic hypotension, 363
Neurogenic shock, 1710
Neurokinin-1 receptor antagonists, 1519t
Neuroleptic malignant syndrome, 1211–1212,
1211t, 1955
Neuroleptics, 1144
Neurologic assessment, 163
Neurologic disorders, 1101–1182
amyotrophic lateral sclerosis in, 1165
ataxia in, 1142–1145
Bell’s palsy, 1160–1161
botulism in, 1163
brachial plexopathy in, 1162–1163
carpal tunnel syndrome in, 1161–1162
of central nervous system, 1172–1176
of cerebellum, 1106
cervical plexopathy in, 1163
chronic, 1165–1171
cocaine in, 1239–1240
coma, 1140–1142
cubital tunnel syndrome in, 1162
cytomegalovirus radiculitis in, 1164
deep peroneal nerve entrapment in, 1162
delirium, 1137–1138
dementia, 1138–1140
diabetic peripheral neuropathy in, 1164
in endocarditis, 1045
examination of, 1101–1106
advanced, 1102
basic, 1102
of cerebellum, 1106
of cranial nerves, 1102–1103
of gait and station, 1106
of higher cerebral functions, 1101–1102
mental status testing, 1101
of motor function, 1103–1105
organizational framework, 1101
of reflexes, 1105–1106, 1106f
of sensory function, 1103
in fractures, 1781
Guillain-Barré syndrome in, 1160
Guyon’s canal syndrome in, 1162
headache in, 1107–1114
in high-altitude disorders, 1383
in HIV infection, 1035–1037
in human immunodeficiency virus
infection, 1164
in hypertension, 401–404
inflammatory myopathies in, 1164
in injection drug users, 1981
intracerebral hemorrhage in, 1117–1118
Lambert-Eaton myasthenic syndrome, 1169
in lightning injuries, 1402
localizing peripheral nerve lesions in,
1159–1160
lumbosacral plexopathy in, 1163
meralgia paresthetica in, 1162
in methylxanthines, 1263
multiple sclerosis in, 1168
myasthenia gravis in, 1165–1168
neuromuscular junction disorders in,
1163–1164
Parkinson’s disease, 1169–1170
peripheral, 1159–1164
plexopathies in, 1162–1163
poliomyelitis in, 1170–1171
Ramsey Hunt syndrome in, 1161
FB:Cardiologia Siglo XXI
seizures in, 1153–1159
stroke, 1119–1136
subarachnoid hemorrhage in, 1114–1117
syncope in, 364
in systemic rheumatic diseases, 1910
ulnar mononeuropathy in, 1162
vertigo, 1145–1153
Neurologic syncope, 364
Neuromuscular blockade, in tetanus, 1050
Neuromuscular blocking agents
in myasthenia gravis, 1166t
in rapid-sequence intubation, 186–187
Neuromuscular disorders, in neonates, 735
Neuromuscular junction disorders,
1163–1164
Neuropathic ulcers, 1656–1657, 1657f
Neuropathy
diabetic, 1425
diabetic peripheral, 1160
hyperglycemic, 1160
in organophosphate poisoning, 1300
peripheral, 573, 1160-1161
Neurovascular injuries, assessment of,
1770–1771
Neurovascular syndromes, 49
Neutral protamine Hagedorn, 622
Neutrons, 48, 48t
Neutropenia, 955, 961, 999, 1002–1004
Neutropenic enterocolitis, 961
Neutropenic fever, 962t
Neutrophil, 517
Nevirapine, 1042t
New left bundle-branch block, 350
New right bundle-branch block, 350
Niacin, 1323t, 1324–1325
Nicardipine, 130, 887t, 1276t
actions of, 130
in acute ischemic stroke, 404t
in acute renal failure, 402, 403t
adverse effects of, 130
in aortic dissection, 403t, 415
dosing and administration, 130
in hypertension, 402, 405t, 406, 407t
in hypertensive encephalopathy, 403t
for hypertensive pediatric patients, 407t
in hypertensive pulmonary edema, 403t
indications for, 130
in intracerebral hemorrhage, 404t
in ischemic stroke, 1128t
pharmacokinetics of, 131t
in subarachnoid hemorrhage, 403t
in sympathetic crisis, 403t
Nicotine, 1262, 1265–1266
epidemiology of, 1265
liquid, 1265
pharmacology of, 1265–1266
toxicity of
clinical features of, 1266
diagnosis of, 1266
treatment of, 1265, 1265t
Nicotinic acid, 1324
Nicotinic toxins, 1410, 1411t
Nifedipine, 133t, 886t, 1276t
in hiccups, 428t
in high-altitude disorders, 1380t
in hypertension, 406, 407t
in preeclampsia and eclampsia, 632, 633t
in urologic stone disease, 602
Nightshade, 1412
Nightstick fracture, 1820
8/2/19 6:02 PM

Nikolsky sign, 1626
Nimodipine, 1276t
in vertigo, 1152t
9–1–1, 1
Nipple
discharge, 661, 662t
irritation, 659, 662
Nisoldipine, 1276t
Nitrates, 348
in methemoglobinemia, 1330t
Nitric acid, 1394
Nitrite reaction by dipstick test, 581
Nitrites, 39, 1322
in methemoglobinemia, 1330t
Nitrofurantoin, in urinary tract infections,
581, 582t
Nitrogen dioxide, 1319t, 1320
Nitrogen narcosis, 1373
Nitrogen oxides, 1320
Nitroglycerin
in aortic dissection, 415
in heart failure, 370–371
in hypertension, 402, 405t, 406
in hypertensive pulmonary edema, 403t
in myocardial infarction, 403t
in NSTEMI, 345t
in STEMI, 344t
in subarachnoid hemorrhage, 1116
in sympathetic crisis, 403t
Nitroprusside, 636, 887t
in acute ischemic stroke, 404t
in aortic dissection, 403t, 415
in diabetic ketoacidosis, 1436
in heart failure, 370–371, 372t
in hypertension, 405t, 406, 407t
for hypertensive pediatric patients, 407t
in resuscitation of children, 683t
in subarachnoid hemorrhage, 1116
Nitrous oxide, 234, 252t, 255–257, 728t
in sedation, 731
Nizatidine, in peptic ulcer disease, 507
Nocturnal asthma, 1091
Nodules
diagnosis of, 1616f, 1616t
in skin lesions, 1611f, 1611t
Nonabsorbable sutures, 273, 273t
Nonalcoholic fatty liver disease, 521
Nonbenzodiazepine sedatives, 1219–1222,
1220t
buspirone, 1219, 1220t
carisoprodol, 1219–1220, 1220t
chloral hydrate, 1220, 1220t
eszopiclone, 1220t
ethchlorvynol, 1221–1222
gamma-hydroxybutyrate, 1220–1221
glutethimide, 1222
melatonin, 1220t, 1221
meprobamate, 1219–1220, 1220t
methaqualone, 1222
overdose and toxicity of, 1219–1222, 1220t
ramelteon, 1220t, 1221
tasimelteon, 1220t, 1221
zaleplon, 1220t, 1221
zolpidem, 1220t, 1221
zopiclone, 1220t, 1221
Nondepolarizing agents, in rapid-sequence
intubation, 186–187
Nongonococcal urethritis, 1018
Non-Hodgkin’s lymphoma, 958
Noni juice, 519t
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2085
Noninvasive airways, 173–179
Noninvasive positive-pressure ventilation,
175–177, 466
advantages and disadvantages of, 176t
applications, 177
complications, 177
initiating and titrating, 176–177
prehospital, 177
Noninvasive ventilation
in asthma, 807
in children, 712, 712f
in chronic obstructive pulmonary disease,
470, 470t
positive-pressure, 807
Nonischemic priapism, 594
Nonketotic hyperglycemic coma. See
Hyperosmolar hyperglycemic state
Nonnucleoside reverse transcriptase
inhibitors, 1042t
Nonopioid agents, 233
Nonseptic bursitis, 1928–1929
Nonsteroidal anti-inflammatory drugs,
233, 263, 264t, 610t, 1259–1262
in abnormal uterine bleeding, 611
in acute kidney injury, 564–566
in back pain, 1886
cyclooxygenase inhibitors, 1259
in disk herniation, 1886
drug interactions with, 1260
antihypertensive agents in, 1260
aspirin in, 1260
warfarin in, 1260
in eye disorders, 1535t
for headache in children, 901
in heart failure, 371–372
in hemolytic anemia, 1492t
in impingement syndrome, 1890
in neck pain, 1883
in peptic ulcer disease, 506–508
pharmacokinetics of, 1259–1260
pharmacology of, 1259–1260
topical, 1260
toxicity of, 1260–1262
acute overdose in, 1258t, 1261
clinical features of, 1257–1259
at therapeutic doses, 1260–1261
treatment of, 1261–1262, 1262f
in urologic stone disease, 600
Norepinephrine, 135
actions of, 135
adverse effects of, 135
for antipsychotics overdose, 1210
in cardiogenic shock, 356, 356t
cardiovascular effects of, 134t
contraindications, 134t
dosing and administration, 134t
indications for, 135
pharmacokinetics of, 136t
in pregnancy, 168t
in pulmonary hypertension, 411t
in resuscitation of children, 683t
in sepsis, 1002
in shock, 61t
Normocytic anemia, 1463f
Normotensive heart failure, 371–372
Norovirus, 1067t
Nortriptyline, 234t, 1194, 1195t
Nose
anatomy of, 288–289, 289f
epistaxis of, 1572–1575
Index   2085
foreign bodies in, 774–775, 1578
fractures of, 1575–1577
anatomy in, 1575–1576, 1575f
clinical features of, 1576
diagnosis of, 1576–1577
examination of, 1576
imaging of, 1576–1577
treatment of, 1577
hematoma of, 1577, 1578f
drainage of, 1577
rhinosinusitis in, 1578–1579
sinusitis in, 1578–1579
Novafil®, 273t
Nuclear medicine imaging, 361
Nucleic acid amplification test (NAAT),
454, 1014
Nucleoside reverse transcriptase inhibitors,
1042t
Nursemaid’s elbow, 911–914
Nursing home patients, pneumonia in,
443
Nutmeg, 1248, 1326t
Nutritional ketosis, 1442–1443
Nystagmus, 1106, 1149
Nystatin
in balanoposthitis, 593
in Candida vaginitis, 650t
in HIV-related infections, 1036t
O
Obesity, 1994–1997
airway management in, 1996–1997,
1997f
epidemiology of, 1994
hyperventilation syndrome in, 1995t
imaging in, 1995–1996, 1996f
medication dosing in, 1995
pathophysiology of, 1994–1995
sedation and, 256, 256t
sedation in, 1996
sphygmomanometry in, 1995
trauma in, 1997
vascular access in, 1995, 1996f
weight estimation in, 1995
Obesity hypoventilation syndrome, 77
Obstetric and gynecologic disorders,
607–667
abdominal and pelvic pain in nonpregnant
female, 612–615
abnormal uterine bleeding, 607–612
breast disorders, 658–662
complications of gynecologic procedures,
663–667
ectopic pregnancy, 615–622
gestational trophoblastic disease, 621
maternal emergencies after 20 weeks of
pregnancy, 631–636
pelvic inflammatory disease, 654–658
spontaneous abortion, 620–621
vulvovaginitis, 647–654
Obstruction airway (Heimlich) maneuver,
147–148
Obstructive lung disease, 192, 192t
Obstructive shock, 58
Obturator
hernia, 536f
nerve entrapment, 1896–1897
test, 523
Occipital condyle fractures, 1703f
Occipital neuralgia, headache in, 1111
8/2/19 6:02 PM
 2086   Index
Occult hip fractures, 1845
Occupational exposure, 1092–1099
assessment of healthcare works after,
1094t
common, 1097t
evaluation of sources of, 1094t
portals for, 1093
report, 1094t
standard precautions in, 1096–1098
testing for, 1094
Octopus injuries, 1365, 1366f
Octreotide, 497, 869, 1432
epidemiology of, 864
Octyl-cyanoacrylate, 282, 283t
Ocular burns, 1396
Ocular decontamination, 1191
Ocular hemorrhage, 1550–1552
Odontogenic abscess, 1598
Odontogenic pain, 1580–1583
cracked tooth syndrome, 1581
dental caries, 1581
facial space infections, 1582
orthodontic appliances in, 1583
pericoronitis, 1580–1581
periradicular periodontitis, 1581–1582
postextraction alveolar osteitis (dry socket),
1582
postextraction bleeding, 1582–1583
postextraction pain, 1582
postrestorative pain, 1583
pulpitis, 1581
tooth eruption, 1580–1581
Odontoid (dens) fractures, 1704f
Office of Emergency Response, 21t
Ofloxacin, 1015t
Ogilvie’s syndrome, 495
Olanzapine, 1519t
in agitation, 1940t
pediatric dosing of, 987t
in bipolar disorder, 1950t
Oleander, 1412
Olecranon
bursitis, 1929
fractures, 1819
fractures of, 910, 913f
Oleoresin capsicum, 1396
Omnibus Budget Reconciliation Act
legislation of 1981, 3
Omnibus Budget Reconciliation Act of 1981, 1
Omphalocele, in children, 678
Onchocerca volvulus, 1091
Onchocerciasis, 1091
Ondansetron, 233t, 482, 622t, 1519t
in emergency contraception, 1969
in emergency delivery, 638t
in nausea and vomiting, 484t
in vertigo, 1144, 1152t
Ontario Lung Association Pediatric Asthma
Action Plan Pathway, 809f–810f
Ontario Lung Association Pediatric Asthma
Care Pathway, 805f
Open chest cardiac compressions, 144
Open fractures, 1768, 1870
Open pneumothorax, 1675, 1735
Open-book fracture, 1838, 1838f
Ophthalmia neonatorum, 767–768, 768t
bacterial, 768
chemical, 767
chlamydial, 768, 769f
gonococcal, 767–768, 768f
Tintinalli_Index_p2025-2116.indd 2086
Ophthalmic drugs, 1534t–1537t
Ophthalmoscope, 1529, 1529f
Opiate antagonists, in emergency delivery,
638t
Opiates, 1232
Opioid agonists-antagonists, 231–233
Opioid analgesics, 231
Opioid overdose, 145
Opioid receptors, 229
Opioids, 1232–1238
in abdominal pain, 236
in acute pediatric pain, 725, 726t
addiction and dependence, 235
antagonists, 1235
nalmefene, 1235
naloxone, 1233–1235
naltrexone, 1235
in back pain, 1886
characteristics of, 1233t
for chronic pain, 262, 263t
classification of, 1233t
in constipation, 494
dosage of, 235
drug interactions with, 235
equipotent doses, 232t
novel synthetic, 1236
overdose and toxicity of, 1233–1235
clinical features of, 1233–1234
diagnosis of, 1234
treatment of, 1234–1235
in palliative care, 2004
pharmacokinetics of, 1232–1233
pharmacology of, 1232
precautions, 235
in pregnancy, 629
respiratory deficiency and, 235
rigid chest syndrome and, 255
screens, 1234
in sedation, 255
synthetic, 255
toxidromes, 1190t
in urologic stone disease, 601
withdrawal syndromes, 1237–1238, 1237t
Opportunistic infections, 818
Optic nerve sheath measurement, 1558, 1560f
Optic neuritis, 1168, 1555
Optokinetic nystagmus, 1525–1526
Oragrafin, 1455
Oral airway, in prehospital care, 5
Oral cancer, 1585
Oral candidiasis, 1040, 1040f
Oral cavity, 1579–1594
aphthous stomatitis, 1584, 1584f
cancer of, 1585
in children, 775–782
erythroplakia in, 1585
frenulum lacerations in, 1589
gingival abscess of, 1583
gingivitis of, 1583
herpes zoster infection of, 1584
leukoplakia in, 1585
medication-related abnormalities of,
1584–1585
mucosal lacerations of, 1589
neurogenic and neurophysiologic
syndromes of, 1582
odontogenic pain in, 1580–1583
peri-implantitis of, 1584
periodontal abscess of, 1583
soft tissue lesions of, 1584
FB:Cardiologia Siglo XXI
soft tissue trauma of, 1589
teeth in. See Teeth
tongue lacerations in, 1589
tongue lesions in, 1585
ulcers of, 1584
Oral contraceptive pill, 610
Oral dysphagia, 742
Oral hydration, 847–848, 2011
Oral sucrose, 727
Orbital blow-out fractures, 1548–1549, 1549f
Orbital cellulitis, 766–767, 766f, 1533–1539,
1539t
Orbital compartment syndrome., 1550
Orbital hemorrhage, 1550–1552
Orbital septum, 1523
Orchitis, 597, 597t, 1912
Organ donation, 2006
Organic meat industry, 1298–1301
Organic spines, removal of, 315
Organochlorines, 1304
Organophosphate poisoning, 1298–1301.
See also Poisoning
chronic toxicity in, 1302
clinical features of, 1301–1302, 1301t
delayed neuropathy in, 1302
diagnosis of, 1302
herbicides in, 1307
intermediate syndrome, 1301–1302
pathophysiology of, 1298–1299
severity of, 1299t
treatment of, 1302–1303, 1302t
Organophosphates, 40
Ornithosis, 1077t
Orofacial pain, 1580–1583
differential diagnosis of, 1581t
odontogenic pain, 1580–1583
Orogastric lavage, 552, 1191–1192
Oropharyngeal airway, 174–175
Oropharyngeal dysphagia, 501t
Oropharyngeal trauma, 798
Orotracheal intubation, 181–185
complications of, 185
endotracheal tube location in,
183–185
equipment in, 182–185
patient positioning in, 182
preoxygenation in, 181
procedure in, 182–183
Sellick or cricoid maneuver in, 182
Orthopedic injuries, 1767–1780
ambulation in, 1780–1781
of ankle, 1862–1870
in children, 904–921
clinical features of, 1769–1771
compartment syndrome in, 1782,
1876–1879
complications of, 1781–1782
diagnosis of, 1771–1773
discharge instructions in, 1781
of elbow and forearms, 1809–1821
in elderly, 1679
in electrical injuries, 1398
evaluation and management of,
1767–1782
of foot, 1870–1876
of hand, 1782–1794
of hip, 1679, 1842–1850
of knees, 1850–1858
of leg, 1859–1870
neurologic deficit in, 1781
8/2/19 6:02 PM
 Index   2087

pathophysiology of, 1768–1769 Ovarian neoplasms, 614 disposition and, 236

of pelvis, 1836–1842 Ovarian torsion, 614–615, 628 evaluation of, 229–230
prehospital care in, 1769–1771 Overuse syndromes, 1899–1901 in hip, 1894–1905
of shoulder, 1821–1836 Oxacillin, 933t in knee, 1894–1905
splinting techniques for, 1784–1789 Oxalic acid, 1394 in neck, 1881–1883
treatment of, 1773–1774 Oxcarbazepine, 234t, 1288 nonpharmacologic treatment, 235–236
upper extremity, 1679 in neuropathic pain, 264t orofacial, 1580–1583
vascular injuries in, 1781–1782 Oxiconazole, 932t pathophysiology of, 229
of wrist, 1794–1809 Oximes, 1303 in peptic ulcer disease, 506
Orthopnea, 425 Oxycel®, 270 pharmacologic treatment for, 230–235
Orthostatic syncope, 363–364, 838 Oxycodone, 232t scales, 229–230, 230f, 230t
Orthotropic bladder substitution, 604 Oxygen in shoulder, 1888–1894
Osborn J waves, 1339 in chronic obstructive pulmonary disease, trauma, 236
Oscillometry, 212 468–469 Pain management
Oseltamivir, 438 in mountain sickness, 1379 acute pain treatment, 725
in HSV infection, 1025 in resuscitation of children, 682 in burns, 1390
in influenza, 438t toxicity in children, 723–727
Osgood-Schlatter disease, 924 in diving disorders, 1373–1374 analgesia in, 727
Osler-Weber disease, 433 in hyperbaric therapy, 141 anxiolysis in, 727, 728t
Osmolal gap, 76 Oxygenation assessment by age, 724
Osmolality, 82t, 1445–1446 in airway management, 174 local anesthesia, 727
Osmolar gap, 1230, 1230f, 1230t in anaphylaxis, 69 oral sucrose for infants, 727
Osmolarity, 82t apneic, 181 topical anesthetics, 727
Osmole, 82t in bronchiolitis, 801 after discharge, 726
Osmotic demyelination syndrome, 85 in cardiac resuscitation, 153–154 in fractures, 1773
Osteitis pubis, 1904–1905 central venous, 1002 in hepatitis, 523
Osteoarthritis, 1883, 1894, 1927 extracorporeal membrane, 356–357, in hip injuries, 1850
Osteochondritis dissecans, 1904 1344–1345 history of, 699t
Osteomyelitis, 1007t, 1425, 1883, 1903–1904, monitoring of, 215 in military medicine, 2011
1904t in post-ROSC complications, 162 in palliative care, 2003
in injection drug users, 1983 in pulmonary hypertension, 410–411 pharmacological treatment, 725–726
in puncture wounds, 319–320 in sepsis, 1002 physical interventions in, 725
in type II diabetes, 1425 in shock, 61–62 in postrepair wound care, 326
vertebral, 1887–1888 in traumatic shock, 65 in procedural pain, 726–727
Osteonecrosis, 190–193, 1903f Oxyhemoglobin psychological interventions in, 725
Osteophytic spurs, 1883 in cyanosis, 430 in urologic stone disease, 601
Osteoporosis of the hip, transient, 1904 dissociation curve, 80f Palliative care, 2000–2004
Osteosarcomas, 960–961, 961f Oxytocin, in emergency delivery, 638t, 653t agitation in, 2003
Ostomy, complications of, 555 code status in, 2003
Otalgia, 756, 1560t, 1561 P communication phrases, 2002t
Otitis, in bacterial infections, 1174 Pacemaker syndrome, 54, 220–221, 221t constipation in, 2003
Otitis externa, 761, 1426t Pacing, cardiac, 216–223 consultation in, 2003
acute diffuse, 1562–1563 asynchronous, 217 description of, 2002t
in children, 761 in beta-blocker toxicity, 1275 dyspnea, 2003
clinical features of, 761 equipment in, 216–217, 217t epidemiology of, 2001
diagnosis of, 761, 761t indications for, 217t, 350t ethical issues in, 2001t
malignant, 1563 permanent, 218–222 family meeting in, 2002
pain control in, 761 coding system in, 221t in functional decline, 2001
treatment of, 761, 1562, 1562t, 1563 complications in, 220–221 of hospice patients, 2004
Otitis media, 756–761, 1563–1564 malfunction of, 221, 222f hospice referrals in, 2003
antibiotics in, 758–759 nomenclature, 219–220 identification of patients for, 2001–2002
in children, 756–761 pacemaker syndrome in, 220–221 imminent death in, 2003
clinical features of, 757, 1563 programming errors in, 222 key findings, 2002t
complications of, 1563–1564 resuscitation in, 220 nausea in, 2003
diagnosis of, 757–758, 757t, 1563 tachycardia in, 221–222 opioid dosing in, 2003
with effusion, 759–761 purpose of, 216 pain control in, 2003
epidemiology of, 756–757 in sudden cardiac death, 54 patient decisional capacity in, 2002
intracranial complications in, 1564 temporary, 350t plan of care in, 2002–2003
lateral sinus thrombosis in, 1564 transcutaneous, 217 prognosis for, 2001–2003
mastoiditis in, 1563–1564 transvenous, 217–218 surrogate decision makers in, 2015
organism in, 1563 Packed red blood cells, 66, 1496, 2010–2011 symptom management in, 2003
pain control in, 758 Paget’s disease, 1904 treatment in, 2003
pathophysiology of, 757, 1563 Pain vomiting in, 2003
treatment of, 758–759, 759t, 760f, 1563 abdominal, 236 Palm, lacerations of, 296
Ototoxicity, 1152–1153 acute, 229–236 Palonosetron, 1519t
Ottawa Ankle Rules for Ankle and Midfoot in back, 1884–1888 Palpation, 212
Injuries, 1864f barriers to control of, 230t in abdominal pain, 474
Ottawa Knee Rules, 1852, 1852t in children, special needs children, 724 in fracture, 1770
Ovarian cysts, 613–614 chronic, 259–266 Pampiniform plexus, 875–876
Ovarian hyperstimulation syndrome, 614, 666 in decompression sickness, 1372 Pancoast’s tumor, 1894

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2087 8/2/19 6:02 PM

 2088   Index
Pancreatic injury, in children, 697
Pancreatitis, 508–512. See also Gastrointestinal
disorders
abdominal pain in, 478t, 863
causes of, 509t
chest pain in, 332
in children, 863
chronic, 513
clinical features of, 509
complications of, 510–511, 512t
in Crohn’s disease, 489t
diagnosis of, 509–510
disseminated intravascular coagulation in,
1472t
drugs associated with, 508–509, 509t
epidemiology of, 508
in gastrointestinal surgery complications,
559
history in, 509
imaging in, 510, 511f
laboratory testing in, 509–510
pathophysiology of, 509
physical examination in, 509
prediction of severity in, 510–511
treatment of, 510, 512t
Panic disorder, 332, 1951
Panniculitis, 1333
Pantoprazole, 870
Papaver somniferum, 1232
Papillary muscle rupture, 350
Papillary muscles, 1746–1747
Papillary necrosis, 563
Papilledema, 1108, 1529, 1530f
Papule, 1613f, 1613t
diagnosis of, 1615f, 1615t
Papulosquamous skin disorders, 1635–1640.
See also Skin disorders
atopic dermatitis, 1640–1641
comparison features of, 1636t
eczema, 1640–1641
lichen planus, 1641–1642, 1641f
pityriasis (tinea) versicolor, 1639–1640,
1640f
pityriasis rosea, 1637–1638, 1639f
psoriasis, 1635, 1638f
scabies, 1642–1643, 1643f–1644f
seborrheic dermatitis, 1635–1637, 1639f
secondary syphilis, 1642, 1642f
tinea corporis, 1638–1639, 1639f
treatment of, 1636t
Paracentesis, 553–554, 554f
Paradoxical embolism syndrome, 390
Paradoxical reaction, 454
Paragonimiasis, 1092
Paralytic agents, 186–187
Paraphimosis, 593, 593f, 876–877,
876f–877f
Paraquat, 1305
Parasitic helminth infections, 1089–1090,
1090t
Parasitic infections, in diarrhea, 851
Parathyroid hormone (PTH), 96
Parietal pain, 473
Parkinsonism, 1170
Parkinson’s disease, 1169–1170
clinical features of, 1166
diagnosis of, 1166
dopaminergic therapy in, 1170
drug-induced, 1170
pathophysiology of, 1169
Tintinalli_Index_p2025-2116.indd 2088
treatment of, 1170
tremor in, 1104
Parkinson’s syndrome, antipsychotic-induced,
1954–1955
Paromomycin, 487t
Paronychia, 1915t, 1916–1917, 1917f
Paroxysmal cold hemoglobinuria, 1491–1492
Paroxysmal nocturnal dyspnea, 425
Paroxysmal supraventricular tachycardia,
110–111, 111f, 111t, 624
Partial seizures, 889
Parulis, 1581
Parvovirus arthritis, 1926t
Parvovirus B19 infection, 946, 954
Passy-Muir devices, 1604–1605, 1604f
Pasteurellosis, 1076, 1077t
treatment of, 1075t
Patellar tendinitis, 1857–1858, 1901, 1901f
Patellar tendon rupture, 1857
Patellofemoral syndrome, 1899–1900
Patent ductus arteriosus, 825, 827
Patent foramen ovale, 1372
Pathologic fractures, 1513, 1767
Patient care, in disasters, 25
Patient encounter form, 18f
Patient transfer, in EMS, 2
Patients
informed consent of, 2014–2016
recordkeeping, in EMS, 2
Patiromer, 91
Pediatric automatic disorders, 838
Pediatric condition. See Children
Pediatric condition falsification, 994–995
Pediatric Respiratory Assessment Measure,
804f
Pediatric trauma, 689–698
abdominal, 697–698
airway management in, 691
behavioral factors in, 689
breathing in, 692
cervical spine injury, 698
circulation in, 692
disability in, 692–693
ED preparedness for, 690
epidemiology of, 689
exposure and environmental control in, 693
fluid management in, 692
head, 694–695, 695t
imaging in, 693–694
laboratory testing in, 693
neck, 695, 696f
primary survey in, 691–693
referral to pediatric center in, 694, 694t
revised score, 694t
score, 694t
secondary survey in, 693–694
thoracic, 695–697
hemothorax, 696
pneumothorax, 696
pulmonary contusions, 695–696
rib fractures in, 696
thoracic and lumbar spine injury, 698
traumatic arrest, 698
Pediatrics. See Children
Pediculosis, 770
Pediculosis pubis, 1652t, 1654
Pediculus capitis, 1633
Pediculus humanus capitis, 937
Pelvic binding, 1769
Pelvic examination, 642–643
FB:Cardiologia Siglo XXI
Pelvic inflammatory disease, 479t, 654–658
agents associated with, 656t
ascending infection in, 655
clinical features of, 655
complications of, 655
diagnosis of, 655–656, 656t
disposition and follow-up in, 658
epidemiology of, 654
imaging in, 656
laboratory testing in, 656
organisms associated with, 654–655
pathophysiology of, 654–655
risk factors for, 655, 655t
treatment of, 656, 657t
in adolescents, 657
antibiotics in, 657
in HIV infection, 657
with IUD in place, 656–657
tubo-ovarian abscess in, 657
Pelvic pain
adenomyosis in, 614
chronic, 252, 262t, 263, 264t
diagnosis of, 612
disposition and follow-up in, 613
endometriomas in, 613–614
endometriosis in, 614
epidemiology of, 612
history in, 612
imaging in, 613
laboratory testing in, 612–613
in non-pregnant female, 612–615
ovarian cysts in, 613–614
ovarian hyperstimulation syndrome in, 614
ovarian neoplasm in, 614
ovarian torsion in, 614–615
physical examination in, 612
treatment of, 613
Pelvic stabilizer, 9
Pelvic trauma, 2012
Pelvis injuries, 1836–1842
anatomy in, 1836, 1836f–1837f
biomechanics in, 1836
in children, 917
clinical features of, 1836–1837
epidemiology of, 1836
fractures in, 1838–1840, 1838t
acetabular, 1839–1840
anterior-posterior compression, 1838
avulsion, 1838–1839, 1839f, 1839t
complications of, 1841–1842
lateral compression, 1838, 1838f
open-book fracture, 1838, 1838f
single-bone, 1838–1839, 1839t
treatment of, 1840–1841
vertical shear, 1838, 1839f
history in, 1836
imaging in, 1837
nerve root injury in, 1842
physical examination in, 1836–1837
rectal injury in, 1842
urogynecologic injury in, 1841
Pemphigus vulgaris, 1624t, 1626t, 1627,
1627f
Penetrating injuries, 1714
in abdominal trauma, 1752
in buttock trauma, 1757
in cardiac trauma, 1744–1746, 1752–1754
cardiac tamponade in, 1744
iatrogenic injuries in, 1744
intracardiac missiles in, 1744
8/2/19 6:02 PM
 Index   2089

pathophysiology of, 1752–1753 obstruction in, 508 Periodontium, 1580

pericardiocentesis for, 1744 pathophysiology of, 505–506 Periorbital cellulitis, 765–766
thoracic great vessels in, 1748 perforation in, 508 Peripartum cardiomyopathy, 383, 624, 636
thoracotomy for, 1745–1746 treatment of, 506–507 Peripheral blood smear, 1468t
tranexamic acid for, 1746 H2 receptor agonists, 507 Peripheral edema
treatment of, 1745–1746 proton pump inhibitors in, 507 in high-altitude disorders, 1382
in chest trauma, 2009 upper gastrointestinal bleeding in, 495 in hypertension, 401
in flank trauma, 1755–1757 Peramivir, 1025 Peripheral nervous system
in head trauma, 1692 in influenza, 438t disorders of, 1159–1164
meningitis in, 756 Percussion, abdominal pain in, 474 electrical injuries of, 1398
in knee, 1858 Percutaneous coronary intervention hydrocarbon toxicity in, 1295
in neck trauma, 1724–1725 in acute coronary syndrome, 344–345 lesions, 1159–1160
laryngotracheal injuries in, 1727–1728, facilitated, 346 neuropathies in, 1159–1161
1728t Percutaneous cricothyrotomy, 198–199, 198f stimulators, 1185
pharyngoesophageal injuries in, 1728 Percutaneous exposure, 1093 Peripheral neuropathy, 573
treatment of, 1725, 1726f Percutaneous nephrostomy, complications of, Peripheral vascular disease, 1425t
vascular injuries in, 1725 604 Peripheral venous access, 201–202
Penicillamine, 1314 Perforated viscus, 479t anatomy of upper extremity in, 201f
Penicillin, 948 Perfusion, 215, 1127–1128 catheter-over-needle technique in, 202f
allergic reactions to, 73 Pericardial effusion, 1514–1515 in children, 721
in animal bites, 1915t Pericardiocentesis, 223–228 complications of, 202t
in facial infections, 1568t anesthesia in, 226–227 in infants, 721
in hemolytic anemia, 1492t approaches to, 226t IV line insertion in, 201t
in postrepair wound care, 325t bedside ultrasound in, 226 materials for IV line placement in, 201t
in puncture wounds, 319 blind subxiphoid approach, 228 techniques for, 201–202
toxicity of, 1327 clinical features in, 223–224 ultrasound-guided, 202
Penicillin G, in premature rupture of complications in, 228 Periradicular periodontitis, 1581–1582
membranes, 635 diagnosis of, 224–225 Peritoneal dialysis
Penile hair-tourniquet syndrome, 594 disposition and follow-up in, 228 complications of, 577–578
Penis, 591 electrocardiogram in, 224f–225f, 225, 228 historical elements in, 578t
disorders of, 593–595 emergency, 225–227 physical examination in, 578
balanoposthitis, 593, 877, 877f epidemiology of, 223 technical aspects of, 577
carcinoma, 595 equipment in, 227t Peritoneal lavage, 1753–1754, 1754f
in infants and children, 876–879 history in, 223–224 Peritonitis, 577–578
paraphimosis, 592, 593f, 876–877, indications for, 226 spontaneous bacterial, 520
876f–877f outcomes assessment, 228 Peritonsillar abscess, 797, 797f, 1596
Peyronie’s disease, 594 pathophysiology of, 223 Permethrin cream, 937, 1633, 1643, 1653
phimosis, 593, 593f, 876, 876f patient preparation and positioning in, Pernio, 1333
priapism, 594–595, 877–878 226 Peroneal nerve, 302f, 1851
tourniquet syndrome, 878 in penetrating cardiac trauma, 1744 Peroneal retinaculum, 1931
entrapment injuries of, 593f, 594 physical examination in, 224 Peroneal tendon injuries, 1863–1864
fracture of, 594 purpose of, 226 Personal protective equipment, 4
intracavernosal injections, 606 risks and precautions in, 226 in chemical exposures, 38f
intraurethral injections, 606 sites for, 227f Pertussis, 438–439, 742
prostheses for, 606 step-by-step technique in, 227–228 in BRUEs/ALTEs, 742
vacuum devices for, 606 Pericarditis, 830–831 clinical features of, 438
zipper injury, 878–879, 878f–879f acute, 384–387, 387t diagnosis of, 439
Pennyroyal, 1326t in acute coronary syndrome, 350–351 immunization for, 438
Pentamidine, 1036t causes of, 385t in neonates, 742
Pentazocine, 233t, 1235 clinical features of, 384–385, 830–831 treatment of, 439
Pentobarbital coma, 894 constrictive, 388 Pesticides, 1300–1309
Pentoxifylline, 1262 diagnosis of, 831 herbicides, 1305–1307
Pepper spray, 1396 dialysis-related, 574 insecticides, 1300–1303, 1300t
Peppers, 1413 in end-stage renal disease, 574 rodenticides, 1307–1309, 1308t
Peptic ulcer, 505–508. See also Gastrointestinal treatment of, 385, 831 Petechiae, 750, 1609f, 1609t
disorders Pericardium, blunt trauma in, 1746 Pethidine, 231, 232t
abdominal pain in, 479t Pericholangitis, in Crohn’s disease, 489t Peyote, 1244–1245
chest pain in, 332 Pericoronitis, 1580–1581 Peyronie’s disease, 594
clinical features of, 506 Peridialytic hypotension, 576 Phalangeal fractures, 916, 1875
complications of, 508 Periductal mastitis, 661t Phalen’s maneuver, 1161
definition of, 506 Peri-implantitis, 1584 Phantom limb pain, 260, 264t
diagnosis of, 506 Perilunate dislocation, 1799–1801, 1800f, Pharmaceutical supplies, 9
ancillary testing in, 506 1808f Pharmacoinvasive therapy, 346
Helicobacter pylori tests, 506 Perilymph fistula, 1151 Pharyngitis
rapid urea test, 506 Perindopril, 1282 Arcanobacterium, 780
disposition and follow-up in, 508 Periodic breathing bacterial, 1594–1595
dyspepsia in, 506 definition of, 740 causes of, 1595t
Helicobacter pylori infection in, 506–508 in neonates, 736 in children, 751, 778–780
hemorrhage in, 507–508 Periodontal abscess, 1583 gonococcal, 780
in infants and children, 867 Periodontitis, periradicular, 1581–1582 group A b-hemolytic Streptococcus, 1595

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2089 8/2/19 6:02 PM

 2090   Index

Pharyngitis (Cont.): of children, 990–993 Pleurisy, 332

group A b-hemolytic Streptococcus
pharyngitis, 779–780, 780t
Streptococcus, 863
viral, 779, 779f
viral infections, 1594–1595
Pharyngoconjunctival fever, 768
Phenanthrene, 232t
Phenazopyridine, 39
Phencyclidine, 402, 1244t, 1246
Phenergan, 628
Phenobarbital, 892, 1158, 1287
Phenols, 1406, 1411t
Phenothiazines
in heat emergencies, 1346
in nausea and vomiting, 484t
Phentolamine
in hypertension, 405t, 406
in sympathetic crisis, 402, 403t
Phenylalkylamines, 1275, 1276t
Phenylephrine, 135–136, 257
actions of, 135
adverse effects of, 136
for antipsychotics overdose, 1210
cardiovascular effects of, 134t
contraindications, 134t
dosing and administration, 134t, 135–136
indications for, 135
pharmacokinetics of, 136t
in pregnancy, 168t
in shock, 61t
Phenylpiperidine, 232t
Phenylpropanoids, 1411t
Phenylpropanolamine, 1239
Phenytoin, 628, 891, 1283–1285
drug interactions with, 1284t
hypersensitivity reactions to, 1285
mechanisms of action of, 1283
metabolism of, 1284
pathophysiology of, 1283–1284
pharmacokinetics of, 1283
protein binding in, 1284
in status epilepticus, 1158
toxicity of
cardiovascular, 1285
central nervous system, 1284
clinical features of, 1285t
diagnosis of, 1285
treatment of, 1285
vascular and soft tissue, 1285
Pheochromocytoma, 402
Philadelphia Protocol, 749, 749t
Phimosis, 593, 593f, 876, 876f
Phlegmasia alba dolens, 392
Phlegmasia cerulea dolens, 392
Phorbol esters, 1413
Phosgene, 39, 1319–1320, 1319t
Phosgene oxime, 41
Phosphine, 39
Phosphodiesterase inhibitors, 1275, 1510
Phosphodiesterase-5 inhibitors, 411, 412t
Phospholipids, in clotting disorders, 1475t
Phosphorus, 98–99, 1308t
disorders of
hyperphosphatemia, 99
hypophosphatemia, 98–99
Photosensitivity, 1634, 1634f, 1634t, 1646
Phototherapy, 739
Physeal fractures, 905–906
Physical abuse
abdominal trauma in, 992
bruises in, 990, 990f–991f
burns in, 991
clinical features of, 990
diagnosis of, 990–992
fractures in, 991
history in, 990
physical examination in, 990
of elderly, 1974
of emancipated minors, 2017
Physiologic dead space, 78
Physostigmine, 1221
Phytodermatitis, 1414
Pickwickian syndrome, 77
Piedmont fracture, 1821
Pigmentation, 1646–1647
Pigmented villonodular synovitis, 1902
Pilar cyst, 1012
Pilon fractures, 1860–1861
Pilonidal sinus, 548–550, 550f
Pinhole testing, of visual acuity, 1525
Pinworms, 1090
in anal pruritus, 548
in vulvovaginitis, 654, 654t
Piperacillin-tazobactam
in animal bites, 1915t
in diverticulitis, 528t
in flexor tenosynovitis, 1915t
in intra-abdominal infections, 480t
in urinary tract infections, 583t
Pirbuterol, in asthma, 464t
Piriformis syndrome, 1897
Pisiform fracture, 1802t, 1804, 1804f
Pit vipers, 1358–1361, 1359f
Pittsburgh Knee Rules, 1852, 1852f
Pituitary apoplexy, 1113
Pityriasis (tinea) versicolor, 1636t–1637t,
1639–1640, 1640f
Pityriasis rosea, 1636t, 1637–1638, 1639f, 1642
Pivmecillinam, 582t
Placenta, delivery of, 641–642
Placenta previa, 634
Plague, 1076–1078, 1077t
signs and symptoms of, 43t
treatment of, 1075t
Planar venography, 396
Plantar fasciitis, 1930
Plantar warts, 1659t, 1664, 1664f
Plant-induced dermatitis, 1413–1414, 1414t
Plaque, 1614f, 1614t
diagnosis of, 1615f, 1615t
Plasma, fresh frozen, 66
Plasmodium falciparum infections, 1057–1063
Plasmodium knowlesi, 1061–1062
Plasmodium malariae, 1061–1062
Plasmodium vivax, 1061–1062
Plastic deformities, 907–908, 908f
Plastic surgery, 271
Platelet function assay, 1468t
Platelets, 66, 1469–1471
functional disorders in, 1471, 1471t
transfusion, 1496–1497
Platypnea, 425
Pleural effusion, 430–432
clinical features of, 431
diagnosis of, 431, 432t
differential diagnosis of, 431t
pathophysiology of, 434
treatment of, 431–432
Plexopathies, 1162–1163
Plica syndrome, 1900
Pneumatic walking brace, 1780
Pneumococcal pneumonia, 440–441
Pneumocystis choroiditis, 1038
Pneumocystis jiroveci infections, 1035
in injection drug users, 1982
Pneumocystis pneumonia, 1039
treatment of, 1036t
Pneumocystis pneumonia, 1039
Pneumomediastinum, 1735
Pneumonia, 439–449. See also Pulmonary
emergencies; Respiratory disorders
abdominal pain in, 863
acute otitis media, 756–759
age-specific causes of, 811–812
in alcoholics, 442–443
antibiotics in, 815–816
aspiration, 446–447, 818
atypical, 811
from atypical bacteria, 441–442
bacterial, 440–441, 440t, 1039
chest pain in, 331
in children, 747, 811–819
clinical features of, 811–812
diagnosis of, 813–815
high-risk groups, 811–812
history in, 812–813
imaging of, 814–815, 815f
laboratory testing in, 814
pathophysiology of, 811
physical examination in, 813
treatment of, 814t, 815–816
classification of, 439t
clinical features of, 440–442, 440t
community-acquired, 439–440
complications of, 816
cystic fibrosis in, 818
in diabetics, 443
diagnosis of, 442
differential diagnosis of, 812, 812t
disposition and follow-up in,
816–817
in elderly, 443
healthcare-associated, 439
in HIV infection, 443–444, 1039
influenza in, 817
lymphocytic interstitial, 1039
mortality predictors, 446t
in neonates, 734
noninvasive positive-pressure ventilation
in, 177
in nursing home patients, 443
pathogen-specific patterns of,
812, 812t
pneumococcal, 440–441
pneumocystis, 1039
Pneumocystis pneumonia, 1039
postoperative, 556
in pregnancy, 167, 443
radiographic evaluation of, 814–815,
815f, 818, 818f
risk factors for, 439t
in sepsis, 1000
severity index, 446, 446t
severity of, 812
staphylococcal, 811
in transplant patients, 444
tuberculosis in, 817–818

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 Index   2091

typical, 811 organophosphate, 1298–1301 Posterior arch of atlas fracture, 1702f

viral, 442 resuscitation in, 1187–1189 Posterior communicating artery aneurysm,
zoonotic, 1077t risk assessment in, 1189 1557
Pneumonitis, chemical, 448t scombroid, 1065–1067, 1068t Posterior cruciate ligament, 1855
Pneumothorax, 457–461, 1733–1735, 1734f, seizures in, 1187–1188 Posterior glenohumeral dislocations, 1829–
1735t. See also Pulmonary emergencies toxidromes in, 1189, 1190t 1830, 1832f
air transport in, 460 Poisonous plants, 1410–1414 Posterior reversible encephalopathy syndrome,
causes of, 457t antimitotic alkaloids, 1412–1413 401
chest X-ray in, 458–459, 458f belladonna alkaloids, 1412 headache in, 1110
clinical features of, 457 calcium oxalate, 1413 Posterior tibial nerve block, 243
diagnosis of, 457–458 capsaicin, 1413 Posterior tibial tendon, 1875
disposition in, 461 cardioactive steroids in, 1412 Postextraction alveolar osteitis, 1582
diving and, 460–461 classification of, 1411t Posthitis, 593, 877
epidemiology of, 457 convulsants, 1412 Postnasal discharge syndrome, 428
failure of lung expansion in, 1735t cyanogenic, 1413 Postoperative patients, abdominal pain in,
imaging of, 457–458 demyelinating anthracenones, 1412 480–481
in injection drug users, 1981 dermatitis from, 1413–1414 Postpartum depression, 1949
open, 1675, 1735 epidemiology of, 1410 Postpartum endometritis, 636, 636t
after pacemaker insertion, 221t nicotinic and nicotine-like toxins, 1410 Postpartum hemorrhage, 644, 646f, 646t
pathophysiology of, 457 sodium channel toxins, 1410–1412 Post–pelvic inflammatory disease (PID), 262t,
in pediatric trauma, 696 toxalbumins, 1412 264t
in penetrating neck trauma, 1723 treatment, 1410 Post–pelvic inflammatory disease pain, 262
postoperative, 556 Pokeweed, 1413 Postpolio syndrome, 1171
primary, 457 Pokkuri, 55 Post-poliomyelitis progressive muscular
secondary, 457 Poliglecaprone 25, 273, 274t atrophy, 1171
size of, 458 Poliomyelitis, 1170–1171 Postseptal (orbital) cellulitis, 1533–1539, 1539t
spontaneous, 457 acute paralytic, 1171 Poststreptococcal reactive arthritis, 925
tension, 1675, 1735 clinical features of, 1171 Posttransplantation lymphoproliferative
needle decompression of, 1740–1741, pathophysiology of, 1171 disorders, 1988
1741f postpolio syndrome in, 1171 Posttraumatic stress disorder, 1951–1952
traumatic, 457 Polysorb®, 274t Postural orthostatic tachycardia syndrome,
treatment of, 459–460 Polyangiitis, 1907t 838
complications in, 460 Polyarteritis nodosa, 1907t Potassium, 88–89
needle decompression in, 459–460 Polybutester, 273t in diabetic ketoacidosis, 1436
needle or catheter aspiration in, 460 Polycystic ovary syndrome, 612 disorders of, 855–856
tube thoracostomy in, 460 Polycythemia, 829, 1463–1464 hyperkalemia, 89–91, 855–856
Podophyllin, 1413 Polyester sutures, 273t hypokalemia, 88–89, 855
Poison Center, 25 Polyethylene glycol, 494t in hyperosmolar hyperglycemic state, 1446
Poison hemlock, 1410 Polyglycolic acid, 274t pathophysiology of, 88
Poison ivy, 1414, 1633, 1634f, 1634t, Polyglyconate, 274t urinary, 90t
1658t, 1659 Polymerase chain reaction, 755 Potassium hydroxide examination, 1619t
Poison oak/sumac, 1414, 1633, 1534t, 1658t, Polymorphic eruption of pregnancy, 1645, Potassium perchlorate, 1455
1659 1646f Potassium permanganate, 1396
Poisoning, 1187–1194 Polymyositis, 1906t Pott’s puffy tumor, 1579
agitation in, 1188 Polyps, 607 Powassan disease, 1075
antidotes, 1187, 1188t Pontiac fever, 1068 Pralidoxime, 40, 1302t, 1303
arrhythmias in, 1187 Popliteal (Baker) cyst, 1901–1902 Pramlintide, 1424, 1430
arsenic, 1314–1316 Popliteal aneurysm, 419, 421t Prandial dosing, 1420
in BRUEs/ALTEs, 742–743 Popliteal artery entrapment, 421t Prasugrel, 1510
carbon monoxide, 39, 1414–1417 Popliteal artery injury, 1851 dosing and administration, 1509t
ciguatera, 1065–1067, 1068t Popliteus tendinitis, 1901 in NSTEMI, 345t
cyanide, 1320–1322 Pork tapeworm, 1090 in STEMI, 344t
decontamination in, 1190–1192 Portal hypertension, 516 Prazosin, 886t, 1281
diagnostic testing in, 1189–1190, Portal vein thrombosis, 521 Precautionary hold, 1934
1190t Portland cement, 1395 Precordial catch syndrome, 332
enhanced elimination in, 1192–1194, Portuguese man-of-war, 1367, 1367f Prediabetes, 1428
1193t Positive end-expiratory pressure (PEEP), Prednisolone, in asthma, 464t
epidemiology of, 1187 191, 192f Prednisone, 626
ethylene glycol, 1229–1232 Positrons, 47, 48t in anaphylaxis, 70t
examination in, 1189, 1190t Postarthroplasty, 1857 in asthma, 464t
history in, 1189 Postarthroscopy, 1857 dosages of, 806t
hyperthermia in, 1187–1188 Post-cardiac arrest syndrome, 169–171 in nonneuropathic pain, 264t
hypoglycemia in, 1187 epidemiology of, 169 Preeclampsia, 632–633
hypothermia in, 1187–1188 ischemia-reperfusion injury, 169–170, 169f diagnosis of, 632
lead, 1312–1314 therapeutic hypothermia for, 169–171 headache in, 1113
mercury, 1316–1318 Postcholecystectomy syndrome, 516 HELLP syndrome in, 632–633, 632t
metal and metalloid, 1309–1316 Postconcussive syndrome, 1695 in hypertension, 400t, 401–402
methanol, 1226t, 1229–1232 Postconization bleeding, 665–666 laboratory testing in, 632t
anion gap in, 1230f Postembolization syndrome, 667 signs and symptoms of, 400t
mushroom, 1404–1409 Posterior ankle mold, 1778–1779, 1779f treatment of, 633

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 2092   Index
Pregabalin, 234t, 1288
in neuropathic pain, 264t
Pregnancy. See also Labor and delivery
abruptio placentae in, 633–634, 633f
adrenal insufficiency in, 1460
airway management in, 167
aortic dissection in, 415
appendicitis in, 526–527
asthma in, 626
autonomic and physiologic changes of, 1681
bacteriuria in, 626–627
bomb and blast injuries in, 33
carbon monoxide poisoning in, 1417
cardiac arrest in, 167–168, 168t
cardiac disorders in, 623–624
cardiovascular changes in, 165–166, 165f
central venous thrombosis in, 627
chronic hypertension in, 631–632
clotting disorder in, 1476
cocaine abuse in, 1240
cocaine in, 1240
comorbid disorders in, 622–631
cystitis in, 626–627
deep venous thrombosis in, 624–625
defibrillation in, 168–169
diabetes in, 622–623
diabetic ketoacidosis in, 1441
disseminated intravascular coagulation in,
1472t
DTaP booster in, 438
dysrhythmias in, 623–624
eating disorders in, 1959
eclampsia in, 633
ectopic, 615–622
electrical injuries in, 1400
in emancipated minors, 2017
emergencies during labor and delivery,
postpartum endometritis, 636t
emergency delivery in, 637–647
extracorporeal membrane oxygenation in,
169
fetal radiation effects in, 630t, 631
gastrointestinal disorders in, 628
genitourinary trauma in, 1762
gestational age in, 640
gestational hypertension in, 631–632
headache and stroke syndromes in, 627–
628, 627t
hepatitis in, 523
high-altitude disorders in, 1383
human immunodeficiency virus infection
in, 628–629
hypertension in, 627, 631–632
hypothyroidism in, 1450
intimate partner violence in, 629,
1974–1975
intracerebral hemorrhage in, 627
malaria in, 1062
maternal and fetal injuries in, 1680–1683
medications in, 629–630
migraine in, 627–628
nausea in, 621
NSAID overdose in, 1261
patient transfer during, 636
pertussis in, 438
physiology of, 165–166, 165t
placenta previa in, 634
pneumonia in, 443
post-cardiac arrest hypothermia, 169
Tintinalli_Index_p2025-2116.indd 2092
preeclampsia in, 632–633, 632t Preterm labor, 634
prehospital care in, 1681 Pretibial lacerations, 303–305, 305t
premature rupture of membranes in, 634– Priapism, 594–595, 877–878
636, 635t in sickle cell anemia, 947, 947f, 948, 1485
preterm birth in, 634–635 in trazodone, 1200
preterm labor in, 634 PRICE protocol, 1866
pulmonary changes in, 165t, 166 Prickly heat, 1347
pulmonary embolism in, 625–626, 625t Prilocaine, 236, 237t
pyelonephritis in, 626–627 Primaquine, 1063t, 1328
rabies in, 1056 Primary ABCD Survey, 155–157, 155f
radiation exposure in, 52 Primary hemostasis, 1465, 1466f, 1467t
respiratory changes in, 166, 168t Primidone, 1287
resuscitation in, 164–169, 1681 Privacy, 2017–2018
sedation in, 257 Probiotics, in gastroenteritis, 849
seizures in, 628, 1156–1157 Procainamide, 124
sepsis in, 166–167, 167t actions of, 124
sexually transmitted infections in, 1017 adverse effects of, 124
starvation ketosis in, 1442 in atrial fibrillation/flutter, 109, 109t
stroke in, 627–628 dosing and administration, 124t
subarachnoid hemorrhage in, 627 indications for, 124
substance abuse in, 629, 630t in tachydysrhythmias, 101t
alcohol abuse, 629 Procaine, 237t
cocaine, 629 Procalcitonin, 754, 1912
opioids, 629 Procedural sedation, 248–258
testing, 615 agents for, 251–256, 251t–252t, 729–731
thromboembolism in, 624–626 barbiturates, 256, 731
thyroid disorders in, 625 dexmedetomidine, 255, 731
thyrotoxicosis in, 1456 etomidate, 254, 731
trauma in, 1680–1683 fentanyl, 731
assessment of, 1681–1683 ketamine, 253–254, 731
imaging in, 1682 ketofol, 254
laboratory testing in, 1682–1683 methohexital, 256
primary survey in, 1681 midazolam, 254, 731
secondary survey in, 1681–1682 nitrous oxide, 731
treatment of, 1682–1683 propofol, 252–253, 731
urinary tract infection in, 583 synthetic opioids, 255
urologic stone disease in, 602 capnography and, 250–251, 251f
vaginal bleeding in, 633–634 in children, 728–731
vasa previa in, 634 monitoring during, 728–729
vasoactive medications in, 168–169, 168t NPO status, 728
venous thromboembolism in, 399, postsedation monitoring and recovery,
624–626 729
vomiting in, 621 presedation checklist, 728
Pregnancy and Lactation Labeling Rule, 629 clinical approach to, 249–252
Prehospital care needs assessment, 249
emergency medical services in, 1–3 patient monitoring and intervention,
equipment, 4–9 250–251
in mass gatherings, 13–18 preprocedural analgesics, 251
ultrasound in, 6 presedation patient evaluation, 249–250
vehicles, 3–4 selection and dosing of agents, 251–252
Preload, 820 comorbid conditions, 256–257
Premature atrial contractions, 104, 104f, 104t completion of, 251
Premature rupture of membranes, in complications of, 257–258, 258t
pregnancy, 634–636, 635t, 637 deep, 249
Premature ventricular contractions, 104–105, defibrillation and, 151
105f dissociative, 249
description of, 105 in elderly, 256–257
ECG features of, 104t equipment and supplies, 250
sinus rhythm of, 104f errors in, 258
treatment of, 105 general anesthesia, 249
ventricular bigeminy in, 105f levels of, 248–249, 249t
Premenarchal girls, ovarian torsion in, minimal, 248
614–615 moderate, 248–249
Premenopausal women, chest pain in, 330 in obese patients, 1996
Prepatellar bursitis, 1928t, 1929 obesity and, 256, 256t
Prescription medications, 518 patient evaluation, 248–249
Preseptal cellulitis, 1134, 1539t patient safety, 248
Preterm birth, 634–635 policies and guidelines, 249
Preterm delivery, 647–649 in pregnancy, 257
FB:Cardiologia Siglo XXI
8/2/19 6:02 PM
 Index   2093

rescue medications, 257 Proton pump inhibitors, 507 Psychoses, 1952–1956

reversal agents, 257 in hypomagnesemia, 93 catatonia in, 1953
risk assessment, 248 in nonvariceal bleeding, 869 in children, 988, 988t
underweight and, 256–257 in upper gastrointestinal bleeding, 497 clinical features of, 1953
during ventilation, 191–192 Protozoa diagnosis of, 1953–1954
Prochlorperazine, 233t, 622t, 628, 901, 1112t, in waterborne illnesses, 1068–1069 disorganized thinking in, 1953
1519t in zoonotic infections, 1079 dopamine hypothesis in, 1970
in nausea and vomiting, 484t Protriptyline, 1194, 1195t in elderly, 1946
Proctitis, 543 Proximal fibula (Maisonneuve’s fracture), 1861 epidemiology of, 1952–1953
Prodrome, 49 Proximal humerus, 1833f medications and drugs causing, 1953t
Progesterone, 264t, 617 Proximal motor neuropathy, 1426t negative symptoms, 1953
Projectile vomiting, 737 Proximal phalanx fractures, 1793 pathophysiology of, 1953
Prolactin, elevated levels of, 659t Proximal tibia pharmacotherapy in, 1954–1955,
Prolene®, 273t anatomy of, 720f 1954t–1955t
Promethazine, 233t, 622t, 628, 901 fractures of, 919 physical examination in, 1953
in nausea and vomiting, 484t metaphyseal, 919 schizophrenia, 1955–1956
in vertigo, 1144, 1152t physeal, 919 Psychosocial disorders, 1933–1966
Promotility agents, 497 tibial spine, 919 anxiety disorders, 1951–1952
Pronator drift, 1103 tibial tuberosity, 919 depressive disorders, 1946–1949
Pronouns, 1998t Proximal ulna fractures, 1819 disposition in, 1937
Propafenone, 124–125 Prucalopride, 494t eating disorders, 1956–1959
in atrial fibrillation, 109 Prunus species, 1413 in elderly, 1940–1946
in tachydysrhythmias, 101t Pruritus, 1646 epidemiology of, 1933
Propionibacterium acnes, 1183 Pruritus ani, 548, 550f evaluation of
Propofol, 186, 251t, 252–253, 257 causes of, 550t admission criteria, 1937
in rapid-sequence intubation, 186, 186t, clinical features of, 548 arrival and triage in, 1933–1934
715t treatment of, 548 clearance, 1933–1935
in refractory status epilepticus, 1158 Pseudoaneurysms, 415 decompensation in, 1935
in sedation, 731 in injection drug users, 1983 frequent ED users, 1936
in seizures, 892–893 vascular access, 575 goals of, 1933
Propofol infusion syndrome, 894 Pseudoclaudication, 1887 history in, 1934
Propranolol, 125 Pseudocoma, 1141 interview techniques in, 1935, 1935t
in atrioventricular blocks, 101t Pseudocowpox, 1078 laboratory testing in, 1935t
indications for, 125t Pseudocyanosis, 430 physical examination in, 1934–1935
in thyroid storm, 1454–1455 Pseudoephedrine, 1239 system review, 1934
Propylene glycol, 1284 Pseudofolliculitis, 1012 violent restraints in, 1935–1936
Propylthiouracil, in thyroid storm, 1455 Pseudogout, 575, 1926 involuntary patients, 1937
Prosecretory agents, 494t Pseudomonas aeruginosa infections, 1070t psychoses, 1952–1956
Prostaglandin analog, 1536t in empyema, 450 safety concerns in, 1941–1942
Prostaglandins, 1261 in otitis externa, 761 substance use disorders, 1959–1966
Prostanoids, in pulmonary hypertension, in otitis media, 1563 triage in, 1933–1934
411, 412t in peritoneal dialysis, 578 Psychotic disorder, alcohol-induced, 1224
Prostate, 592 in pneumonia, 440t, 441, 443 Psychotropics, 1411t
Prostate surgery, 605 in psoas abscess, 1896 Psyllium, 494t
Prostatitis, 597 in puncture wounds, 318 Puberty blockers, 1999
Prosthetic valves in type II diabetes, 1426t Public safety agencies, 2
bioprosthetic, 379 in waterborne illnesses, 1068 Puerperal mastitis, 659–660, 660f, 661t
dysfunctions of, 379–380 Pseudomonas infections, in corneal ulcer, 1543 Puerperium, 627
clinical features of, 379 Pseudo-rigor mortis, 1339 Pulled elbow, 911–914
complications of, 379 Pseudoseizures, 1155 Pulmonary arterial hypertension, 410, 1908
diagnosis of, 379 Pseudostrabismus, 764f Pulmonary barotrauma
treatment and disposition of, 379 Pseudotumor cerebri syndrome, 1557 barotrauma of ascent, 1370, 1371f
endocarditis in, 1047 headache in, 1111–1112 in bomb and blast injuries, 31
macrovascular hemolysis in, 1494 Pseudotumor of infancy, 789 Pulmonary contusion, 1731–1732, 1731f,
mechanical, 379 Psilocybin, 1243–1244, 1244t 1732t
reversal of anticoagulation with, 379–380 Psittacosis, 43t, 1075t, 1076, 1077t Pulmonary contusions, 695–696
Protamine, 1507t, 1508 Psoas sign, 523 Pulmonary diffusion, irritant agents in, 40
Protease inhibitors, 1042t–1043t Psoriasis, 1635, 1638f, 1658t, 1660 Pulmonary disorders, 425–471
Protected health information, 2018–2019 comparison features of, 1636t acute bronchitis, 436–439
Protective custody, 1934 differential diagnosis of, 1661t asthma, 461–466
Protein C, 1468t, 1475t guttate, 1638f chronic obstructive pulmonary disease,
deficiency of, 1475–1476 pustular, 1638f, 1660, 1661f 467–471
Protein S, 1468t, 1475t Psoriasis vulgaris, 1661f empyema, 449–450
deficiency of, 1475–1476 Psychiatric disorders hemoptysis, 432–436
Proteus mirabilis infections, 1896 features of, 1941t lung abscess, 450–451
Prothrombin, 1475t in HIV infection, 1037 pneumonia, 439–449
gene mutation, 1475 syncope in, 364 pneumothorax, 457–461
time, 517 Psychogenic pseudosyncope, 364 respiratory distress, 425–432
Prothrombin complex concentrate, 1498 Psychomotor seizures, 1154 tuberculosis, 451–457

FB:Cardiologia Siglo XXI

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 2094   Index
Pulmonary edema
characteristics of, 368t
in diving disorders, 1373
in end-stage renal disease, 574
in high-altitude disorders, 1381–1382
in hypertension, 400t, 402, 403t
immersion cooling, 1373
in injection drug users, 1981
signs and symptoms of, 400t
Pulmonary embolism
algorithms for evaluation of, 393f
in cardiac arrest, 162
chest pain in, 331
clinical features of, 390–391, 391t
drugs for, 397t
epidemiology of, 389
fibrinolysis for, 398–399
as gynecologic-abdominal surgery
complication, 665
isolated subsegmental, 399
physical examination in, 390–391
postoperative, 556
in pregnancy, 625–626, 625t
in pulmonary infiltrates, 448t
revised Geneva Score for, 394t
risk stratification in, 398t
rule-out criteria, 394t
in syncope, 363, 365
treatment of, 397–399
Well’s score for, 394t
Pulmonary emergencies
in hydrocarbon toxicity, 1293–1294
in nonsteroidal anti-inflammatory
drugs, 1260
in systemic rheumatic diseases, 1908
in volatile substance toxicity, 1293–1294
Pulmonary hypertension, 408–412
classification of, 408, 409t
clinical features of, 409
in congenital heart disease, 828
diagnosis of, 409–410
drugs for, 411t
epidemiology of, 408
imaging in, 410
intravascular volume in, 411
laboratory testing in, 410
oxygenation in, 410–411
pathophysiology of, 409
right coronary artery perfusion in, 411
right ventricular afterload in, 412t
right ventricular function in, 411
in sickle cell disease, 945
in syncope, 838
treatment of, 410–411
ventilation in, 410–411
Pulmonary infiltrates, 447–449
clinical features of, 449
noninfectious causes of, 448t
treatment of, 449
Pulmonary overinflation, 1370
Pulmonary trauma, 1729–1742
anatomy in, 1730, 1731f
blast injuries, 1739
blunt injuries in, 1740
cervical tracheal injuries in, 1737
chest wall injuries in, 1738
clinical features of, 1730–1731
diagnosis of, 1739–1740
diaphragmatic injuries in, 1737
epidemiology of, 1729–1730
Tintinalli_Index_p2025-2116.indd 2094
esophageal injuries in, 1737
flail chest, 1738
history in, 1730
intrabronchial bleeding in, 1736–1737
life-threatening, 1742–1744
in lower trachea and major bronchi, 1736
pathophysiology of, 1730
physical examination in, 1730–1731
rib fractures in, 1738
specific injuries in, 1731–1736
hematomas, 1735
hemopneumothorax in, 1736
hemothorax, 1732–1733, 1732f–1733f
massive hemothorax, 1733, 1733f
open pneumothorax, 1735
pneumomediastinum, 1735
pneumothorax, 1733–1735, 1734f, 1735t
pneumothorax in, 1734f
pulmonary contusion, 1731–1732, 1731f,
1732t
tension pneumothorax, 1735
sternum fracture in, 1738
subcutaneous emphysema, 1738
systemic air embolism in, 1738–1739
thoracic duct injuries in, 1737
tracheobronchial injuries in, 1736–1737
treatment of, 1740–1742
tube thoracostomy in, 1741–1742
ventilation in, 1740, 1740t
Pulmonic stenosis, 378
Pulmonic valve, 378
Pulpitis, 1581
Pulse contour analysis, 215
Pulse oximetry, 80
in venous thromboembolism, 391
Pulse pressure, in shock, 60t
Pulse ventricular tachycardia, 56–57
Pulseless arrest decision tree, 687f
Pulseless electrical activity, 56–57, 57t
algorithm on management of, 160–161,
161f
Pulsus paradoxus, 223, 387
Punctate burns, 1403, 1403f
Puncture wounds, 317–321
assessment of, 318
complications of, 319–320
diagnosis of, 318
epinephrine autoinjector injuries in,
320–321
high-pressure injection injuries in,
320, 320f
needle-stick injuries in, 320
pathophysiology of, 317–318
treatment of, 318–319
Pupils
dilated, 1103
examination of, 763, 1527
irregularity, 1528
Marcus-Gunn, 1527, 1528f
pupillary dysfunction, 1528
Purpura, 1610f, 1610t, 1666, 1666f
Purpura fulminans, 750, 1624t, 1628–1629,
1628f
Purpuric skin disorders, 1628–1629
Push-dose pressors, 257
Pustular psoriasis, 1660, 1661f
Pustule, 1613f, 1613t
diagnosis of, 1616f, 1616t
Pyelonephritis, 166–167, 578, 1000
acute, 579
FB:Cardiologia Siglo XXI
clinical features of, 580
complicated, 579
emphysematous, 1426t
in pregnancy, 626–627
treatment of, 583
Pyloric stenosis, 844
Pyoderma faciale, 1631–1632
Pyoderma gangrenosum, 1656
in Crohn’s disease, 489t
Pyrantel pamoate, for pinworms, 654t
Pyrantel pamoate, in trichomoniasis, 656t
Pyrazinamide
in HIV-related infections, 1036t
toxicity of, 1329
in tuberculosis, 454, 455t
Pyrethroid, 1304
Pyridium, 39
Pyridoxine, 970, 1323t, 1325
in resuscitation of poisoned patient, 1188t
Pyrimethamine, 1036t
Pyrogenic granuloma, 1666, 1666f, 1667t
Pyrrolizidines, 1326t, 1411t
Pyuria, 581, 871t
Q
Q fever, 442, 1076, 1077t
signs and symptoms of, 43t
treatment of, 1075t
Quadriceps tendinitis, 1901
Quadriceps tendon rupture, 1857
Quetiapine, in bipolar disorder, 1950t
Quick Essential Organ Failure Assessment
tool, 997–998
QuickClot®, 270
Quick-Wee method, 872
Quinapril, 1282
Quincke’s edema, 1596
Quincke’s triad, 419
Quinidine, 1063t
Quinidine gluconate, 1061t
Quinine, 1063t, 1328–1329
Quinine sulfate, 1061t
Quinolones, 1902
3-Quinuclidinyl benzilate, 40
R
Rabies, 323, 1051–1057
bite exposure in, 1052
bites from healthy-appearing animals,
1054
bites from stray animals, 1054
in children, 1056
clinical, 1056–1057, 1056t
epidemiology of, 1051, 1051t
exposure to bats in, 1053
exposure to vaccinated animals, 1052
human rabies immunoglobulin, 1055
in immunocompromised persons,
1055–1056
incubation period in, 1051
nonbite exposure in, 1052
pathophysiology of, 1051
in persons with prior immunization,
1055
person-to-person transmission of, 1054
in pregnant women, 1056
prophylaxis
postexposure, 1051–1056, 1053f,
1054t
preexposure, 1051, 1052t
8/2/19 6:02 PM

risk assessment in, 1051–1054,
1052t–1053t
in travelers, 1056
vaccines for, 1054–1055
vectors, 1051t
wound care in, 1054
Radial artery, 209
Radial head fractures, 911, 914f, 1819–1820
Radial neck fractures, 911, 914f
Radial nerve block, 241
Radial styloid, 1796
Radial styloid fracture, 1808–1809, 1809f
Radiation exposure, 47–52
acute radiation syndrome in, 49, 49t,
50–51
allowed annual dose of, 48, 49t
biologic effects of, 48–49
clinical effects of, 49
decontamination in, 50, 51t
emergency response in, 49–50, 50t
fetal, 630t, 631
fundamentals of, 47–48
internal contamination in, 51
ionizing, 48–49
lethal dose of, 58
local injuries in, 49, 51
measurement of, 48
monitoring equipment in, 48, 49t
in pregnancy, in disaster situation, 52
sources of assistance, 52
treatment of, 50–51, 51t
triage in, 50
types of radiation in, 47, 48t
units of measure in, 48t
Radiation pneumonitis, in pulmonary
infiltrates, 448t
Radiculopathy, cervical, 1882t, 1883
Radio Access Network, 4
Radio frequencies, 4
Radiography, 310f, 453
in abdominal pain, 476, 857
in aneurysms, 417–418, 417f
in aortic dissection, 413, 414f
in back pain, 1885
in cardiogenic shock, 354
in cervical spine imaging, 1711
of cervical spine injuries, 707–708, 708f
in chronic obstructive pulmonary disease,
467f
in esophageal foreign bodies, 503f
in foot and leg lacerations, 302
in fractures, 1771–1773
in head trauma, 693
in heart failure, 369
in hemothorax, 1732f
in low-probability acute coronary
syndrome, 358
in neck trauma, 1724, 1724t
in obese patients, 1996f
in pediatric trauma, 693
in pericarditis, 385
of pleural effusion, 432f
in pneumomediastinum, 1748f
in pneumonia, 814–815, 815f, 818, 818f
in pneumothorax, 458–459, 458f, 1732f,
1735f
in pulmonary barotrauma, 1371f
in pulmonary contusion, 1731f
in pulmonary trauma, 1739–1740
in puncture wounds, 318, 318f
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2095
in shock, 59
in soft tissue foreign bodies, 309–310,
310f–311f, 314f
of thoracic great vessels, 1749, 1750f,
1750t
of trauma to extremities, 1764, 1765f
in tuberculosis, 453f
in urologic stone disease, 601
in venous thromboembolism, 391
of wrist injuries, 1796–1797, 1797t
Radius diaphyseal fractures, 915
Radius fractures, 1821
Raltegravir, 1043t, 1096t
Ramelteon, 1220t, 1221
Ramosetron, 1519t
Ramsay Hunt syndrome, 1161, 1629
Raney clips, 270
Range-of-motion exercises, 1890–1891
Ranitidine
in anaphylaxis, 70t
in peptic ulcer disease, 507
in skin disorders, 1622t
Rapid Rhino, 1574
Rapid urea test, 506
Rapid urine tests, 872
Rapid-sequence intubation, 6, 185–187
in children, 715
induction agents in, 186, 186t
medications in, 715t
paralytic agents in, 186–187
pretreatment agents in, 186, 186t
steps in, 186t
Rapivab, 438t
Rasagiline, 1205t
Rashes, 925–944
in bacterial infections, 933–937
bullous impetigo, 933–934, 934f
cellulitis, 935–936
erysipelas, 935–936, 935f
impetigo, 933, 933f
meningococcemia, 936–937
scarlet fever, 934–935, 935f
staphylococcal scalded skin syndrome,
933–934, 934f
in children
in cutaneous drug reactions, 941–942,
942t
erythema multiforme, 942, 942f
Henoch-Schönlein purpura, 943–944,
943f
Kawasaki’s disease, 942–943, 943t
in fungal infections, 931–933
in infestations, 937–938
lice, 937–938, 938f
scabies, 937, 938f
in neonates, 938–941
acne, 939, 940f
atopic dermatitis, 940, 941f
diaper dermatitis, 940–941, 941f
erythema toxicum, 939, 939f
seborrheic dermatitis, 939–940,
940f
transient neonatal pustular melanosis,
939, 939f
in viral infections, 926–931
enteroviruses in, 926
erythema infectiosum, 929–930,
929f
herpes virus, 930–931, 930f
measles, 926–927, 928f
Index   2095
roseola infantum, 931
rubella, 927–929, 929f
varicella, 931, 931f
Rasmussen’s aneurysm, 433
Rat-bite fever, 323
Raynaud’s disease, 421t, 1914t
Reactive arthritis, 1927
Recombinant tissue plasminogen activator,
626, 1128t, 1129–1132, 1129t,
1130t–1131t
Rectal prolapse, 543–546
clinical features of, 545
after rectal surgery, 561
treatment of, 545–546, 547f
Rectal surgery, complications of, 561
Rectovaginal fistula, 551, 551t
Recurrent aphthous stomatitis, 1584
Recurrent ischemia, 351–352
Red blood cells
agglutination of, 1491
in anemia, 1461
clinical features of, 1461
diagnosis of, 1461–1462
in hematuria, 583
laboratory testing in, 1462t
normal values for adults, 1462t
oxidative stress-causing drugs, 1489t
packed, 66, 1496
Red eye, 739, 767–770, 1531–1533,
1538t–1539t
Red squill, 1308t
Reducible hernia, 532
Refeeding, 1957
Referred pain, 473, 1895
Reflexes, neurologic examination of,
1105–1106, 1106f
Reflux hypersensitivity, 261t, 264t
Refractory ischemia, 351–352
Refractory status epilepticus, treatment of,
1158–1159
Regional anesthesia, 238–247
digital blocks, 239–240
extremity blocks, 246–247
facial nerve blocks, 244–246
foot and ankle blocks, 242–244
hand and wrist blocks, 240–242
hematoma block, 248f
intravenous (Bier block), 247–248
Regional nerve entrapment syndromes,
1896–1897
Reglan, 628
Regurgitation, 736–737
aortic, 377–378
mitral, 375–377
Reiter’s syndrome, 1014
Relapsing fever, 1085
Relapsing polychondritis, 1907t
Relenza, 438t
Remifentanil, 252t, 255, 257
Renal colic, 479t
Renal disorders
acute kidney injury, 563–570
analgesics and, 235
cardiac troponins in, 333
in children, 881–888
acute kidney injury, 881–882
chronic kidney disease, 888
glomerulonephritis, 883–885
hematuria, 887–888
hypertension, 885–887
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 2096   Index
Renal disorders, in children (Cont.):
nephrotic syndrome, 882–883
renal tubular acidosis, 885
coagulation disorders in, 1472
cocaine in, 1237
in eating disorders, 1957
end-stage renal disease, 573–578
amyloidosis in, 575
bleeding diathesis of, 575
complications in, 573–575
epidemiology of, 573
hemodialysis in, 575–577
immunologic deficiency in, 574
pathophysiology of, 573
peritoneal dialysis in, 577–578
uremia in, 573–575
in heat emergencies, 1350
in HIV infection, 1039
hydrocarbon toxicity in, 1295
in mushroom poisoning, 1409
nephrolithiasis in, 598–602
in nonsteroidal anti-inflammatory drugs,
1260–1261
rhabdomyolysis, 570–572
in shock, 60t
in systemic rheumatic diseases, 1910–1911
transplantation in, infections in,
1989–1991
in type II diabetes, 1425t
Renal papillary necrosis, 1425t
Renal replacement therapy, 569, 569t
Renal stones, 862–863
Renal tubular acidosis, 885
Repaglinide, 1429–1430
Reptile bites, 1358–1362. See also Bites and
stings
coral snakes, 1361–1362
elapids, 1361–1362
laboratory testing in, 1360t
pit vipers, 1358–1361, 1359f
treatment of, 1359–1360, 1359t–1360t,
1360f
Rescue breathing, 146
Rescue collapse, 1339
Reserpine, 1282, 1455
Respiratory acidosis, 75, 77–78
acid-base status in, 78t
clinical approach to, 75
treatment of, 78
Respiratory alkalosis, 78
clinical approach to, 75
clinical features of, 78
treatment of, 78
Respiratory disorders
in children with special healthcare needs,
978
in eating disorders, 1957
in hydrocarbon toxicity, 1293–1294
from industrial toxins, 1317–1318, 1319t
in natural disasters, 27
opioids and, 235
in shock, 60t
in systemic rheumatic diseases, 1908
in volatile substance toxicity, 1293–1294
Respiratory distress, 425–432. See also
Pulmonary emergencies; Respiratory
disorders
clinical features in, 425
cough, 428–429
cyanosis, 430
Tintinalli_Index_p2025-2116.indd 2096
definition of, 425
diagnosis of, 425
hiccups, 429–430
hypercapnia, 427–428
hypoxemia, 426–427
hypoxia, 426–427
imaging in, 425–426
laboratory testing in, 425–426
pleural effusion, 430–432
in sickle cell disease, 945
in tracheostomy, 1601f
Respiratory exposure, 1093
Respiratory failure, 425
signs and symptoms of, 173
types of, 173
Respiratory quotient, 426
Respiratory toxins, 1319–1320, 1319t
ammonia, 1319t, 1320
chlorine, 1319t, 1320
nitrogen dioxide, 1319t, 1320
phosgene, 1319–1320, 1319t
Restrictive cardiomyopathy, 384
clinical features of, 384
diagnosis of, 384
epidemiology of, 384
pathophysiology of, 384
treatment of, 384
Resuscitation, 53–141, 143–228
abdominal pain in, 473
advance directives, 172
airway management in, 144–146
head tilt-chin lift maneuver, 145
jaw thrust maneuver, 145, 145f
surgical, 194–200
suspected opioid overdose, 145
in allergies, 71–73
American Heart Association chain of
survival in, 144t
in anaphylaxis, 68–71
in angioedema, 71–73
antiarrhythmics in, 123–132
antihypertensives in, 132–133
blood gases in, 78–81
cardiac, 153–164
cardiac pacing in, 216–223
in cardiac rhythm disturbances, 99–123
cardiopulmonary, 143–148
cellular responses to, 172
of children, 679–689
airway management in, 680
bag-valve mask, 682
basic life support, 679–680, 680f–681f,
681t
breathing, 682
choking and foreign-body management,
679–680, 682f
circulation, 682
coping with death of child, 689, 689t
drugs for, 683t, 684–686
family presence during, 689
fluids, 683
hemostatic, 692
mouth-to-mouth, 682
neonates, 673–679
termination of, 687–689
vascular access, 682
closed chest compressions in, 143–144,
144t, 145f
complications of, 148
counseling for survivors, 173
FB:Cardiologia Siglo XXI
defibrillation, 149–153
in disasters, 23
drugs used in, 158–159
in electrical injuries, 1399
ethical considerations in, 148
ethical issues of, 172–173, 173t
ethnical considerations in, 148
experimental techniques, 148
family presence during, 172
fluids and electrolytes in, 81–99, 2010–2011
in foreign body obstruction, 146–148
chest thrust maneuver, 147–148, 148f
finger-sweep maneuver, 148
Heimlich maneuver, 147, 147f
obstruction airway (Heimlich) maneuver,
147
futility of, 172
in heat emergencies, 1369
hemodynamic monitoring in, 212–216
hemostatic-hypotensive, 65
hyperbaric oxygen therapy in, 137–141
hypotensive, 65
inotropes in, 137
intubation in, 179–190
low-volume, 2010
in mass casualty triage, 2013
mechanical devices for chest compression,
148
mechanical ventilation in, 190–193
in nontrauma shock, 57–63
open chest cardiac compressions in, 144
outcomes, 172
in patients with permanent pacemaker,
220
in pericardiocentesis, 223–228
in poisoning, 1187–1189
post-cardiac arrest syndrome, 169–171
in pregnancy, 164–169, 1681
procedures on recently deceased patients,
172–173
in pulmonary trauma, 1741–1742
research, 173
in sepsis, 1001
sequence of steps in, 143, 144t
in sudden cardiac death, 53–57
after suicide attempts, 172
surgical airways in, 194–200
systematic approach to, 144t
termination of, 148, 172
tracheal intubation, 179–190
vascular access in, 201–211
vasopressors in, 133–137
ventilation in, 146
mouth-to-mask, 147, 147f
mouth-to-mouth, 146, 146f
mouth-to-nose, 146
mouth-to-stoma or tracheotomy, 146
witnessed, 2006
Resuscitative endovascular balloon resuscitation
of the aorta (REBOA), 1672–3, 1672f
Resuscitative hysterotomy, 1683
Reteplase, 344t, 1511
Reticulocytes, in anemia, 1462t
Retinal detachment, 1556, 1559, 1559f
Retinal hemorrhages, 771
Retinitis, 1038, 1038f
Retinoblastoma
in children, 771, 959–960
clinical features of, 959
diagnosis of, 959–960
8/2/19 6:02 PM

epidemiology of, 959
treatment of, 959–960
Retinopathy
diabetic, 1426t
in high-altitude disorders, 1382–1383
hypertensive, 400f, 400t
Retrobulbar hematoma, 1550, 1720f
Retrograde technique, in fishhook removal,
315, 316f
Retropharyngeal abscess, 796–797, 796f,
1597–1598, 1597f
Return of spontaneous circulation (ROSC)
anoxic brain injury after, 170
cellular responses to, 169
clinical features after, 170
organ system effects of, 169–170
oxygenation in, 162
ventilation in, 162
Reverse coagulopathy, 1118
Reverse Colles’ fracture, 1806, 1808f
Reverse Monteggia fracture, 1821
Reversible cerebral vasoconstriction
syndrome, headache in, 1110–1111
Revised Geneva Score, 392, 394t
Reye’s syndrome, 931
Reynolds’ pentad, 514
Rh seroconversion, 620
Rhabdomyolysis, 570–572
associated conditions, 571t
clinical features of, 570
complications of, 572, 572t
defined, 570
diagnosis of, 570–571
differential diagnosis of, 571
disposition and follow-up in, 572
emergency care of, 572
epidemiology of, 570
pathophysiology of, 570
prehospital care in, 572
treatment of, 572
Rhabdomyosarcoma, 789, 960
Rheumatic diseases, systemic, 1905–1914
acute coronary syndromes in, 1908–1909
acute heart failure in, 1909
adverse drug reactions in, 1912, 1913t
airway emergencies in, 1906–1908
alveolar hemorrhage in, 1908
cardiovascular emergencies in, 1908–1910,
1909t
catastrophic antiphospholipid syndrome
in, 1910
categories of, 1906t
clinical features of, 1906, 1906t–1907t
complications of, 1906t–1907t
cricoarytenoid joint arthritis in, 1906
diagnosis of, 1906
drugs for, 1913t
gastrointestinal emergencies in, 1911–1912,
1911t
immunosuppression in, 1912–1914
infections in, 1912
interstitial lung disease in, 1908
intubation in patients with, 1908
neurologic emergencies in, 1910
ocular emergencies in, 1910, 1911t
pulmonary emergencies in, 1908
pulmonary hypertension in, 1908
renal emergencies in, 1910–1911
spinal cord compression in, 1910
thromboembolism in, 1909–1910
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2097
tracheomalacia in, 1906–1908
transverse myelitis in, 1910
vascular and valvular disease in,
1915–1916
Rheumatic fever, 924–925
Rheumatic heart disease, 1043
Rheumatoid arthritis, 1907t, 1914t, 1927
Rhinitis, 773–774
Rhinocerebral mucormycosis, 1426t
Rhinosinusitis, 1578–1579
clinical features of, 1578
complications of, 1579
diagnosis of, 1578–1579
pathophysiology of, 1578
treatment of, 1579
Rhododendron, 1410–1412
Rib fractures, 1738
in child abuse, 991, 991f
in pediatric trauma, 696
Riboflavin, 1323t, 1324
Richter hernia, 535
Ricin, 41, 1412
Ricinus communis, 41
Rickets, 885, 1324
Rickettsia prowazekii, 43t
Rickettsia rickettsii infection, 1071t,
1665–1666
Rickettsial spotted fever, 1084
Rifabutin
in HIV-related infections, 1036t
in tuberculosis, 454, 455t
Rifampin
in HIV-related infections, 1036t
toxicity of, 1329
in tuberculosis, 454, 455t
Rifapentine, 454
Rifapentine, in tuberculosis, 455t
Rifaximin, in diarrhea, 486t
Rift Valley fever, 1031
Right ventricular infarction, 340f, 351
Right-sided valvular heart disease, 378–379
clinical features of, 378–379
diagnosis of, 379
epidemiology of, 378
pathophysiology of, 378
treatment of, 379
Right-to-left shunt, in hypoxemia, 426
Rigid chest syndrome, 255
Rilpivirine, 1096t
Riluzole, 1165
Ring tourniquet syndrome, 299
Riot control agents, 40
Risk management, 2022–2023
Risperidone
in agitation, 1940t
in agitation, pediatric dosing of, 987t
in bipolar disorder, 1950t
Ritonavir, 1043t
Rivaroxaban, 1465, 1506
in deep venous thrombosis, 397t
in pulmonary embolism, 397t
River blindness, 1091
Rochester Criteria, 749, 749t
Rocky Mountain spotted fever, 1071–1072,
1077t, 1665–1666
treatment of, 1073t
Rocuronium, 187, 187t, 715t, 1211
Rodenticides, 1307–1309
anticoagulants, 1307–1309
nonanticoagulants, 1307, 1308t
Index   2097
Rodents, 323
Rohypnol, 1969
Rolando’s fracture, 1793
Rolapitant, 1519t
Romano-Ward syndrome, 55
Ropivacaine, 236, 237t
Rosary pear, 1412
Rosenbaum chart, 1525
Roseola infantum, 931, 932f
Rotator cuff tears, 1891
Rotavirus, 1067t
Roundworms, 1089–1090
Roux-en-Y gastric bypass, 480t
Rovsing’s sign, 523
Rubella, 785, 927–929, 929f
Rubella arthritis, 1926t
Rubin maneuver, 643
Rufinamide, 1288
Rumack-Matthew nomogram, 1254–1255,
1255f
Runner’s knee, 1899–1900
Rust ring, 1546–1547, 1546f
Rutherford criteria, 421, 422t
S
Sacral fractures, 1706f, 1713
Sacroiliitis, in Crohn’s disease, 489t
Sager® splint, 8–9, 9f
Salbutamol, 626, 806t
Salicylates, 1248–1252, 1411t
ancillary testing of, 1250–1251
in Crohn’s disease, 490
overdose and toxicity of, 1249–1252
in adults, 1250, 1250t
alkalinization in, 1251
in children, 1249–1250
clinical features of, 1249–1250
diagnosis of, 1250–1251
hemodialysis in, 1252
pathophysiology of, 1249, 1249t
treatment of, 1251–1252, 1251f
toxicologic testing of, 1250
Saline
load test, 293
in shock, 62t
Salivary gland infections, 1567–1569
Salmeterol xinafoate, 465
Salmonella, 43t, 846t, 1066t
Salmonella enterica, 1071t
Salmonella paratyphi infection, 1082
Salmonella typhi infection, 1067, 1082
Salmonellosis, 1036t
Salter (epiphyseal plate) fractures, 1767
Salter-Harris fractures, 905–906, 905f–906f,
1773, 1773f, 1773t, 1774f
Salvia, 1244–1245, 1326t
Salvinorin A, 1247t, 1248
San Francisco Syncope Rule, 365
Saphenous nerve block, 244
Saquinavir, 1043t
Sarcoidosis, in pulmonary infiltrates,
448t
Sarcoptes scabiei mite, 937
Sarin, 40
Saw palmetto, 519t
Saxagliptin, 1430
Scabies, 937, 938f, 1617, 1619f, 1636t–1637t,
1642–1643, 1643f–1644f, 1652t,
1653–1654, 1653f
Scales, in skin lesions, 1618f, 1618t
8/2/19 6:02 PM
 2098   Index

Scalp dexmedetomidine, 255, 731 Seidel test, 1528, 1529f, 1545

anatomy of, 285 etomidate, 254, 731 Seizures, 1153–1159. See also Neurologic
disorders of, 1631–1633 fentanyl, 731 disorders
dissecting cellulitis of, 1631–1632, 1632f ketamine, 253–254, 731 absence, 1154
lacerations of, 285–292, 1689 ketofol, 254 active, 1155–1156
layers of, 286f methohexital, 256 in alcohol abuse, 1157
trauma of midazolam, 254, 731 alcohol withdrawal, 1224
anatomy of, 286f nitrous oxide, 255–256, 731 in BRUEs/ALTEs, 742
clinical features, 286 propofol, 252–253, 731 causes of, 1154t
repair of lacerations, 286 synthetic opioids, 255 in children, 888–896
suturing guidelines for, 287t capnography and, 250–251, 251f clinical features of, 889
Scaphocapitate syndrome, 1805 in children, 728–731 diagnosis of, 889–891
Scaphoid, 1796–1797 monitoring during, 728–729 epidemiology of, 888–889
Scaphoid fracture, 1802–1803, 1802f, 1802t NPO status, 728 evaluation of, 892f
Scapholunate ligament instability, 1797–1799, postsedation monitoring and recovery, history in, 889, 889t
1798f 729 imaging in, 890
Scapula fractures, 1823–1824 presedation checklist, 728 laboratory testing in, 890
anatomy in, 1823 clinical approach to, 249–252 pathophysiology of, 889
clinical features of, 1823 needs assessment, 249 physical examination in, 889
diagnosis of, 1823 patient monitoring and intervention, treatment of, 891–894
scapulothoracic dissociation in, 1824 250–251 types of, 889
sites of, 1824f preprocedural analgesics, 251 in children with special healthcare needs,
Scapular manipulation technique, presedation patient evaluation, 978
1829, 1829f 249–250 classification of, 1153–1154, 1153t
Scarlet fever, 934–935, 935f selection and dosing of agents, 251–252 clinical features of, 1154–1155
Scarpa’s fascia, 591 comorbid conditions, 256–257 in cyclic antidepressant overdose,
Scars, 1612f, 1612t completion of, 251 1197–1198
Schiötz tonometer, 1530, 1530f complications of, 257–258, 258t diagnosis of, 1155
Schistosomiasis, 1087 deep, 249 in epilepsy, 895
Schizoaffective disorder, 1956 defibrillation and, 151 events masquerading as, 891t
Schizophrenia dissociative, 249 febrile, 756, 894–895
diagnostic criteria for, 1955t in elderly, 256–257 first unprovoked, 1156
in elderly, 1946 equipment and supplies, 250 generalized, 1153–1154
spectrum of disorders, 1955–1956 errors in, 258 glucose and electrolyte abnormalities in,
Schwannomas, 789 general anesthesia, 249 894
Sciatica, 1886 levels of, 248–249, 249t in head trauma, 1688
Sclera, 1523 minimal, 248 in heat emergencies, 1350
Scleroderma, 1907t, 1914t moderate, 248–249 history in, 1154
Scleroderma renal crisis, 1910–1911 in obese patients, 1996 in HIV patients, 1156
Sclerosis, 1610f, 1610t obesity and, 256, 256t in hyponatremia, 85t
SCOFF questionnaire, 1958t patient evaluation, 248–249 idiopathic, 1153
Scombroid fish poisoning, 1065–1067, 1068t patient safety, 248 imaging in, 1155
Scombroid poisoning, 1068t policies and guidelines, 249 laboratory testing in, 1155
Scopolamine, 1144, 1152t, 1236, 1247t, 1248 in pregnancy, 257 methylxanthine-induced, 1264–1265
Scorpion stings, 1355–1356, 1356t rescue medications, 257 in monoamine oxidase inhibitors, 1207
Scorpionfish, 1364 reversal agents, 257 neonatal, 895
Scrotum, 591, 591f risk assessment, 248 in neonates, 739, 742
abscess in, 592 underweight and, 256–257 partial (focal), 1154
disorders of, 592, 874–876 during ventilation, 191–192 in pediatric cancer, 964–965
epididymitis, 875 Sedatives, 1219–1222 physical examination in, 1154–1155
hydrocele, 875 buspirone, 1219, 1220t in poisoning, 1187–1188
in infants and children, 874–876 carisoprodol, 1219–1220, 1220t in pregnancy, 628, 1156–1157
testicular torsion, 874–875 chloral hydrate, 1220, 1220t primary, 1153
torsion of testicular appendage, 875 eszopiclone, 1220t provoked (secondary), 1154t
edema in, 592–593 ethchlorvynol, 1221–1222 psychomotor, 1154
Fournier’s gangrene of, 592–593 gamma-hydroxybutyrate, 1220–1221 signs and symptoms of, 890t
Scrub typhus, 1084 glutethimide, 1222 status epilepticus in, 1157
Scurvy, 1325 melatonin, 1220t, 1221 therapeutic, 1134
Sea snakes, 1364–1365 meprobamate, 1219–1220, 1220t in trauma, 895–896
Sea urchin stings, 1366, 1366f methaqualone, 1222 treatment of, 1153f, 1155–1156
Seatworm, 1090 nonbenzodiazepine, 1219–1222, 1220t ventriculoperitoneal shunt in, 895
Seborrheic dermatitis, 939–940, 940f, 1629, overdose and toxicity of, 1219–1222, vs. syncope, 364, 889
1629f, 1630t, 1635–1637, 1636t, 1639f, 1220t Seldinger technique, 204t, 205f, 460, 588–589
1652t, 1654 ramelteon, 1220t, 1221 Selective aortic arch perfusion (SAAP), 164,
Second impact syndrome, 1695 in rapid-sequence intubation, 715t 164f
Secondary ABCD Survey, 157, 157t tasimelteon, 1220t, 1221 Selective H1 antagonist, 1536t
Secondary hemostasis, 1465, 1466f, 1467t toxicity of, 1190t Selective serotonin norepinephrine inhibitors,
Sedation, procedural, 248–258 zaleplon, 1220t, 1221 1947–1948, 1969
agents for, 251–256, 251t–252t, 729–731 zolpidem, 1220t, 1221 Selective serotonin reuptake inhibitors,
barbiturates, 256, 731 zopiclone, 1220t, 1221 1201–1202

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2098 8/2/19 6:02 PM


adverse effects of, 1201
for anxiety disorders, 1969
for depressive disorders, 1947–1948
dosage of, 1201t
overdose and toxicity of, 1201–1202
treatment of, 1202, 1202t
pharmacokinetics of, 1201
Selegiline, 1205t
Selenium sulfide, 933
Self-adhesive electrodes, 686
Sellick maneuver, 182
Semimembranosus tendinitis, 1901
Sengstaken-Blakemore tube, 497, 498f,
552–553, 553f
Senna, 494t, 519t
Sensory ataxia, 1143
Sensory dermatomes, 1103, 1104f
Sensory examination, 1103
Sentinel tags, 537, 538f
Separation pain, 619
Sepsis, 997–1004
in adrenal insufficiency, 1460
annual incidence, 997
in children, 747
clinical features of, 998–1000
definition of, 997, 998t
diagnosis of, 1000–1001
gastrointestinal changes in, 999
hematologic changes in, 999–1000
imaging in, 1000–1001
laboratory testing in, 1000–1001
metabolic changes in, 1000
mortality rate of, 997
in neonates, 733, 733t
neutropenic fever in, 1002–1004
pathogenic sequence of events in, 999f
pathophysiology of, 998
in patients with positive blood cultures,
1002
in postsplenectomy patients, 1002–1004
in pregnancy, 166–167, 167t
pulmonary injury in, 998–999
Quick Essential Organ Failure Assessment
tool, 997–998
renal injury in, 999
resuscitation in, 1001
SEP-1 quality measure for, 997
severe, 997
skin manifestations of, 1000
systemic inflammatory response syndrome
in, 998, 998f
treatment of, 1001–1002, 1003t–1004t
for urinary tract infection, 580
Septic abortion, 621
Septic arthritis, 1914t, 1925–1926
bacterial nongonococcal, 1925
in children, 921–922
clinical features of, 922
diagnosis of, 922
gonococcal, 1925–1926
imaging of, 922
in injection drug users, 1983
joint aspiration in, 1921t
organisms in, 1925–1926
risk factors for, 1920t
synovial fluid analysis in, 1920
treatment of, 922
Septic bursitis, 1928t, 1929
Septic cardiomyopathy, 998
Septic pelvic thrombophlebitis, 665
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2099
Index   2099
Septic shock, 997, 998t, 999f Sexual orientation, 1998t
Septic abortion, 620t Sexually transmitted infections, 1013–1024
Seromas chancroid, 1021
postoperative, 557–558 in child sexual abuse, 994
wounds, 665 chlamydial, 1014–1017
Serotonergic agents, 494t diagnosis of, 1014
Serotonin, 1190t genital ulcerative, 1018–1023, 1018t
Serotonin antagonists, in nausea and vomiting, gonorrhea, 1017–1018
484t granuloma inguinale, 1022
Serotonin receptor antagonists, 1519t herpes simplex, 1020–1021
Serotonin syndrome, 1202–1204, 1948 in HIV infection, 1041
clinical features of, 1203, 1203t lymphogranuloma venereum, 1021–1022
drugs associated with, 1203t in pregnancy, 1017
in monoamine oxidase inhibitors, 1206 prevention of, 1014t
severity of, 1203t prophylaxis, 1969
treatment of, 1204, 1204t screening for, 1014, 1014t
vs. neuroleptic malignant syndrome, 1211 in sexual abuse and assault, 1969
Serotonin/norepinephrine reuptake inhibitors, prophylaxis after, 1017
1202 syphilis, 1018–1019
in acute pain management, 234 treatment of, 1014, 1015t–1016t
adverse effects of, 1202 treatment of emancipated minors, 2017
dosage of, 1202t trichomonal, 1018
overdose and toxicity of, 1202 urethritis in, 1018
clinical features of, 1202 viral infections in, 1023–1024
treatment of, 1202, 1204t Shearing, 30
pharmacokinetics of, 1202 Shellfish toxins, 1068t
Serrata marcescens infections, 1896 Shields, 1098
Serum glucose monitoring, 1423 Shigella, 846t, 1066t
Serum lactate, 998 Shiitake dermatitis, in mushroom poisoning,
Sestamibi, 361 1409
Severe acute respiratory syndrome, 1092 Shiley® esophageal tracheal airway, 178, 178f
Sex (gender), 1998t Shin splints (exertional compartment
Sex hormones, 1457 syndrome), 1862
Sexual abuse and assault, 1967–1971 Shock
of adolescents, 1971 in congenital heart disease, 825–826
of children, 993–994, 1971 aortic stenosis, 825
anogenital examination in, 993–994, 994f clinical features of, 825–826
clinical features of, 993–994 coarctation of the aorta, 825
forensic specimens in, 994 diagnosis of, 826
history in, 993 hypoplastic left heart syndrome, 825
laboratory examination in, 993 physical examination in, 825–826
physical examination in, 993–994 treatment of, 826
sexually transmitted infections in, 994 distributive, 57
treatment of, 994 in elderly, 1680
cultural differences in, 1967 hypovolemic, 57
drug-facilitated, 1969 neurogenic, 1710
of elderly, 1971, 1975 spinal, 1710
emergency contraception in, 1969–1970, Shock, cardiogenic, 352–357
1970t causes of, 353t
evaluation of, 1967–1969 clinical features of, 353
forensic examination in, 1968–1969 diagnosis of, 353–355, 354f
consent in, 1968 differential diagnosis of, 353t
global issues in, 1971 early revascularization in, 356
healthcare responsibilities in, 1967 epidemiology of, 352
history in, 1968, 1968t extracorporeal membrane oxygenation in,
laboratory testing in, 1969 356–357
minorities and, 1967 hemodynamic monitoring in, 355
physical examination in, 1968 history in, 353
prophylaxis of sexually transmitted diseases imaging in, 354–355
in, 1969–1970, 1970t inotropes for, 355–356, 356t
sexually transmitted infections in, 1969 intra-aortic balloon pump counterpulsation
of transgenders and lesbians, 1971 in, 356
treatment of, 1969–1970 laboratory testing in, 354
emancipated minors, 2017 pathophysiology of, 352–353
triage in, 1967–1968 physical examination in, 353
Sexual assault forensic examiner (SAFE), risk factors for, 353t
1967 stabilization in, 355
Sexual assault nurse examiners (SANEs), thrombolytic therapy in, 356
1967 treatment of, 356–357
Sexual assault response teams (SARTs), 1967 ventricular assist devices in, 356
8/2/19 6:02 PM
 2100   Index
Shock, nontrauma, 57–63
airway management in, 60
breathing control in, 60
cardiac output in, 58
cardiogenic, 57
categories of, 57–58, 59t
clinical features of, 58–59
comorbidities in, 58
compensatory mechanisms in, 58
diagnosis of, 59–60, 60t
disposition, 63
distributive, 57
epidemiology of, 57
fluid therapy in, 62–63
fluids in, 60–61
hemodynamic monitoring in, 60
history in, 58
hypovolemic, 57
imaging in, 59–60
laboratory testing in, 59
lactic acid in, 58
obstructive, 59
oxygen delivery in, 61–62
pathophysiology of, 57–58, 59f
physical examination in, 58–59, 60t
physiologic equations in, 58t
prognosis for, 63
in shock, 60
sodium bicarbonate use in, 63
systemic inflammatory response
syndrome in, 59t
transition to intensive care unit, 63
treatment of, 60–63
Shock, traumatic, 63–68
clinical features of, 64–65
diagnosis of, 65
pathophysiology of, 64
treatment of, 65–68
Shock-related arterial ischemia, 421t
Short QT syndrome, 56, 122–123
syncope and, 363
Short-arm gutter splint, 1777–1778, 1777f
Short-term memory, 1101
Shoulder, 1821–1836
acromioclavicular joint injuries of,
1824–1825
adhesive capsulitis of, 1892
anatomy of, 1888
anterior glenohumeral dislocations of,
1827–1828
arthrocentesis of, 1922, 1922f
biceps tendon disorder of, 1892–1893
bones and joints, 1888, 1889f
brachial plexus injuries of, 1834
bursae, 1889
calcific tendinitis of, 1891–1892
clavicle fractures, 1822–1823
coracoacromial arch, 1889, 1889f
dystocia, 642–643, 642t
glenohumeral joint dislocation,
1825–1828
humeral shaft fractures of, 1833–1834
immobilization of, 1776, 1776f
joint aspiration of, 1922
muscles, 1105t, 1888–1889,
1888f–1889f
osteoarthritis of, 1894
pain, 1888–1894
neck as source of, 1894
Tintinalli_Index_p2025-2116.indd 2100
posterior glenohumeral dislocations, Simple wedge fracture, 1699f
1829–1830, 1832f Single-bone pelvic fracture, 1838–1839, 1839t
rotator cuff tears of, 1891 Sinus barotrauma, 1370
scapula fractures, 1823–1824 Sinus bradycardia, in acute coronary
sternoclavicular sprains and dislocations in, syndrome, 349
1821–1822 Sinus tachycardia
subacromial impingement syndrome of, in acute coronary syndrome, 349
1889–1891 in antipsychotics overdose, 1210
Shrapnels, embedded, 31 Sinusitis, 1578–1579
Shunting acute, 772
right-to-left, 426 antibiotics in, 773t
transjugular intrahepatic portosystemic, 520 bacterial, 772–774
Sialadenitis, 786f in bacterial meningitis, 1174, 1174f
Sialolithiasis, 1569 in children, 747, 772–774
Sick sinus syndrome, 54, 841 chronic, 772–774
Sickle cell anemia (HbSS disease), 1483–1488 clinical features of, 772, 772t, 1578
abdominal crisis in, 1485 complications of, 1578
acute chest syndrome in, 1484–1485, 1485f, diagnosis of, 772, 1578–1579
1486t pathophysiology of, 772, 1578
acute stroke in, 1486 in special populations, 773
aplastic crisis in, 1486 treatment of, 772, 773f, 1578
bone pain in, 1484 Sitagliptin, 1430
cardiovascular complications of, 1487 Situational syncope, 838
complications of, 1483t Sjögren’s syndrome, 1907t
dermatologic complications, 1487 Skew, test of, 1150
genitourinary disorder in, 1485 Skin
hemolytic anemia in, 1486 architecture of, 1005f
infections in, 1486–1487 dermis, 1384, 1384f
splenic infarction and sequestration in, epidermis, 1384, 1384f
1485–1486 infections, in natural disasters, 27
transfusion practice, 1484 Skin disorders, 1607–1667
vaso-occlusive pain crisis in, 1483, 1483t allergic contact dermatitis, 1633–1634, 1634t
Sickle cell disease, 1482–1488. See also angioedema, 1644–1645, 1644t
Hematologic disorders atopic dermatitis, 1640–1641
avascular necrosis in, 944, 945f blistering diseases, 1648
b-thalassemia in, 1489 bullous pemphigoid, 1649, 1649f
in children, 944–949 Buruli ulcers, 1657, 1657f
epidemiology of, 1482 calluses, 1662–1663, 1663t
hemoglobin C in, 1487 candidiasis, 1652–1653, 1653f
hemoglobin O-Arab, 1487 in children with special healthcare needs,
in high-altitude disorders, 1383 979
multiorgan failure syndrome in, 1487 corns, 1662–1663, 1663t
parvovirus infection in, 946 cutaneous larva migrans, 1664, 1664t
pathophysiology of, 944, 1482–1483 dermatitis herpetiformis, 1663–1664, 1663f,
priapism in, 947, 947f 1664t
sickle cell anemia, 1483–1488 diabetic ulcers, 1656–1657, 1657f
sickle cell trait, 1487 diagnosis of, 1607–1619, 1608t
stroke in, 1136 DRESS syndrome, 1627–1628, 1628f
symptoms of, 944–947 drug reactions in, 1646–1647, 1647f, 1647t
abdominal pain, 945 dyshidrosis, 1660f
anemia, 946 eczema, 1640–1641
chest pain, 945 erythema migrans, 1645–1646, 1646f
extremity pain, 944–945 erythema multiforme, 1623–1626, 1625f,
fever, 945–946, 948 1626t
neurologic complaints, 946–947 erythema nodosum, 1660–1661
neurologic disorders, 946–947 examination of, 1607–1614
priapism, 948 exfoliative dermatitis, 1627, 1627f
respiratory distress, 945 of extremities, 1655–1665
stroke, 948 of face, 1629–1631
treatment of, 947–949 fish tank granuloma, 1676–1677
vaso-occlusive pain crisis in, 941–942, 945t, folliculitis, 1650, 1651f
947–948, 1483 generalized, 1623–1629
Sideroblastic anemia, 1461–1462, 1464t of groins and skinfolds, 1651–1655
Silent ischemia, 1425 head lice, 1633
Silk sutures, 273t herpes simplex, 1630–1631, 1631f, 1631t
Silo filler disease, 1320 herpes zoster infection, 1629–1630, 1630f,
Silver, 1318t 1631t, 1648–1649
Simple interrupted percutaneous sutures, 275, herpetic whitlow, 1661, 1662f
275t, 276f hidradenitis suppurativa, 1655f
FB:Cardiologia Siglo XXI
8/2/19 6:02 PM
 Index   2101

history in, 1607 Sleep, 704–705 Solanine, 1411t, 1413

in hydrocarbon toxicity, 1295 at high altitude, 1378 Solids, properties of, 35
infections in, 1652–1653 in neonates, 732 Soman, 40
intertrigo, 1654–1655, 1654f Sling procedures, 643 Somatostatin analogs, in upper gastrointestinal
Kaposi’s sarcoma, 1651, 1651f Slings, 1769 bleeding, 497
leishmaniasis, 1658, 1658f Slipped capital femoral epiphysis, 917–918 Sorbitol, 494t
lesion arrangement in, 1607, 1608t Slit lamp examination, 1530–1531, 1531f Sotalol, 128–129
lesion distribution and pattern in, 1608t SLUDGE syndrome, 1407 actions of, 128
lesion morphology in, 1608t–1614t Smallpox, 43t adverse effects of, 129
lichen planus, 1641–1642, 1641f Smith’s fracture, 1806, 1808f dosing and administration, 129
lichen simplex chronicus, 1662–1663, 1663t, Snail fever, 1087 indications for, 129
1676f Snake bites. See also Bites and stings pharmacokinetics of, 128–129
melanoma, 1661, 1662f elapids, 1361–1362 Southern tick-associated rash illness, 1074
meningococcemia, 1628, 1628f laboratory testing in, 1360t Space of Poirier, 1795, 1795f
miliaria, 1650 pit vipers, 1358–1359, 1359f Spalling, 30
molluscum contagiosum, 1650, 1650f treatment of, 1359–1360, 1359t–1360t, Special needs children, pain assessment in, 724
morbilliform/urticarial eruptions, 1360f, 1362 Spectinomycin, 1015t, 1017
1643–1646 Snapping knee syndrome, 1901 Spherocytosis, hereditary, 1489. See also
neuropathic ulcers, 1656–1657, 1657f Snellen chart, 1525 Hematologic disorders
in nonsteroidal anti-inflammatory drugs, Snow disasters, 29 Sphygmomanometry, 212, 1995
1261 Sodium Spice (synthetic cannabinoids), 1244t,
papulosquamous, 1635–1640 in diabetic ketoacidosis, 1436 1246–1247
pediculosis pubis, 1654 disorders of, 854–855 Spider bites, 1351–1355
pemphigus vulgaris, 1626t, 1627, 1627f hypernatremia, 85–87, 854–855 armed, 1354–1355
photosensitivity, 1634–1635, 1634f, hyponatremia, 83–85, 842–843 complications and treatment, 1352t
1634t–1635t and fluids, 81–88 funnel-web, 1355
pityriasis (tinea) versicolor, 1639–1640, fractional excretion of, 567 hobo, 1353
1640f in hyperosmolar hyperglycemic state, 1445 Loxosceles, 1352–1353, 1352f, 1353–1354
pityriasis rosea, 1637–1638, 1639f Sodium azide, 39 tarantulas, 1355
plantar warts, 1664, 1664f Sodium bicarbonate, 159, 238 widow, 1353–1354, 1353f
psoriasis, 1635, 1638f, 1660–1661 for antipsychotics overdose, 1210 Spigelian hernia, 532–535
purpura, 1666, 1666f in beta-blocker toxicity, 1272, 1275 Spinal boards, 6–7
purpura fulminans, 1628–1629, 1628f in cardiac arrest, 159 Spinal cord
purpuric, 1628–1629 in pregnancy, 168t anatomy of, 1696–1697
pustular psoriasis, 1661f in resuscitation of children, 683t, 685–686 anterior cord syndrome, 1709
pyoderma gangrenosum, 1656 in resuscitation of poisoned patient, 1188t Brown-Séquard syndrome, 1710
pyrogenic granuloma, 1666, 1666f, 1667t in shock, 63 cauda equina syndrome, 1710
rocky Mountain spotted fever, 1665–1666 in toxicity of cyclic antidepressants, central cord syndrome, 1709–1710
scabies, 1642–1643, 1643f–1644f, 1653– 1196–1197 compression, 964, 1514, 1514t, 1887, 1910
1654, 1653f Sodium channel blockers, 123–125, 1411t electrical injuries of, 1398
of scalp, 1631–1633 flecainide, 124–125 incomplete spinal cord syndromes, 1709
seborrheic dermatitis, 1629, 1629f, 1630t, lidocaine, 124 infections in, 1887–1888
1635–1637, 1639f, 1654 procainamide, 124 injuries of
secondary syphilis, 1642, 1642f propafenone, 124–125 in children, 698
in sickle cell disease, 1487 Sodium channel modulators, 1411t flexion, 1698f–1699f
sunburn, 1652 Sodium fluoroacetate, 1308t level, 1707f
sycosis barbae, 1629, 1630f, 1630t Sodium nitroprusside, 1283 neurogenic shock, 1710
tinea barbae, 1629, 1630f, 1630t Sodium oxybate, 1220 shock, 1710
tinea capitis, 1632–1633, 1632f Sodium thiosulfate, 1322 stimulators, 1185
tinea corporis, 1638–1639, 1639f Sodium zirconium cyclosilicate, 91 Spinal epidural abscess, 1888
tinea cruris, 1652, 1652f Sodium-glucose transporter 2 inhibitors, 1430 Spinal immobilization, 6
tinea manuum, 1664–1665 Soft tissue infections, 1005–1013 sequence of, 7
tinea pedis, 1664–1665, 1665f anatomy in, 1005f Spinal manipulative therapy, 1886–1887
toxic epidermal necrolysis, 1626, 1626f carbuncles, 1008–1010 Spinal stenosis, 1887
treatment of, 1619–1623 cellulitis in, 1005–1008 Spine
antihistamines in, 1622, 1622t cutaneous abscesses, 1008–1010 anatomy of, 1696–1697, 1707f
antimicrobials in, 1622 epidermoid cyst, 1012 fracture of, 1910
nonantimicrobial topical agents in, erysipelas in, 1005–1008 imaging of, 1711–1712
1622–1623 folliculitis, 1012 injuries, 1697
topical corticosteroids in, 1620–1622 furuncles, 1008–1010 cardiovascular complications of, 1714
of trunk, 1635–1661 in injection drug users, 1982 coccyx fracture, 1706f
ulcers, 1655–1658 necrotizing, 1010–1011 extension, 1702f–1703f
urticaria, 1644–1645, 1644t, 1645f pilar cyst, 1012 flexion-distraction, 1700f
venous leg ulcers, 1655–1656 sporotrichosis, 1012–1013, 1013f flexion-rotation, 1700f
venous stasis dermatitis, 1655–1656, 1655f Soft tissue injuries sacral fracture, 1706f
Skin hook, 275f of elbow, 1813–1815 treatment of, 1713–1714
Skin tags, 538f of forearm, 1813–1815 vertical compression, 1701f
Skull, fractures of, 1689, 1689f–1690f of mouth, 781–782 instability of, 1910
Skullcap, 519t in natural disasters, 27 lesions, 1697, 1706

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2101 8/2/19 6:02 PM

 2102   Index
Spine (Cont.):
precautions in ED, 1708
trauma of, 1696–1714
clinical features of, 1708–1710
diagnosis of, 1710–1713
fracture stability in, 1697
history in, 1708
hypotension in, 1708
mechanisms of injury, 1698f–1706f
pathophysiology of, 1697
physical examination in, 1708–1709
prehospital care in, 1707–1708
Spinous process fracture, 1699f
Spirillum minus/minor, 323
Spironolactone, 1281, 1999
Spleen injuries, in children, 697
Splenic artery aneurysm, 419
Splints, 1769, 1775–1780
cock-up wrist, 1777
immobilization dressings, 1776–1780
long-arm gutter, 1777
non-prepadded plaster, 1775
prepadded material, 1775–1776
principles of, 1775
short-arm gutter, 1777–1778
sugar-tong, 1777
thumb spica, 1778
Spontaneous abortion, 620–621
diagnosis of, 620
terminology in, 620t
treatment of, 620–621
Spontaneous bacterial peritonitis, 520
Spontaneous coronary artery dissection, 624
Spontaneous pneumothorax, chest pain in,
332
Sporothrix schenckii, 1012
Sporotrichosis, 1012–1013, 1013f
Spousal abuse. See Intimate partner violence
and abuse
Sprain, 1767
Spurling test, 707
Spurling’s sign, 1881
Squeeze test, 1863
St. John’s wort, 1325t–1326t
Staphylococcal scalded skin syndrome,
933–934, 934f, 1624t
Staphylococcal toxic shock syndrome,
1017–1019, 1624t
case definition for, 1017t
clinical features of, 1018
diagnosis of, 1018–1019
epidemiology of, 1017
pathophysiology of, 1018
treatment of, 1019
Staphylococcus aureus infections, 1017–1021,
1066t
acute unilateral lymphadenopathy in,
785–786
in cellulitis, 1566
in corneal ulcer, 1543
in empyema, 450
in felon/paronychia, 1917–1918
in flexor tenosynovitis, 1916
of hand, 1914
in human bite wounds, 294
mastitis in, 660
in otitis externa, 761
in otitis media, 1563
in peritoneal dialysis, 578
in pneumonia, 439, 440t, 441–442
Tintinalli_Index_p2025-2116.indd 2102
in psoas abscess, 1896
in puncture wounds, 318
in septic arthritis, 1920
in shunts, 1183
in spinal infections, 1888
in vascular access, 575
Staphylococcus epidermidis infections
in epidural abscess, 1178
in otitis externa, 761
in peritoneal dialysis, 578
in shunts, 1183
Staphylococcus infections
in corneal ulcer, 1543
in foot and leg lacerations, 307
Staphylococcus pneumoniae infections, 812t
Staples, 272t, 280–282
laceration repair with, 281f
removal of, 326f, 326t
Starfish, 1366
Starvation ketosis, 1442
Stasis dermatitis, 1007t
Statin-related myopathies, 570
Station, examination of, 1106
Status asthmaticus, 465–466
Status epilepticus, 628, 893f, 893t, 1157
anticonvulsants in, 1158
in children, 889
medications for, 893t
refractory, 1158–1159
treatment of, 893f, 1153f, 1157–1159
Stavudine, 1042t
ST-elevation myocardial infarctions (STEMI),
343–344
antiplatelets for, 344t
treatment of, 343–344
Stenosing tenosynovitis, 1918
Stenosis, 1883
aortic, 377
mitral, 374
pyloric, 844
of vascular access, 575
Sterilization
of CSF, 756, 1173
hysteroscopic, 664
tubal, 616, 663
in wound preparation, 269
Sternoclavicular dislocations, 1821–1822,
1822f
Sternoclavicular sprains, 1821–1822
Sternum fracture, 1738, 1739f
Steroids
in asthma, 464t
cardioactive, 1248, 1412
in eye disorders, 1535t
in meningitis, 755
in myasthenia gravis, 1166t
in sepsis, 1002
Stevens-Johnson syndrome, 1624t, 1625
Stifneck®, 6
Stimson technique, 1828–1829
Stingrays, 1364
Stiripentol, 1289
Stomach stapling, 480t
Stomas, 561
Stomatitis, 777–778
Stonefish, 1364
Strabismus, 764
Strain, 1767
Strategic National Stockpile, 21t, 47
Strawberry tongue, 1585
FB:Cardiologia Siglo XXI
Streptobacillus moniliformis, 323
Streptococcal pneumoniae infections, in
spontaneous bacterial peritonitis, 520
Streptococcal toxic shock syndrome, 1624t
case definition for, 1020t
clinical features of, 1020
diagnosis of, 1020
epidemiology of, 1019
pathophysiology of, 1019–1020
treatment of, 1020
Streptococcus aureus infections, in necrotizing
soft tissue infections, 1010
Streptococcus dysgalactiae subspecies
equisimilis, 1595
Streptococcus infections
in epiglottitis, 1596
in foot and leg lacerations, 307
in human bite wounds, 294
Streptococcus iniae cellulitis, 1071t
Streptococcus pharyngitis, 863
Streptococcus pneumoniae infections, 436,
1038
in bacterial meningitis, 1172–1173
in children, 747, 752
in injection drug users, 1982
in meningitis, 752
in otitis media, 1563
in pneumonia, 440, 440t
in septic arthritis, 1920
in shunts, 1183
Streptococcus pyogenes infections, in cellulitis,
1566
Streptokinase, 626, 1511
in STEMI, 344t
Stress fractures, 1767, 1861, 1875
Stridor, 736, 789–798
airway foreign body in, 794–796
bacterial tracheitis in, 793–794
causes of, 790t–791t
croup in, 790–792
diphtheria in, 797–798
epiglottitis in, 792–793
Ludwig’s angina in, 797, 797f
oropharyngeal trauma in, 798
peritonsillar abscess in, 797, 797f
retropharyngeal abscess in, 796–797
String-pull technique, in fishhook removal,
315–316, 316f
Stroke, 1119–1136, 1123t, 1426t. See also
Neurologic disorders
anatomy in, 1119, 1119f–1120f, 1120t
antiplatelet therapy in, 1129
blood pressure control in, 1128
cerebellar, 1146, 1150t
clinical features of, 1119–1121
diagnosis of, 1126–1128
embolic, 1121t
endovascular therapy for, 1132–1134
epidemiology of, 1119
hemorrhagic, 1121t, 1126
history in, 1120–1121
imaging in, 1126–1127
interventions for, 1127t
ischemic, 400t, 404, 1121t, 1122–1126,
1128–1130
mimics, 1122t
myocardial infarction in, 1136
National Institute of Health Stroke Scale,
1123t–1124t
nontraumatic subarachnoid, 1121t
8/2/19 6:02 PM

pathophysiology of, 1119
in pediatric cancer, 964
physical examination in, 1121–1122
in pregnancy, 627–628
prehospital care in, 1119
prehospital scales, 1121t
in sickle cell anemia, 1486
in sickle cell disease, 948, 1136, 1487
symptoms, 1122t
thrombolysis in, 1129–1132
thrombotic, 1121t
time recommendations for, 1127t
transient ischemic attack in, 1134–1136
treatment of, 1128–1130
types of, 1121t
in young adults, 1136
Strongyloides stercoralis, 1090
Strychnine, 1308t
Stun guns, 1403
Stunning (keraunoparalysis), 1401–1402
Stuttering priapism, 594
Stye, 1539–1540, 1540f
Subacromial impingement syndrome,
1889–1891
clinical features of, 1889–1890, 1890f
diagnosis of, 1890
pathophysiology of, 1889
treatment of, 1890–1891
Subarachnoid hemorrhage, 1114–1117,
1126
clinical features of, 1114
diagnosis of, 1114–1115, 1115t
epidemiology of, 1113
grading scales for, 1116, 1116t
headache in, 1110
in hypertension, 400f
imaging of, 1115, 1115f–1116f
lumbar puncture in, 1115–1116
pathophysiology of, 1114
in pregnancy, 627
risk factors for, 1114t
spontaneous, 364
traumatic, 1690, 1691f
treatment of, 403t, 404, 1116
vasospasm in, 1116
Subclavian artery aneurysm, 419
Subclavian steal syndrome, 364
Subclavian vein, 206–207
anatomy of, 206f
central venous access in, 206–207,
206f–207f, 721
infraclavicular approach to, 206, 207f
supraclavicular approach to, 206–207, 207f
Subconjunctival hemorrhage, 1542, 1542f
Subcutaneous emphysema, 1738
Subdermal anesthesia, 238
Subdural hematoma, 1691
chronic, 1691, 1692f
headache in, 1110
Subglottic stenosis, 790
Subluxation, 1767–1768
Subscapularis, 1888
Substance abuse. See also Drug users,
injection
in children, 988
in elderly, 1945
headache in, 1108
in pregnancy, 629, 630t
Substance use
in children, 988
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2103
headache in, 1108
in pregnancy, 629, 630t
treatment of emancipated minors, 2017
Substance use disorders, 1959–1966
brief intervention for, 1960–1962, 1961f
diagnosis of, 1960
in elderly, 1945
epidemiology of, 1959
evaluation of, 1962
opioid use disorder, 1963–1966
screening for, 1960, 1960f
treatment referral for, 1962
unhealthy alcohol use, 1959–1960,
1962–1963
Subtrochanteric fractures, 1845
Subungual hematoma, 298
Subxiphoid approach, 228, 228f
Succimer, 1314, 1317t
Succinylcholine, 187, 1160, 1211
complications and contraindications of,
187t, 715t
in rapid-sequence intubation, 715t
Sucralfate, 507
Sudden arrhythmic death syndrome, 54
Sudden cardiac death, 53–57. See also Heart
disorders
Brugada’s syndrome in, 55, 55f
cardiomyopathy in, 53–54
catecholaminergic polymorphic ventricular
tachycardia in, 56
congenital heart disease in, 54
early polarization syndrome in, 55f
early repolarization syndrome in, 55
epidemiology of, 53
factors in, 54t
hereditary channelopathies in, 54–56
ion channel disease in, 54–55
long QT syndrome in, 55–56
pathophysiology of, 53–56
predisposing factors in, 837t
prevention of, 56
pulse ventricular tachycardia in, 56
pulseless electrical activity in, 56–57
resuscitation in, 56–57
severe left ventricular dysfunction in, 53
short QT syndrome in, 56
sick sinus syndrome in, 54
sudden arrhythmic death syndrome in, 54
in syncope, 837, 837t
valvular heart disease in, 54
ventricular fibrillation in, 56–57
Sudden infant death syndrome, 745–746
clinical features of, 746
epidemiology of, 745
pathophysiology of, 745–746
risk factors for, 745
Sudden sensorineural hearing loss, 139
Sufentanil, 255
Sugammadex, 187
Sugar-tong, 1777, 1777f
Suicide
in children, 985–987, 985f, 985t, 986f, 986t
in elderly, 1945
risk of, 1947
Sulbactam, in pelvic inflammatory disease,
657t
Sulfadiazine, 1036t
Sulfhemoglobinemia, 1332
Sulfonamides, 1489t
Sulfonylureas, 1429–1430
Index   2103
Sulfur mustard, 41, 1395
Sulfuric acid, 1392
Sumatriptan, 628, 1112t
Super glue, 1553
Superficial erythema, 1403
Superficial peroneal nerve block, 243–244
Superficial thrombophlebitis, 398, 1007t
Superfund Amendments and Reauthorization
Act, 36
Superior mediastinal syndrome, 963–964
Superior vena cava, 1515
Superior vena cava syndrome, 963–964, 963f
Superwarfarins, 1307–1309
Suppository, 494t
Suppurative parotitis, 923t, 1568t, 1569
Supracondylar fractures, 1816–1817
in children, 910, 911f–912f
complications of, 1817, 1818t
extension-type, 1816–1817, 1818f
flexion-type, 1817
Supraglottic airways, 5, 177–179
CobraPLA®, 178
converting to endotracheal tub, 178–179
i-gel®, 177
King Laryngeal Tube, 177
Laryngeal Mask Airway®, 177
Shiley® esophageal tracheal airway, 178
Supraglottitis, 1596–1597
Supraorbital nerve block, 244, 245f
Suprapubic catheterization, 587–589
obturator technique in, 588
peel-away sheath technique in, 588–589
urine leakage in, 589
Suprascapular nerve compression, 1894
Supraspinatus, 1888
Supratrochlear nerve block, 244
Supraventricular tachycardia, 839
Supraventricular tachydysrhythmias, 106–111
atrial fibrillation, 106–110
atrial flutter, 106–110
multifocal atrial tachycardia, 110, 111f
paroxysmal supraventricular tachycardia,
110–111
Sural nerve block, 244
Surgery
abdominal, 664–666
bariatric, 477–480, 480t, 559–560
biliary tract, 560–561
breast, 558
complications of, 555–561, 556t
drug therapy, 558
fever, 555–556, 557t
genitourinary, 556–557
respiratory, 556
vascular, 558
wounds, 557–558
emergency decompressive, 1887
gastric bypass, 560t
lower gastrointestinal bleeding, 500
pelvic organ prolapse, 666
plastic, 271
prostate, 605
rectal, 561
Surgical airways, 194–200
cricothyrotomy, surgical (open), 195–198
emergency airways in, 195
jet ventilation in, 189f–190f, 198–199, 199t
patient age in, 194
patient selection in, 194
tube selection in, 195
8/2/19 6:02 PM
 2104   Index
Surgical gut, 274t
Surgical shunt dysfunction, in congenital heart
disease, 828
Surgipro®, 273t
Sutures, 272t, 273–280
absorbable, 273, 274t
based on wound type, 275t
buried dermal, 275t, 276, 278f
continuous (running) percutaneous,
275–276, 275t, 277f
continuous subcuticular, 275t, 277, 278f
horizontal half-buried mattress, 279, 281f
horizontal mattress, 275t, 277–279, 280f
in lip lacerations, 290, 291f
nonabsorbable, 273, 273t
removal of, 326f, 326t
simple interrupted percutaneous, 275, 275t,
276f
size based on laceration location, 274t
vertical mattress, 275t, 276–277, 279f
Swan neck deformity, 295, 295f, 1791f
Swaths, 1769
Swelling, in fractures, 1773
Swinging flashlight test, 1528f
Sycosis barbae, 1629, 1630f, 1630t
Sympathetic crashing acute pulmonary
edema, 624
Sympathetic crisis
in hypertension, 400t, 402
treatment of, 402, 403t
Sympatholytic agents, 1280t, 1281–1282
Sympathomimetic drugs, 402, 1190t, 1346
Symptomatic drowning, 1376
Syncope, 362–367. See also Cardiovascular
disorders
ancillary testing in, 365
arrhythmogenic ventricular
cardiomyopathy in, 838
breath-holding spells in, 837–838
cardiac, 362–363, 835
carotid massage in, 365
causes of, 362–363, 363t
in children, 835–839
clinical features of, 362–364, 835–837
coronary artery abnormalities in, 838–839
cyanotic heart disease in, 838
diagnosis of, 365
in elderly, 367
epidemiology of, 362, 835
evaluation of, 364–367
history in, 364, 836
hyperventilation maneuver in, 365
laboratory testing in, 365, 836–837
medication-induced, 363t, 364
neurally/reflex-mediated, 363
neurocardiogenic, 835, 837
neurologic, 364
neurologic testing in, 365
orthostatic, 363–364, 838
pathophysiology of, 362, 835
physical examination in, 364–365, 836
post-ED testing for, 366t
in pregnancy, 365
in psychiatric disorders, 364
pulmonary embolism in, 363, 365
pulmonary hypertension in, 838
risk assessment in, 365, 366t
risk factors for, 835–836, 835t
situational, 838
sudden cardiac death in, 837, 837t
Tintinalli_Index_p2025-2116.indd 2104
treatment of, 365, 837
unexplained, 365
valvular diseases in, 838
vasovagal, 363
vs. seizures, 889, 1155
Syndesmosis injuries, 1863
Syndrome of inappropriate antidiuretic
hormone secre­tion (SIADH), 84,
84t–85t, 963–964
Synovial osteochondromatosis, 1904
Synovitis, 1902
crystal-induced, 1926
Syphilis, 1018–1019
clinical features of, 1018–1019, 1018t
diagnosis of, 1019
primary, 1019
secondary, 1019, 1636t–1637t, 1642, 1642f
in sexual abuse and assault, 1969
tertiary or latent, 1019
treatment of, 1016t, 1019
Systemic air embolism, 1738–1739
Systemic inflammatory response syndrome,
59, 59t, 998, 998f
Systemic lupus erythematosus, 1907t
in hemoptysis, 433
Systemic rheumatic diseases, 1905–1914
acute coronary syndromes in, 1908–1909
adverse drug reactions in, 1912, 1913t
airway emergencies in, 1906–1908
alveolar hemorrhage in, 1908
cardiovascular emergencies in, 1908–1910,
1909t
catastrophic antiphospholipid syndrome
in, 1910
categories of, 1906t
clinical features of, 1906, 1906t–1907t
complications of, 1906t–1907t
cricoarytenoid joint arthritis in, 1906
diagnosis of, 1906
drugs for, 1913t
gastrointestinal emergencies in, 1911–1912
immunosuppression in, 1912–1914
infections in, 1912
interstitial lung disease in, 1908
intubation in patients with, 1908
neurologic emergencies in, 1910, 1917t
ocular emergencies in, 1910, 1911t
pulmonary emergencies in, 1908
pulmonary hypertension in, 1908
renal emergencies in, 1910–1911
spinal cord compression in, 1910
thromboembolism in, 1909–1910
tracheomalacia in, 1906–1908
transverse myelitis in, 1910
vascular and valvular disease in, 1909
Systemic sclerosis, 1907t
Systolic blood pressure, in shock, 60t
Systolic dysfunction, 368
in cardiomyopathy, 380–383
Systolic pressure, 212
T eruption of, 1580–1581
Tabun, 40
Tachycardia
adenocarcinoma in, 102
atrioventricular nodal reentrant, 110–111
beta-blockers in, 102
calcium channel blockers in, 102
catecholaminergic polymorphic ventricular,
56
FB:Cardiologia Siglo XXI
in children, 839
classification of, 102f
decision tree, pediatric, 688f
in hypothermia, 1360
metoprolol in, 102
multifocal atrial, 111f, 111t
narrow-complex, 102, 106–110
pacemaker-associated, 221–222
paroxysmal supraventricular, 110–111, 111f,
111t
pulse ventricular, 56
sinus, 349
supraventricular, 839
ventricular, 114–116, 349
verapamil in, 102
wide-complex, 103, 119t
Tachydysrhythmias, 100–103, 363
drugs for, 101t
narrow-complex tachycardia, 102, 104t
supraventricular, 106–111
treatment of, 103f
wide-complex tachycardias, 103, 103f
Tachyphylaxis, 1622
Tachypnea, 425
in hypothermia, 1360
in pneumonia, 813t
Tadalafil, in high-altitude disorders, 1380t
Taenia saginata, 1090
Taenia solium infections, 1090, 1156
Takayasu’s arteritis, 421t, 1907t
Takotsubo syndrome, 1239
Talar tilt, 1863
Talc lung, 1981
Talus fractures, 1872, 1872f
Tamiflu, 438t
Tamsulosin, in urologic stone disease, 602
Tapeworms, 1090
Tarantulas, 1355
Tarsal tunnel syndrome, 1930
Taser, 1396, 1403
Tasimelteon, 1220t, 1221
Tattoos, traumatic dermal, 317
Tdap vaccine, 1050–1051
Tear gas, 40, 1396
Technology-dependent children, 979–980
cerebrospinal fluid shunts in, 980, 980t
feeding tubes for, 979
indwelling venous catheters in, 979–980
mechanical ventilation in, 979, 979t
tracheostomy care for, 979
urinary diversion in, 980
Technosphere insulin, 1420
Teeth
acute necrotizing ulcerative gingivitis,
1583
anatomy of, 1579, 1580f
avulsion of, 781, 1588
caries of, 1581
concussions of, 1587
cracked tooth syndrome in, 1581
dental trauma in, 781
extrusion of, 781
fractures of, 781f–782f, 1586–1587
classification of, 1586f
crown-root, 1587
enamel, 1586
enamel-dentin, 1586
enamel-dentin-pulp, 1586–1587
root, 1587
8/2/19 6:02 PM

gingival abscess, 1583
intrusion of, 781
luxation of, 781, 1587–1588
normal eruptive patterns, 1579f
numbering system, 1580f
periodontal abscess, 1583
and periodontium, 1580
postextraction alveolar osteitis, 1582
postextraction bleeding. See Teeth
postextraction pain, 1582
pulpitis of, 1581
replantation of, 1588–1589
subluxation of, 781, 1587
Telangiectasia, 1610f, 1610t
Telepaque, 1455
Telmisartan, 1282
Temperature
core, in hypothermia, 1339
in head trauma, 1688
in shock, 60t
Temporal arteritis, 1556
clinical features of, 1907t
complications of, 1907t
headache in, 1111, 1111t
Temporal lobe seizures, 1154
Temporomandibular joint disorders,
1570–1572
anterior temporomandibular joint
dislocation, reduction of, 1571–1572
facial pain in, 1584
mandible dislocation in, 1571–1572
temporomandibular joint dysfunction,
1570–1571
Tendinitis, 1918–1919, 1930–1931
patellar, 1857–1858
Tendinopathy, 1902
Tendon, 1767
Achilles tendon, 301, 1863
injuries of, 1875
rupture of, 1861–1862, 1866,
1866f, 1931
anterior tibialis, 1931
of foot, 304f
injuries of, 1864–1866, 1875
lacerations of, 1931
posterior tibialis, 1931
ruptures of, 1931
Tenecteplase, 1511
in STEMI, 344t
Tennis elbow, 1815
Tenofovir, 1042t, 1096t
Tenosynovitis, 1918–1919, 1930–1931
Tension enterothorax, 1737
Tension pneumothorax, 1735
in cardiac arrest, 162
in military medicine, 2009
Teratogenic period, 629
Terazosin, 602, 1281
Terbinafine, 932t, 933, 1629, 1630t
Terbutaline sulfate, 626
Terbutaline, in asthma, 464t
Terconazole, in Candida vaginitis, 652t
Terpenoids, 1411t
Terrorist attacks, 30
Testes, 591, 591f
disorders of, 595–597
appendageal torsion, 595t, 596
epididymitis, 595t, 596, 597t, 875f
intrascrotal tumors, 876
malignancy, 597
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2105
orchitis, 595, 597t
testicular torsion, 595–596, 595t
varicocele, 875–876
Testicular torsion, 595–596, 595t, 874–875
Testicular tumor, 960, 960f
Testosterone, 1457
Tet spells, 821, 824–825
Tetanic contractions, 1398
Tetanus, 1048–1051
antibiotics for, 1050
autonomic dysfunction in, 1050
cephalic, 1049
clinical features of, 1049
diagnosis of, 1049
differential diagnosis of, 1049t
epidemiology of, 1048
in gastrointestinal surgery complications,
559
immunization for, 293, 1050–1051
immunoglobulin, 1049–1050
local, 1049
muscle relaxants in, 1050
neuromuscular blockade in, 1050
pathophysiology of, 1048–1049
prophylaxis, 325, 325t
treatment of, 1049–1050, 1050t
wound management in, 1049–1050,
1050t
Tetracaine, 236, 237t, 727
Tetracycline
avoiding in pregnancy, 627–628
in puncture wounds, 319
in syphilis, 1016t
Tetrahydrocannabinol, 1411t
Tetralogy of Fallot, 821
Tetramine, 1308t
Tetrodotoxin, 1068t
Thalassemia, 1487–1488. See also Hematologic
disorders
carrier, 1488
hemoglobin H disease in, 1488–1489
minor, 1488
trait, 1488
Thallium, 1318t
Thallium sulfate, 1308t
Thallium-201 imaging, 361
Thenar muscles, 1783
Theobromine, 1263
Theophylline, 1263
clearance, 1263t
toxicity of, 1264
Therapeutic hypothermia, 168f, 169
in children, 171
complications, 171
cooling and supportive care in, 171, 171t
criteria for, 170, 170t
practical considerations in, 170–171
prehospital applications of, 171
Thermal burns. See also Burns
classification of, 1386t
clinical features of, 1385–1388
depth of, 1385–1386, 1386t, 1387f
epidemiology of, 1384
fluid resuscitation in, 1389, 1389t
inhalation injury in, 1388
initial assessment of, 1388–1389
minor, 1390–1391
physiologic effects of, 1385t
prehospital care in, 1388
size of, 1385, 1385f
Index   2105
transfer to burn unit, 1387–1388
treatment of, 1388, 1389t
escharotomy in, 1390f
hyperbaric oxygen therapy, 140
wound care in, 1389–1390
Thiamine, 1323t, 1324
in resuscitation of poisoned patient,
1188t
Thiazides, 1279
Thigh
anatomy of, 300f
lacerations, 303
Thionamides
in thyroid storm, 1455
in thyrotoxicosis, 1456t
Thompson test, 1866, 1866f
Thoracic aortic aneurysms, 419
Thoracic duct injuries, 1737
Thoracic great vessels, 1747–1751
blunt injury to, 1747
cardiac biomarkers, 1748
clinical features of injury to, 1748
diagnosis of injury to, 1748–1751
imaging of, 1748–1751
penetrating injury to, 1748
treatment of injury to, 1751
Thoracic outlet syndrome, 1894
Thoracic pump theory on chest
compressions, 143
Thoracic trauma, in children, 695–697
Thoracolumbar spinal injuries, 1678
imaging of, 1712, 1712f
treatment of, 1713
Thoracolumbar spine fractures, in children,
698
Thoracotomy, 1745–1746
Threatened abortion, 620t
Thrombin, in postpartum hemorrhage,
646t
Thrombinase complex, 1465
Thromboangiitis obliterans, 421t
Thrombocytopenia, 1469–1471
in children, 954–955
drug-induced, 1469t, 1470
heparin-induced, 1476
immune, 955, 1469–1471
in leukemia, 956
nonimmune causes of, 1471
pathophysiology of, 1469t
in sepsis, 999
in systemic rheumatic diseases, 1912
treatment of, 1470t
Thrombocytosis, 1471
Thromboelastography, 68
Thromboelastometry, 68
Thromboembolic disease, in Crohn’s disease,
489t
Thromboembolism
in malignancy, 1518
in pregnancy, 624–626
in systemic rheumatic diseases,
1909–1910
venous, 389–399
Thrombogenic foams and gels, 1574
Thrombolysis, 1129–1130
Thrombolytic therapy
in cardiogenic shock, 356
catheter-directed, 399
in deep venous thrombosis, 397t
in pulmonary embolism, 397t
8/2/19 6:02 PM
 2106   Index

Thrombomodulin, 64, 64f Thyroxine, 1447, 1449, 1455–1456 Toe injuries, in children, 921
Thrombophilia, 389 Tiagabine, 1289 Toenails, ingrown, 1929, 1929f
activated protein C resistance in, 1475 Tibial shaft fractures, 1859–1860, 1860t Tolnaftate, 932t
antithrombin deficiency in, 1475 Tibial spine fractures, 919 Toluidine, 1969
clinical features of, 1475t Tibial tuberosity fractures, 919 Tongue
conditions associated with, 1475–1476 Tibialis anterior tendon, 1875 benign migratory glossitis of, 1585
diagnosis of, 1474–1475 Ticagrelor, 1510 geographic, 775f, 776
pathophysiology of, 1474 dosing and administration, 1509t lacerations of, 1589
protein C and S deficiencies, 1476 in NSTEMI, 345t lesions of, 1585
prothrombin gene mutation in, 1475 in STEMI, 344t Mallampati criteria, 181f, 182
Thrombophlebitis Ticarcillin, 319 strawberry, 1585
after pacemaker insertion, 221t Tick paralysis, 1072, 1163–1164 Tonicity, 82, 82t
superficial, 398, 558 Tickborne infections, 1070–1075 Tonometer, 1530, 1530f
Thrombosis anaplasmosis, 1073–1074 Tono-Pen®, 1530
in arterial occlusion, 420 babesiosis, 1074–1075 Tonsillectomy, posttonsillectomy bleeding of,
of axillary artery, 1894 Colorado tick fever, 1074 1599
calf vein, 398 ehrlichiosis, 1073–1074 Tonsillitis, 1594–1596
cavernous sinus, 1584 Lyme disease, 1072–1073 Tooth squeeze, in barotrauma of descent,
central venous, 627 prevention of tick bites in, 1071 1370
cerebral venous, 1110 prophylactic treatment in, 1071 Tooth-knuckle injury, 294
coronary, 162 Rocky Mountain spotted fever, 1071–1072 Topical anesthesia, 238
hemostasis tests in, 1465 Southern tick-associated rash illness, in children, 727
pulmonary embolism, 162 1074 in eye disorders, 1534t
of vascular access, 575 tick paralysis, 1072 Topical corticosteroids, 1620–1622
Thrombotic stroke, 1121t tick removal in, 1071 application of, 1621
Thrombotic thrombocytopenic purpura, tickborne relapsing fever, 1074 correct amount of, 1621–1622, 1622t
1492–1493 treatment of, 1073t by potency group, 1621t
clinical features of, 1493 tularemia, 1074 recommended potency, 1621t
pathophysiology of, 1492–1493 Tickborne relapsing fever, 1074 strength of, 1621
treatment of, 1493 clinical features of, 1072t tachyphylaxis in, 1622
Thrombotics, 1500–1513 treatment of, 1073t Topical medications, 234, 235t
Thrombus, 421t Ticlopidine, 1510 Topiramate, 1152t, 1289
Thrush, 1036t, 1040, 1040f Tidal volume, 78 Tornadoes, 28–29
Thujone, 1411t Tietze’s syndrome, 332 Torsade de pointes, 102
Thumb metacarpal fractures, 1793 Tinea barbae, 1629, 1630f, 1630t in antipsychotics overdose, 1210
Thumb spica splint, 1778, 1778f Tinea capitis, 929f, 932–933, 932f, 1632–1633, Torsemide, in heart failure, 372t
Thunderclap headache, 1107, 1107t 1632f Torus fractures, 906–907, 907f, 915
Typhlitis, 961 Tinea corporis, 932–933, 932t, 1636t, 1638, Total anomalous pulmonary venous return,
Thyroglossal duct cysts, 787 1639f 823
Thyroid cancer, 789 Tinea cruris, 932, 932t, 1652, 1652f, 1652t Total body water, 81
Thyroid disorders, in pregnancy, 623 Tinea manuum, 1664–1665 Total shoulder arthroplasty, 1835–1836
Thyroid storm, 1450 Tinea pedis, 932, 932t, 1619f, 1659t, Tourniquet syndrome of penis, 878
clinical features of, 1452, 1452f 1664–1665, 1665f Tourniquets, 270–271, 293
congestive cardiac failure in, 1457 Tinel’s sign, 1161 in military medicine, 2008
diagnosis of, 1452–1453, 1453t Tinidazole posttourniquet care, 2008–2009
disposition and follow-up in, 1456 in bacterial vaginosis, 1015t Toxalbumins, 1411t
in elderly, 1456 in diarrhea, 487t Toxic conditions. See also Specific substances
laboratory testing in, 1452–1453 in trichomoniasis, 1016t from acetaminophen, 1252–1258
mortality rate of, 1450 Tinnitus, 1560t, 1561 agitation in, 1187
pathophysiology of, 1452 Tinzaparin, 1508t from alcohols, 1222–1232
precipitants of, 1452t in deep venous thrombosis, 397t from amphetamines, 1238–1242
treatment of, 1453–1456, 1454t in pulmonary embolism, 397t from anticholinergics, 1309–1312
definitive therapy in, 1456 Tioconazole, in Candida vaginitis, 650t from anticonvulsants, 1283–1289
identification of precipitation factors in, Tipranavir, 1043t from antidepressants
1456 Tirofiban, 1510 atypical, 1199–1201
inhibition of hormonal release in, 1455 in NSTEMI, 345t cyclic, 1194–1199
inhibition of peripheral adrenergic in STEMI, 344t antidotes, 1187, 1188t
effects, 1453–1455 Tissue adhesives, 272t, 282–284, 283f, 284t from antihypertensives, 1279–1283
preventing peripheral conversion Tissue factor pathway, 1465 from antimicrobials, 1327–1328
of thyroxine to triiodothyronine, Tissue hypoxia, 1415 from antipsychotics, 1208–1212
1455–1456 Tissue plasminogen activator, 1511 arrhythmias in, 1187
supportive care, 1453 Titratable acid, 1297 from barbiturates, 1214–1215
thyroid hormone removal in, 1456 TMP-SMX, 933t from benzodiazepines, 1215–1218
Thyroid-stimulating hormone (TSH), 1447, Toad venom, 1248 from beta blockers, 1270–1275
1451 Tobramycin, in urinary tract infections, 583t in caustic ingestions, 1296–1300
Thyrotoxicosis, 1450 Tocolytics, 635 from cocaine, 1238–1242
atrial fibrillation in, 1457 Toddlers, 669 decontamination in, 1190–1192
drug interactions and, 1457 pain assessment in, 724 diagnostic testing in, 1189–1190, 1190t
emergency surgery for, 1456 Toddler’s fractures, 919, 919f, 992 from digital glycosides, 1267–1270
in pregnant women, 1456 Toe, amputation of, 306 enhanced elimination in, 1192–1194, 1193t

FB:Cardiologia Siglo XXI

Tintinalli_Index_p2025-2116.indd 2106 8/2/19 6:02 PM


epidemiology of, 1187
examination in, 1189, 1190t
from hallucinogens, 1242–1248
history in, 1189
from hydrocarbons, 1292–1296
hyperthermia in, 1187
hypoglycemia in, 1187
hypothermia in, 1187
from industrial toxins, 1318–1323, 1319t
of iron, 1289–1292
from lithium, 1212–1214
from metals and metalloids, 1312–1318
from methylxanthines, 1262–1265
from monoamine oxidase inhibitors,
1204–1208
from nicotine, 1265–1266
from nonbenzodiazepine sedatives,
1219–1222, 1220t
from nonsteroidal anti-inflammatory drugs,
1259–1262
from opioids, 1232–1238
from pesticides, 1300–1309
poisoning, 1187–1194
resuscitation in, 1187–1189
risk assessment in, 1189
from salicylates, 1248–1252
seizures in, 1187
from selective serotonin reuptake inhibitors,
1201–1202
in serotonin syndrome, 1202–1204
from serotonin/norepinephrine reuptake
inhibitors, 1202
toxidromes in, 1189, 1190t
from vitamins, 1323–1325
Toxic epidermal necrolysis, 1624t, 1626, 1626f
Toxic inhalants, 38
Toxic shock syndromes, 1007t, 1624t
Toxic syndromes, 43t
Toxidromes, 1189, 1190t
Toxocara canis, 1078
Toxocariasis, treatment of, 1075t
Toxoplasma gondii, 1079
Toxoplasma retinochoroiditis, 1038
Toxoplasmosis, 787, 1077t, 1079
drugs for, 1036t
in HIV infection, 1035–1037
Tracheal intubation, 179–190
airway assessment in, 180–181
anticipated intubation difficulty, 189
blind nasotracheal intubation, 189
flexible fiberoptic laryngoscopy, 188–189
orotracheal, 181–185
preparation of, 179, 180f
rapid-sequence intubation, 185–187
steps of, 182t
unanticipated intubation difficulty, 189–190
video laryngoscopy, 187, 188f
Tracheitis, 793–794
Tracheoesophageal fistula, in children,
678–679
Tracheomalacia, 1906–1908
Tracheostomy, 1600–1605
bleeding in, 1602
cannulas, 1600–1603, 1603t
complications of, 1600–1602
dislodgement in, 1601–1602
infection in, 1602
mechanical ventilation in, 1602–1603
obstruction in, 1601
respiratory distress in, 1601f
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stenosis in, 1602
in technology-dependent children, 979
tracheoinnominate artery fistula, 1602
tubes, 1600–1603, 1603f
Traction splints, 8–9
Traction-countertraction technique
(modified Hippocratic), 1828, 1828f
Training, 1
Tramadol, 1236
dose of, 232, 232t
in neuropathic pain, 264t
Trandolapril, 1282
Tranexamic acid, 67, 270, 610t, 1480,
1674, 1746, 2009
Transabdominal feeding tubes, 554–555,
554t
Transaminases, 517
Transcutaneous pacing, 217
in bradyarrhythmias, 100
device removal, 199
equipment in, 217t
in infants and children, 686
outcomes assessment, 217
placement of electrodes, 218f
risks and precautions, 217
technique, 217
Transesophageal echocardiography
in aortic dissection, 413
of thoracic great vessels, 1750
Transfeminine, 1998t
Transfusion, 1494–1500
acute lung injury in, 1500
of blood products, 1496–1500
coagulation factor VIIa (recombinant),
1498
complications of, 1498–1500
allergic reactions in, 1500
febrile reactions in, 1499–1500
hemolytic reactions in, 1499
infections, 1500
cross-matching in, 1496
cryoprecipitate, 1497–1498
electrolyte imbalance in, 1500
fibrinogen concentrate, 1498
fresh frozen plasma, 1497, 1497t
graft-versus-host disease in, 1988, 1989t
massive, 1496
packed red blood cells in, 1496
platelet, 1496–1497
reactions, 1499t
Transgender patients, 1997–2000
alternative names for body parts, 1998t
clinical environment for, 1998
defined, 1998t
examination of, 1998
gender-affirming surgeries, 1999–2000
genital feminizing, 1999–2000
genital masculinizing, 1999–2000
gender-affirming treatments for, 1998–1999
gonadotropin blockers for, 1999
greeting, 1998
history, 1998
hormones, 1998–1999, 1999t
intimate partner violence in, 1974
masculinizing hormones, 1999
mental health of, 2000, 2000t
sexual abuse and assault of, 1971
terminology for, 1998
Transient hyperthyroidism of hyperemesis
gravidarum, 623
Index   2107
Transient ischemic attack, 1134–1136
anticoagulation in, 1135
antiplatelet agents in, 1135
diagnosis of, 1134–1135
endarterectomy in, 1135
risk stratification in, 1135–1136
treatment of, 1141
Transient neonatal pustular melanosis, 939,
939f
Transient osteoporosis, 1904
Transient synovitis of the hip, 922–923
Transition, 1998t
Transitional circulation, 820
Transjugular intrahepatic portosystemic
shunt, 520
Translational fracture-dislocation, 1705f
Transmasculine, 1998t
Transplantation, 1984–1994
adverse reactions to immunosuppressants,
1986t
of cornea, 1993–1994
in diabetes mellitus, 1424
differential diagnosis in, 1984–1985
graft-versus-host disease in, 1986–1988,
1986t
in heart disorders, complications in, 1994t
historical elements in, 1985t
infections in, 1986–1987, 1987t
antimicrobial therapy for, 1989t
in cardiac transplantation, 1993
in corneal transplantation, 1993–1994
in liver transplantation, 1991
in lung transplantation, 1991–1993
in renal transplantation, 1989–1991
of kidney
diagnosis in, 1990–1991, 1991t
dysfunctions and failure in, 1991t
imaging in, 1990
infections, 1989–1991
of liver, 1991
complications, 1992t
of lung, 1991–1993
complications of, 1992
infections in, 1991–1993
medical effects, 1988
medications for, 1990t
physical examination in, 1984, 1985t
pneumonia in, 444
posttransplantation lymphoproliferative
disorders, 1988
rejection, 1988, 1990t
Transportation
in accidental hypothermia, 1340f
air medical transport, 9–13
of children, 671–673
conduct, 673
consent for, 673
decisions in, 672
environment in, 672, 672t
modes, 672–673
neonates, 672
precautions in, 672
preparation for, 673
shared decision making, 673
situations requiring, 672, 672t
team in, 671–672
in emergency medical services, 2
Transposition of great arteries, 821–823
Transthecal block, 240
Transthoracic echocardiography, 215, 410
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 2108   Index

Transvenous pacing, 217–218 imaging in, 1675–1676 Trepopnea, 425

in bradyarrhythmias, 100 in impaled objects, 1675 Triage
complications of, 218t laboratory testing in, 1675–1676 in bomb and blast injuries, 33t
equipment in, 218t level 1 centers for, 1670t in chemical exposures, 37–38
insertion in, 219t in marine environment, 1362–1363 in disasters, 22–25, 25t
technique, 218 epidemiology of, 1362–1363 mass casualty, 2013
Transverse myelitis, 1883, 1887, 1910 soft tissue infections in, 1363 cardiopulmonary resuscitation in, 2013
Tranylcypromine, 1205t mechanical ventilation in, 192 individual casualty assessment, 2013
Trapezium fracture, 1802t, 1803–1804, 1804f in natural disasters, 26 three-tier prioritization in, 2013
Trapezoid fracture, 1802t, 1805 of neck, 1722–1729 in psychosocial disorders, 1933–1934
Trash foot syndrome, 421t in obese patients, 1997 in radiation exposure, 51
Trauma, 236, 1669–1766 pain, 236 in sexual abuse and assault, 1967–1968
of abdomen, 1675, 1678–1679, 1751–1755, pelvic, 2012 in trauma, 1669, 1670t
2012 penetrating chest, 2009 Triamcinolone acetonide, 1621
in abdominal/pelvic pain, 614 in postpartum hemorrhage, 646t Triamterene, 1281
airway management in, 1669–1671 in pregnancy, 1680–1683 Triazoles, 1328
in back pain, 1884 prehospital care in, 1681 Triceps, 1811, 1812f, 1877f
barotrauma, 140–141 preplanned care in, 1670f tendon rupture in, 1815
of ascent, 1369t, 1370 primary survey in, 1669–1675, 1671t Trichomonas vaginalis infections, 650–651
of descent, 1369–1370, 1369t pulmonary, 1729–1742 complications of, 651
inner ear, 1370 of scalp diagnosis of, 651, 1018
pathophysiology of, 1390 anatomy of, 286f in HIV patients, 651
pulmonary, 1370, 1371f clinical features, 286 in nongonococcal urethritis, 1018
sinus, 1370 repair of lacerations, 286 pelvic inflammatory disease in, 654
blunt chest wall, 173 suturing guidelines for, 287t premature rupture of membranes in, 634
in bomb and blast injuries, 31 secondary survey in, 1671t, 1675 treatment of, 651, 651t, 1016t, 1018
breathing in, 1671 seizures in, 895–896 Trichophyton infections, 1632–1633
to buttocks, 1755–1757 of spine, 1675, 1696–1714 drugs for, 1037t
cardiac, 1742–1751 thoracolumbar spinal injuries in, 1678 treatment of, 1037t
cardiac arrest in, 1675 triage in, 1669, 1670t Trichuris, 1090
of cervical spine, 1678 Trauma patients Tricuspid atresia, 823
of chest, 1678 helicopter transport for, 11, 12t Tricuspid regurgitation, 378
in children, 689–698. See also Pediatric pain scale performance in, 230 Tricuspid stenosis, 378
trauma Trauma-induced coagulopathy, 64 Tricuspid valve
circulation in, 1671–1674 Traumatic brain injury, 1683 Ebstein’s malformation of, 838
dentoalveolar, 1586–1587 in children, 695t regurgitation, 378
in dermal tattoo, 317 classification of, 1683 stenosis, 378
disability in, 1674 prevalence of, 1683 Trifluridine, 1542
disseminated intravascular coagulation in, Traumatic ischemias, hyperbaric oxygen Trigeminal neuralgia, 260, 264t, 1584
1472t therapy in, 140 Trigger finger, 1918
in elderly, 1677–1680 Traumatic spondylolisthesis (hangman’s Triiodothyronine, 1447, 1449–1450,
exposure in, 1674 fracture), 1703f 1455–1456
to extremities, 1762–1766 Travel, 1079–1092 Trimalleolar fracture, 1869f
of eye, 1544–1552 abdominal and urinary diseases in, 1087 Trimethobenzamide, in nausea and vomiting,
blunt eye trauma, 1548–1552 abdominal pain-associated diseases in, 484t
chemical injuries, 1552–1553 1088–1089 Trimethoprim-sulfamethoxazole, 73
corneal abrasion, 1545, 1545f, 1545t chronic fever-associated diseases in, in diarrhea, 486t
corneal foreign bodies, 1546–1547, 1546f 1086–1087 in diverticulitis, 528t
corneal laceration, 1546 CNS-associated diseases in, 1086 in facial infections, 1568t
lid lacerations, 1547 diagnostic testing in, 1080–1081 in granuloma inguinale, 1016t
of face, 1714–1721 diarrhea-associated diseases in, 1088–1089 in HIV-related infections, 1036t
to flank, 1755–1757 evaluation of returning traveler, 1080–1081 in pertussis, 439
genitourinary, 1757–1762 eye or skin diseases in, 1090–1091 in puncture wounds, 319
of hand fever in, 1081–1085 toxicity of, 1327
in children, 294 fever-associated diseases in, 1081–1085 in urinary tract infection, 873t
clenched fist injuries, 294, 294f, 323, 1916 hemorrhage-associated diseases in, Trimipramine, 1195t
digital amputations, 296–297 1085–1086 Triquetrolunate ligament instability, 1799,
digital nerve injuries, 297 history of, 1080, 1080t 1806f
extensor tendon lacerations, 294–295 incubation period, 1080t Triquetrum fracture, 1803, 1803f
finger lacerations, 296 physical examination in, 1080–1081, 1082t Trochanteric bursitis, 1897–1898
fingertip injuries, 297–298 pulmonary diseases in, 1091–1092 Trochanteric fracture, 1845
flexor tendons lacerations, 296 rabies in, 1056 Trochlea fractures, 1819
lacerations, 292–299 risk of exposure, 1080t Tropisetron, 1519t
nail and nail bed injuries, 298, 298f tropical infections in, 1083t–1084t Troponin assays, high-sensitivity, 333
palm lacerations, 296 worm infections in, 1089–1090 Troponins, 574
ring tourniquet syndrome, 299 Traveler’s diarrhea, 851 Truncal vagotomy, 560
volar, 295–296 Trazodone, 1200–1201, 1948–1949 Truncus arteriosus, 823
of head, 1675, 1678, 1683–1695 Tremor, 1104 Trunk, skin disorders of, 1635–1661
of heart, 1742–1751 Trench foot, 1333 Trypanosoma brucei gambiense, 1086–1087
hypothermia in, 1345 Trench mouth, 1584 Trypanosoma brucei rhodesiense, 1086–1087

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Trypanosomiasis, 1086–1087
Tsunamis, 29
Tube replacement, 555
Tube thoracostomy, 460, 1741–1742
Tubercles, 451
Tuberculin skin test, 452–453
Tuberculosis, 451–457. See also Pulmonary
emergencies; Respiratory disorders
blood tests in, 453
chest radiographs in, 453, 453f
in children, 456
clinical features of, 452
diagnosis of, 452–454
differential diagnosis of, 452–454
disposition and follow-up in, 455
drugs for
ethambutol, 1329
isoniazid, 1329
pyrazinamide, 1329
rifampin, 1329
toxicity of, 1327t, 1329
epidemiology of, 451
extensive drug-resistant, 456
extrapulmonary, 456
in HIV infection, 455–456, 1039
hospital admission in, 455
latent, 453, 455
Mantoux test for, 452–453
microscopy/cultures in, 453–454
miliary, 456
multidrug-resistant, 456
outpatient care in, 455
pathophysiology of, 451
in pneumonia, 817–818
pneumonia in, 811
primary and latent infection, 451–452
reactivation, 452–453, 453f
in travelers, 1092
treatment of, 454–455, 455t
tuberculin skin test for, 452–453
Tuberculous meningitis, 456–457
Tubo-ovarian abscess, 479t, 657
Tularemia, 769, 787, 1074, 1077t
clinical features of, 1072t
signs and symptoms of, 43t
Tulips, 1414
Tumor lysis syndrome, 564, 962–963, 963t,
1517
Tumors
airway obstruction in, 1513, 1513t
anorectal, 546–547, 547t
brain, 1110
in children
bone and soft tissue sarcomas, 960–961
cardiopulmonary complications in, 965
catheter-related complications in, 965
central nervous system tumors, 958
complications in, 961–965
Ewing’s sarcomas, 961, 961f
gastrointestinal complications in, 965
genitourinary complications in, 965
germ cell tumors, 960, 960f
infection in, 961–962
intracranial pressure in, 964
metabolic complications in, 962–965
nephroblastoma (Wilms’ tumor), 959,
959f
neuroblastoma, 958–959
neurologic emergencies in, 964–965
osteosarcomas, 960–961, 961f
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retinoblastoma, 959–960
rhabdomyosarcoma, 960
seizures in, 964–965
spinal cord compression in, 964
stroke in, 964
superior mediastinal syndrome in,
963–964
superior vena cava syndrome, 963–964
clotting disorders in, 1476
complications of, 1513, 1513t
febrile neutropenia in, 1517–1518
hyperviscosity syndrome in, 1518
pericardial effusion with tamponade,
1514–1515
in skin lesions, 1611f, 1611t
spinal cord compression, 1514, 1514t
Turf toe, 1875
T-wave inversion, 54
Two-way radio, 4
Tympanic membrane, perforation of, 1565–
1566, 2012
Type I vehicles, 4
Type II vehicles, 4
Type III vehicles, 4
Typhoid fever, 1082
Typhus fever, 43t, 1084
Tyramine, 1208
Tzanck smear, 1620f
U Umbilical vein access, 722
Ulcerative colitis, 261t, 264t, 491–492, 868
clinical features of, 491
complications of, 492
diagnosis of, 491
differential diagnosis of, 491
disposition in, 492
epidemiology of, 491
pathophysiology of, 491
treatment of, 491–492
Ulcers, 1655–1658, 1657f
arterial, 1425
Buruli, 1657, 1657f
corneal, 1543, 1543f
diabetic, 1656–1657, 1657f
differential diagnosis of, 1618f, 1618t
leishmaniasis, 1658, 1658f
neuropathic, 1656–1657, 1657f
of oral cavity, 1584
pyoderma gangrenosum, 1656f
in skin lesions, 1609f, 1609t
venous, 1425
venous leg ulcers, 1655–1656
venous stasis dermatitis, 1655–1656, 1655f
Ulipristal acetate, 1970t
Ulna diaphyseal fractures, 915
Ulnar fractures, 915, 1820–1821
Ulnar mononeuropathy, 1162
Ulnar nerve block, 241–242
Ulnar styloid fracture, 1809
Ultrasonography
in abdominal pain, 476
in abdominal trauma, 1753, 1753f
in abdominal/pelvic pain, 613, 613f
in aneurysms, 417–418, 417f
in appendicitis, 524, 525f, 860–861, 861f
in arterial catheterization, 210
in central venous access, 203
in central venous pressure, 214
in cholecystitis, 514, 514f
in ectopic pregnancy, 617–618, 618f
Index   2109
in eye disorders, 1556–1559
intracranial pressure, 1559–1560, 1559f
of intraocular foreign body, 1558, 1559f
of ocular trauma, 1558
of retinal detachment, 1559, 1559f
scanning technique in, 1556–1557
of vitreous hemorrhage, 1559, 1559f
in femoral vein localization, 208
in head trauma, 693–694
in heart failure, 369–370, 369f
in hemothorax, 1732f
in pediatric trauma, 693–694
in pericardiocentesis, 226
in peripheral venous access, 202
in pneumothorax, 458, 458f
in prehospital care, 6–7
in pulmonary hypertension, 410f
in pulmonary trauma, 1740
in shock, 60–61
in soft tissue foreign bodies, 311–312,
312f–313f
of trauma to extremities, 1764
in urologic stone disease, 601, 601f
in venous thromboembolism, 395, 396f
Ultraviolet keratitis, 1543–1544
Umbilical cord
clamping, 640–641, 674
prolapse of, 642
Umbilical hernia, 535, 536f
Uncal herniation syndrome, 1140
Underweight, 256–257
Undifferentiated wide-complex tachycardias,
116–117
clinical features of, 116–117
description of, 116
methods for differentiation, 117t
treatment of, 117
Unfractionated heparins, 347, 1506–1507,
1508t
in acute limb ischemia, 422
in arterial occlusion, 423t
in deep venous thrombosis, 397t
in intracerebral hemorrhage, 1118t
in pulmonary embolism, 397t
Unhealthy alcohol use, 1959–1960
Unilateral facet dislocation, 1700f
Upper arm lacerations, 294
Upper extremity, muscles, 1105t
Upper gastrointestinal bleeding, 495–498.
See also Gastrointestinal disorders;
Lower gastrointestinal bleeding
antibiotics in, 497
balloon tamponade in, 498, 498f
blood transfusion in, 496–497
coagulopathy in, 497
diagnosis of, 496–497
in Dieulafoy lesions, 495
disposition and follow-up in, 498
endoscopy in, 497–498
epidemiology of, 495
in erosive gastritis, 495
in esophageal and gastric varices, 495
in esophagitis, 495
history in, 496
laboratory testing in, 496
in Mallory-Weiss syndrome, 496
nasogastric lavage in, 496
pathophysiology of, 495–496
in peptic ulcer disease, 495
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 2110   Index

Upper gastrointestinal bleeding (Cont.): Urinary tract infection causes of, in perimenopausal women,
physical examination in, 496 antibiotics in, 873–874, 873t 609t
promotility agents in, 497 in children, 747, 870–874 clinical features of, 607
proton pump inhibitors in, 497 clinical features of, 871 historical elements in, 609t
risk stratification in, 497, 497t comorbidities in, 871 history in, 607
somatostatin analogs/octreotide in, 497 culture-negative dysuria and pyuria, hypothyroidism in, 609
treatment of, 497, 497t 871t illness in, 612
Upper motor neuron syndrome, 1106 diagnosis of, 871–873 imaging in, 610
Upper respiratory tract infections, 436–439 epidemiology of, 870–871 inherited bleeding disorders in, 611–612
common cold, 437 history in, 871 laboratory testing in, 610
influenza, 437–438 imaging in, 872 leiomyomas in, 608–609
pertussis, 438–439 laboratory testing in, 872–873 malignancy in, 609, 609t
Urapidil, 887t pathophysiology of, 871 massive uterine bleeding, 611
Urea breath test, 507 physical examination in, 871 menstrual cycle in, 607, 608f
Urea-substituted herbicides, 1307 risk factors for, 871t ovulatory dysfunction in, 609, 609t
Uremia, 74t, 573–575 treatment of, 873 physical examination in, 607
b2-microglobulin amyloidosis in, 575 in children with special healthcare needs, in polycystic ovary syndrome, 612
cardiovascular complications in, 574 982 polyps in, 607
clinical features of, 573–575, 573t as gynecologic-abdominal surgery rapid weight change in, 612
defined, 573 complication, 665 stress in, 612
in end-stage renal disease, 573 postoperative, 556 treatment of, 610t, 611
hematologic complications in, 574–575 urolithiasis in, 874 atony of, 644, 646f
neurologic complications in, 573–574 in urologic stone disease, 601 inversion of, 644
renal bone disease in, 575 Urinary tract infections, 578–583 rupture of, 644–646
Uremic cardiomyopathy, 574 asymptomatic bacteriuria, 578 Utstein template, 3
Uremic encephalopathy, 573 catheter-associated, 579, 602–603 Uveal tract, 1523
Ureteral colic, 479t clinical features of, 579–580 infections of, 1544
Ureteral injuries, 1759 complicated, 579, 579t, 580, 583 Uveitis, 1544
Ureteral stents, complications of, 604–605, cystitis, 578, 582 in Crohn’s disease, 489t
605t diagnosis of, 580 Uvular edema, 1596
Urethra urinalysis in, 579–580, 580t Uvulitis, 780–781, 781f
disorders of, 597 disposition and follow-up in, 583
foreign bodies in, 597 etiologic agents of, 580t V
injuries to, 1760–1761, 1760f–1761f in HIV/AIDS, 583 Vaccine
strictures, 597 imaging in, 581 acellular, 438
Urethral catheterization, 587, 588f microbiology of, 579, 580t whole-cell, 438
Urethritis, 578 outpatient management of, 582t Vagal maneuvers, 102t
clinical features of, 579–580 pathophysiology of, 578–579 Vaginal bleeding
nongonococcal, 1018 in pregnancy, 583 causes of, 607–610
Uric acid, 963 pyelonephritis, 579 endometrial, 609–610
Urinalysis, 567, 579–580, 872 recurrent, 579, 583 iatrogenic, 610
dipstick test treatment of, 580–582 nonstructural, 609–610
leukocyte reaction by, 581 uncomplicated, 579, 582 structural, 607–609
nitrite reaction by, 581 urethritis, 578 causes of, by age group, 609t
normal rates and specimen type in, 580t Urine culture, 872, 872t coagulopathies in, 609
urine and blood culture in, 581 Urography, 601 in emergency delivery, 642–643
WBC count, 581 Urolithiasis, 874 ovulatory dysfunction in, 609, 609t
Urinary agents, 1489t Urologic stone disease, 598–602 in pregnancy, 633–634
Urinary alkalinization, 1193, 1215 in children, 602 terminology for, 608t
Urinary catheters, 475 clinical features of, 599 Vaginal cuff, 665
Urinary catheters, complications of, diagnosis of, 599–600 Vaginitis, 1653
602–604 differential diagnosis of, 598t Candida, 649–650
Urinary diversion disposition and follow-up in, 602 signs and symptoms, 651t
complications of, 604 epidemiology of, 598 Vaginosis
in technology-dependent children, 980 imaging in, 600–601 bacterial, 649–651
Urinary fluorescence, 1230 indications for admission in, 602t pelvic inflammatory disease in, 654
Urinary retention, 481, 586–590 laboratory testing in, 599–600, 600t premature rupture of membranes in, 634
causes of, 587t medical expulsion therapy in, 602 treatment of, 1015t
clinical features, 586–587 pathophysiology of, 598–599 Valacyclovir, 1016t, 1020, 1036t–1037t,
clot retention in, 589 in pregnancy, 602 1631t
diagnosis of, 587 risk factors for, 598t–599t in vertigo, 1152t
epidemiology of, 586 treatment of, 601–602 Valerian, 519t, 1325t
in females, 589 Urticaria, 71–72, 1644–1645, 1644t, 1645f Valganciclovir, 1036t
gross hematuria in, 589 cold, 1333 Valproate, 1112t
pathophysiology of, 586 Uterotonics, in emergency delivery, 638t in hiccups, 428t
pharmacologic agents in, 585t Uterus toxicity of, diagnosis of, 1286
postcatheterization care in, 589 abnormal bleeding of, 607–612 Valproic acid, 628, 1286–1287
postoperative, 556–557, 589 adenomyosis in, 608 in bipolar disorder, 1950t
treatment of, 587–589, 587t causes of, 607–610 pathophysiology of, 1286
urethral catheterization in, 587, 588f causes of, by age group, 609t in seizures, 892

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in status epilepticus, 1158
toxicity of, 1286–1287
clinical features of, 1286
treatment of, 1286–1287
in vertigo, 1152t
Valsalva maneuver, 102, 102t, 1112
Valsartan, 132, 133t, 1282
Valvular heart disorders, 374–380
aortic regurgitation, 377–378
aortic stenosis, 376–377
mitral regurgitation, 374–376
mitral valve prolapse, 376–377
new murmurs in, 374
prosthetic valve disease, 379–380
right-sided, 378–379
in sudden cardiac death, 54
in systemic rheumatic diseases, 1915
Vancomycin
in acute kidney failure, 566
in bacterial infections, 933t
in cellulitis, 1915t
in deep space infection, 1915t
in diarrhea, 487t
in facial infections, 1568t
in flexor tenosynovitis, 1915t
in intra-abdominal infections, 480t
in peritonitis, 578
in pneumonia, 445t
in premature rupture of membranes, 635
toxicity of, 1327
Variceal bleeding, 867, 869
Varicella, 1027–1029
in children, 931, 931f
clinical features of, 1028, 1029f
diagnosis of, 1028–1029
in HIV infection, 1041
pathophysiology of, 1028, 1028f
rashes in, 931, 931f
treatment of, 1029
vaccines for, 1028
Varicocele, 875–876
Variola major, 43t, 45t
Vas deferens, 592
Vasa previa, 634
Vascular access, 201–211
aneurysms, 575
arterial access in, 209–211
bleeding in, 575–576
central venous access in, 202–208
in children, 719–722
central venous access, 721–722
intraosseous access, 719–721
neonates, 676
peripheral venous access, 721
complications of, 575–576
endotracheal substitution for, 196–197
equipment, 6
in hemodialysis, 575
hemorrhage from, 575, 576t
infections, 575
IO, 208–209, 209f, 209t
in obese patients, 1995, 1996f
peripheral venous access in, 201–202
pseudoaneurysms, 576
in traumatic shock, 65–66
ulcerated hemodialysis fistula, 576
venous cutdown in, 208
Vascular dementia, 1944
Vascular ectasia, lower gastrointestinal
bleeding in, 498
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Index   2111
Vascular imaging, 1126–1127 calf vein thrombosis in, 398
Vascular injuries in cancer patients, 399
in bomb and blast injuries, 32, 32f clinical features of, 391–392
in electrical injuries, 1398–1399 deep vein thrombosis in, 391–392
in lightning injuries, 1402 diagnosis of, 391–396
in neck trauma, 1725, 1727t clinical assessment in, 392
penetrating, 1725, 1727t D-dimer testing, 392, 394t
Vascular rings and slings, 790 decision rules in, 392
Vasculitis, 421t, 1477 steps in, 396–397
in hemoptysis, 433 epidemiology of, 389
in systemic rheumatic diseases, 1912 history in, 390
Vasectomy, complications of, 606 imaging in, 392–396
Vasoactive agents, 61t in malignancy, 1518
in pregnancy, 168–169, 168t pathophysiology of, 389–390
Vasodilation, 370 physical examination in, 390–391
in heart failure, 371 in pregnancy, 399, 624–626
Vasodilators, 133t, 1282–1283 risk factors for, 390t
in aortic dissection, 415 superficial thrombophlebitis in, 398
fenoldopam, 1283 Venous ulcers, 1425
in heart failure, 372t Ventilation
hydralazine, 1282–1283 in acclimatization, 1377
in hypertension, 405t, 406 assisted, 470, 471t
hypotension in, 371t in asthma, 466, 807, 808t
mechanism of action, 1280t bag-mask, 711–712, 711f
minoxidil, 1283 in bronchiolitis, 803
sodium nitroprusside, 1283 in cardiopulmonary resuscitation, 146
in vertigo, 1152t mouth-to-mask, 147, 147f
Vaso-occlusive pain crisis, 1483–1484 mouth-to-mouth, 146, 146f
Vasopressin, 136, 159 mouth-to-nose, 146
actions of, 136 mouth-to-stoma or tracheotomy, 146
adverse effects of, 136 rescue breathing, 146
cardiovascular effects of, 134t in children, 710–718
contraindications, 134t anatomy in, 710–711, 711t
dosing and administration, 134t bag-mask ventilation, 711–712
indications for, 136 equipment in, 712–713, 713t
pharmacokinetics of, 136t neonates, 675–676
in pregnancy, 168t noninvasive ventilation in, 712
in sepsis, 1002 physiology in, 710
in shock, 61t in chronic obstructive pulmonary disease,
in variceal bleeding, 869 470, 470t
Vasopressors, 91t, 133–137 jet, 198–199
administration recommendations and mechanical, 190–193, 466
complications, 133–135 noninvasive, 470, 471t, 712, 712f
in adrenal crisis, 1459t noninvasive positive-pressure, 175–177,
in anaphylaxis, 71 466
angiotensin II, 136–137 positive-pressure, 675–676, 807
bolus-dose administration of, 135 in post-ROSC complications, 162
cardiovascular effects of, 134t in pulmonary hypertension, 410–411
contraindications, 134t in pulmonary trauma, 1740, 1740t
dopamine, 135 sedation during, 191–192
dosing and administration, 134t in sepsis, 1002
epinephrine, 135 in traumatic shock, 65
norepinephrine, 135 Ventilation–perfusion (V/Q) lung scanning,
phenylephrine, 135–136 395, 395f
in sepsis, 1001–1002 Ventilation-perfusion, in hypoxemia, 426
in shock, 61 Ventilatory acclimatization, 1377
vasopressin, 136 Ventilatory failure, 425
Vasospasm, 1116 Ventral hernia, 532
Vasovagal syncope, 363 Ventral septal defect, acute, 353
Vector borne illnesses, in natural disasters, 27 Ventricular arrhythmias, in pregnancy, 624
Vecuronium, 187, 187t Ventricular fibrillation, 117–118, 118f
Vehicles, 3–4 in acute coronary syndrome, 349
Venlafaxine, 1202 algorithm on management of, 160f
Venography, 396 in cardiac arrest management, 159–160
Venomous fish stings, 1364 epidemiology of, 152
Venous blood gas analysis, 80 in sudden cardiac death rescue, 56
Venous cutdown, 208 Ventricular free wall rupture, 350
Venous leg ulcers, 1655–1656 Ventricular premature contractions, in acute
Venous stasis dermatitis, 1655–1656, 1655f coronary syndrome, 349
Venous thromboembolism, 389–399 Ventricular septal defect, 816
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 2112   Index
Ventricular tachycardia, 114–116
in acute coronary syndrome, 349
algorithm on management of, 159–160,
160f
clinical significance of, 115
electrocardiograms of, 115f, 115t
epidemiology of, 152
pulseless, 159–160
treatment of, 115–116
Ventriculoperitoneal shunt, 895
Verapamil, 129, 1276t
actions of, 129
adverse effects of, 130
in atrioventricular blocks, 101t
dosing and administration, 130
indications for, 129
pharmacokinetics of, 129, 130t
in tachycardia, 102
Verbal de-escalation, 1940
Vernakalant, 129
in atrial fibrillation/flutter, 109
in tachydysrhythmias, 101t
Vertebral artery dissection, 1125–1126
Vertebral column, 1696
Vertebral osteomyelitis, 1887–1888
Vertical banded gastroplasty, 480t
Vertical mattress sutures, 275t, 276–277,
279f
Vertical shear fracture, 1838
Vertigo, 1145–1153
alternobaric, 1370
bedside testing in, 1147
benign paroxysmal positional,
1148–1149, 1150t
causes of, 1146t
clinical features of, 1147
diagnosis of, 1148f
Dix-Hallpike test in, 1147
drug therapy for, 1144, 1152t
epidemiology of, 1145–1146
HINTS testing in, 1149–1150
history in, 1147
in Ménière’s syndrome, 1151
in multiple sclerosis, 1153
nystagmus in, 1149
in ototoxicity, 1152–1153
pathophysiology of, 1146–1147, 1147f
in perilymph fistula, 1151
peripheral, 1144–1148
persistent continuous ongoing, 1148
physical examination in, 1147
posttraumatic, 1153
stroke and, 1128
treatment of, 1148–1153
in vestibular ganglionitis, 1151–1152
in vestibular migraine, 1152t
in vestibular neuritis, 1149–1150
in Wallenberg’s syndrome, 1153
Vesicants, 40–41, 1395
Vesicles, 1612f, 1612t
diagnosis of, 1617f, 1617t
Vesicovaginal fistulas, 665
Vestibular ganglionitis, 1151–1152
Vestibular migraine, 1152t
Vestibular neuritis, 1140, 1149–1150, 1150t
Vibrio cholerae infection, 43t, 846t, 1066t,
1067
Vibrio parahaemolyticus, 1066t
Vibrio vulnificus, 1066t, 1069f, 1070t
Video laryngoscopy, 187, 188f
Tintinalli_Index_p2025-2116.indd 2112
Vigabatrin, 1289 cycling vomiting syndrome, 483–484
Vilazodone, 1201 differential diagnosis of, 483t
Vildagliptin, 1430 epidemiology of, 481
Vincent’s disease, 1583 history, 481–482
Viral arthritis, 1926 imaging in, 483
Viral encephalitis, 1175–1176 laboratory testing in, 482
clinical features of, 1175 in neonates, 737
diagnosis of, 1176 in palliative care, 2003
pathophysiology of, 1175 pathophysiology of, 481
physical examination in, 1176 physical examination in, 482, 483t
treatment of, 1176 in pregnancy, 621
Viral hepatitis serologies, 517 projectile, 737
Viral infections, 1024–1032 treatment of, 483, 484t
arboviral, 1031–1032 von Willebrand factor–cleaving protease,
cytomegalovirus, 1030 1492
Ebola virus, 1032 von Willebrand’s disease, 611–612, 951t, 952,
Epstein-Barr, 1029–1030 1481–1482. See also Hematologic
hemorrhagic fever, 1032 disorders
herpes simplex, 1025–1027 in children, 952
herpes zoster, 1027–1029 classification of, 1481t
influenza, 1024–1025 clinical features of, 952, 1481
measles, 1030–1031 diagnosis of, 952
varicella, 1027–1029 epidemiology of, 1481
Viral meningitis, 1175 nontransfusional therapy in, 1481
in children, 752 pathophysiology of, 1481–1482
signs and symptoms of, 754 transfusional therapy in, 1481–1482
Viral parotitis (mumps), 1568–1569 treatment of, 952, 1481–1482
Viroptic, 1542 Vortioxetine, 1201
Visceral pain, 473, 474t Vulvovaginitis, 647–650, 880
Viscoelastic hemostatic assays, 68 acute, 648t
Visual acuity, 763, 1525–1526 atrophic vaginitis, 653
Vital signs bacterial, 649–651
in children, 691t bacterial vaginosis, 648–669
in headache, 1108 Bartholin gland cyst and abscess in, 653,
Vitamin A, 1323, 1323t 653f
Vitamin B1 (thiamine), 1323t, 1324 Candida vaginitis, 649–650
Vitamin B12 (cyanocobalamin), 1323t, 1325 causes of, 649t
Vitamin B2 (riboflavin), 1323t, 1324 clinical features of, 648
Vitamin B3 (niacin), 1323t, 1324–1325 contact, 652
Vitamin B6, 622t diagnosis of, 648
Vitamin B6 (pyridoxine), 1323t, 1325 based on secretions, 648t
Vitamin C, 1323t, 1325 factors associated with, 648t
Vitamin D, 1323t, 1324 foreign bodies in, 654
Vitamin E, 1323t, 1324 pathophysiology of, 647
Vitamin K, 1323t, 1324 pinworms in, 654, 654t
Vitamin K deficiency bleeding, 952–953 signs and symptoms of, 648t
Vitamins, overdose and toxicity of, 1322t,
1323–1325 W
Vitreous hemorrhage, 1544, 1559, 1559f Waddling gait, 1143
Vitreous humor, 1544 Walkers, 1781
Vocal cord paralysis, 790 Wallenberg’s syndrome, 1153
Volar forearm, lacerations of, 295–296 Warfarin, 636, 1503–1505
Volatile substances, 1292–1296, 1293t in coagulopathy, 1504–1505, 1504f
Volkmann’s ischemic contracture, 1817 interaction with NSAIDs, 1260
Volunteer coordination center, in disasters, interactions, 1503t
22 in intracerebral hemorrhage, 1118t
Volvulus, 858–859, 868 in necrosis, 1476–1477
Vomiting, 481–484. See also Gastrointestinal rodenticides, 1307–1309
disorders Warts
ancillary testing in, 483 anal, 547
bilious, 843 plantar, 1664, 1664f
causes of, by, 843t Wasp stings, 1350–1351
in chemotherapy, 1518–1519 anaphylaxis in, 1351
in children, 842–843 clinical features of, 1350–1351
causes of, 844t treatment of, 1351
gastroesophageal reflux in, 843–844 venom in, 1350
intussusception in, 844 Water hemlock, 1412
malrotation in, 832 Waterborne illnesses, 1068–1070
pyloric stenosis in, 844 bacteria in, 1067–1068
clinical features, 481–482 clinical features of, 1069, 1069t
FB:Cardiologia Siglo XXI
8/2/19 6:02 PM

diagnosis of, 1069
enteric viruses in, 1069
epidemiology of, 1067
protozoa in, 1068–1069
treatment of, 1069–1070, 1070t
Weeverfish, 1364
Wegener’s granulomatosis, 433, 563,
1907t
in pulmonary infiltrates, 448t
Weil’s disease, 1084
Welch Allyn Panoptic® direct
ophthalmoscope, 1529, 1529f
Well’s score, 392, 394t, 625
Wernicke’s aphasia, 1102
Wernicke-Korsakoff syndrome, 520
Wernicke’s syndrome, 1324
West Nile virus encephalitis, 1075
treatment of, 1075t
Westermark’s sign, 391
Western water hemlock, 1412
Wheal, 1612f, 1612t
diagnosis of, 1616f, 1616t
Wheezing, 798–810
asthma in, 803–810
bronchiolitis in, 801–803
in children, 798–810
clinical features of, 800
diagnosis of, 800
differential diagnosis of, 800t
history in, 799t
respiratory physiology in, 799, 799f
Whipworm disease, 1090
White blood cell
count
in ascitic fluid, 517
in systemic rheumatic diseases, 1912
in urinalysis, 581
White phosphorus, 1396
Whole-bowel irrigation, 1192, 1277
Whooping cough. See Pertussis
Wide-complex tachycardias, 100, 103, 103f,
114–118
electrocardiograms of, 111f
undifferentiated, 116–117
ventricular fibrillation, 117–118
ventricular tachycardia, 114–116
Wide-complex tachydysrhythmias, ventricular
fibrillation, 118f
Widow spiders, 1353f
Wife battering. See Intimate partner violence
and abuse
Wilms’ tumor, 959, 959f
Winter disasters, 29
Withdrawal hallucinosis, 1224
Withdrawal syndromes
alcohol, 1224–1225, 1225t
amphetamines, 1242
barbiturates, 1215
benzodiazepines, 1218
cocaine, 1242
opioids, 1236–1237, 1237t
Wolf spiders, 1355
Wolff-Parkinson-White syndrome, 100,
118–120
atrial fibrillation in, 121f
in children, 839–840, 840f, 840t
clinical features of, 118–119
dysrhythmias in, 118t
electrocardiogram of, 119f, 119t,
120f
FB:Cardiologia Siglo XXI
Tintinalli_Index_p2025-2116.indd 2113
Women
abdominal pain in, 477
abnormal uterine bleeding in, 607–612
abortion in
induced, 666, 666t
spontaneous, 620–621
abuse and assault of, 1971–1974
assessment of, 1972
clinical features of, 1972–1973
consequences of, 1972t
definition of, 1971
documentation of, 1973–1974
hotlines for patients, 1974t
legal considerations in, 1974
in pregnancy, 629, 1974–1975
risk assessment in, 1972–1973
screening for, 1972, 1973t
signs of, 1972t
obstetric and gynecologic disorders in,
607–667
abdominal and pelvic pain in
nonpregnant female, 612–615
abnormal uterine bleeding, 607–612
breast disorders, 658–662
complications of gynecologic procedures,
663–667
ectopic pregnancy, 615–622
gestational trophoblastic disease, 621
maternal emergencies after 20 weeks of
pregnancy, 631–636
pelvic inflammatory disease, 654–658
spontaneous abortion, 620–621
vulvovaginitis, 647–654
pregnancy in, 631–632
abruptio placentae in, 633–634, 633f
adrenal insufficiency, 1460
airway management in, 167
aortic dissection in, 415
appendicitis in, 526–527
asthma in, 627
bacteriuria in, 626–627
bomb and blast injuries in, 33
carbon monoxide poisoning in, 1417
cardiac arrest in, 165–166, 168t
cardiac arrhythmias in, 623–624
cardiovascular changes in, 165–166, 165t
central venous thrombosis in, 627
chronic hypertension in, 631
clotting disorder in, 1476
cocaine in, 1238
comorbid disorders in, 622–631
cystitis in, 626–627
deep venous thrombosis in, 624–626
diabetes in, 622–623
in diabetic ketoacidosis, 1441
disseminated intravascular coagulation
in, 1472t
DTaP booster in, 438
eating disorders in, 1959
eclampsia in, 633
ectopic, 615–622
electrical injuries in, 1400
in emancipated minors, 2017
emergencies during labor and delivery,
640t
emergency delivery in, 637–647
fetal radiation effects in, 631, 631t
gastrointestinal disorders in, 628
genitourinary trauma in, 1762
gestational age in, 642
Index   2113
gestational hypertension in, 632
headache and stroke syndromes in,
627–628
hepatitis in, 523
high-altitude disorders in, 1383
human immunodeficiency virus infection
in, 628–629
hypertension in, 627
hypothyroidism in, 1450
intimate partner violence in, 629,
1974–1975
intracerebral hemorrhage in, 627
malaria in, 1062
maternal and fetal injuries in, 1680–1683
medications in, 629–630
migraine in, 627–628
nausea in, 621
patient transfer during, 636
physiology of, 165–166, 165f, 165t
placenta previa in, 634
pneumonia in, 443
preeclampsia in, 632–633, 632t
prehospital care in, 1681
premature rupture of membranes in,
634–636, 635t
preterm birth in, 634–635
preterm labor in, 634
pulmonary changes in, 165t, 166
pulmonary embolism in, 625–626, 625t
pyelonephritis in, 626–627
rabies in, 1056
radiation exposure in, 52
respiratory changes in, 165t, 166
resuscitation in, 164–169
sedation, 257
seizures in, 628, 1156–1157
sepsis in, 166–167, 167t
sexually transmitted infections in, 1017
stroke in, 627–628
subarachnoid hemorrhage in, 627
substance abuse in, 629, 630t
testing, 615
thromboembolism in, 624–626
thyroid disorders in, 623
thyrotoxicosis and, 1456
trauma in, 1680–1683
vaginal bleeding in, 633–634
vasa previa in, 634
venous thromboembolism in, 399
vomiting in, 621
Wood splinters, removal of, 315, 315f
Wood’s light, 1619
Wood’s lamp, 1528
Woods’ corkscrew maneuver, 643, 643f
Woolsorter’s disease, bacterial skin infections,
1078
Word catheter, 653f
Wormwood, 1326t
Wounds
antibiotics for, 324–325, 325t
bites, 321–324
in burns, 1389–1390
closure of, 272–285
adhesive tapes, 272t, 282, 282f
bite wounds, 321
cyanoacrylate tissue adhesives, 282–284,
283f, 284t
delayed (tertiary), 272
in foot and leg lacerations, 303
hair apposition, 272t, 284, 285f
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 2114   Index
Wounds, closure of (Cont.):
primary, 272
secondary, 272
staples, 272t, 280–282, 281f
sutures, 272t, 273–280, 273t–274t
techniques, 272t
in trauma to extremities, 1764
dehiscence, 558
drains, 325–326
dressings in, 324
edge eversion, 276f
evaluation of, 267–269
principles, 267
risk assessment, 267
examination of, 268
foreign bodies in, 307–317
in foot injuries, 306
hematoma, 665
imaging of, 268–269
infections of, 321–324
abdominal surgery, 664–666
breast, 662
risk factors for, 267, 268t–269t
tetanus, 325, 325t
of leg and foot, 299–307
marine-associated, 1363, 1363t
medical history and, 268t
patient education on, 269
postoperative complications, 557–558
postrepair care, 324–327
cosmetic outcome, 327
edema reduction in, 324
follow-up, 325–326
pain control in, 326
tetanus prophylaxis, 325
water contact and cleaning, 325
preparation, 269–272
anesthesia in, 269
control of bleeding, 270
debridement in, 271, 271f
in foot and leg lacerations, 303
foreign body removal in, 271–272
hair removal in, 269
hemostasis in, 270–271
irrigation in, 270–271
skin disinfection in, 269
sterilization in, 269
puncture, 317–321
in rabies, 1054
risk assessment, 267
seromas, 665
in tetanus, 1049–1050, 1050t
in trauma to extremities, 1764
Tintinalli_Index_p2025-2116.indd 2114
W-plasty, 271, 271f–272f for influenza, 438
Wrist in influenza, 438t
anatomy of, 1794, 1794f, 1796f Zidovudine, 1042t, 1096t
arthrocentesis of, 1923, 1923f Zika virus, 1024, 1084–1085
bones of, 1782f Zinc, 1308t, 1318t
carpal bone fractures of, 1802–1805 in gastroenteritis, 849
carpal bones of, 1795 Ziprasidone
distal radius and ulna fractures of, in agitation, 1940t
1805–1809, 1806t in bipolar disorder, 1950t
Barton’s fracture, 1808, 1808f Zolpidem, 1220t, 1221
Colles’ fracture, 1805–1806, 1807f Zonisamide, 1289
distal radioulnar joint disruption, 1809 Zoonotic encephalitis, 1075
radial styloid, 1808–1809, 1809f Zoonotic infections, 1070–1079
Smith’s fracture, 1806, 1808f anaplasmosis, 1073–1074
ulnar styloid, 1809 anthrax, 1076
distal radius of, 1794–1795 babesiosis, 1074–1075
distal ulna of, 1794–1795 bacterial skin infections, 1078
imaging of, 1796–1797 brucellosis, 1076
injuries of, 1794–1809 Colorado tick fever, 1074
clinical features of, 1795–1796 common systemic infections, 1071t
pathophysiology of, 1795 cutaneous anthrax, 1078
joint aspiration of, 1923, 1923f dermatologic, 1078
lacerations of, 294–296 ehrlichiosis, 1073–1074
ligamentous injuries of, 1797–1801 encephalitis, 1075
lunate dislocation, 1799–1801, 1801f hantavirus, 1078
perilunate dislocation, 1799–1801, helminths (worms) in, 1078
1800f–1801f household pets in, 1078, 1079t
scapholunate ligament instability, in immunocompromised persons,
1797–1799, 1798f 1079, 1079t
triquetrolunate ligament instability, lower respiratory, 1076–1078
1799, 1806f Lyme disease, 1072–1073
ligaments of, 1795f meningitis, 1075
radiography of, 1796–1797, 1797t pasteurellosis, 1076
Wrist block, 240–242 plague, 1076–1078
Wuchereria bancrofti, 1091 protozoa in, 1079
psittacosis, 1076
X pulmonic plague, 1076–1078
Xanthochromia, 1114 Q fever, 1076
Xanthopsia, 1267 risk factors for, 1070t
Xiphodynia, 332 Rocky Mountain spotted fever,
Xofluza, 438t 1071–1072
tick paralysis, 1072
Y tickborne, 1070–1075
Yellow fever, 1031, 1085 tickborne relapsing fever, 1074
Yellow sac spiders, 1355 treatment of, 1075t
Yersinia, 846t, 1066t tularemia, 1074
Yersinia pestis, 42, 43t, 45t, 1071t upper respiratory, 1076
Yew, 1410–1412 viral skin infections, 1078
Yohimbe, 1326t Zoonotic meningitis, 1075
Zopiclone, 1220t, 1221
Z Zovirax, 1542
Zaleplon, 1220t, 1221 Zygoma fractures, 1719f, 1720, 1720f
Zanamivir
FB:Cardiologia Siglo XXI
8/2/19 6:02 PM