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The Abcs of Emergency Medicine

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The Abcs of Emergency Medicine THE ABCS OF EMERGENCY MEDICINE Fourteenth Edition 2015 Divisions of Emergency Medicine Faculty of Medicine, University of Toronto Staff Editor Laura Hans, M.D. St. Michael’s Hospital Student Editors Alyx Holden & Emily Stewart CURRENT AND PAST CONTRIBUTORS Bryan Au, M.D. Brian Goldman, M.D. Dave MacKinnon, M.D. St. Michael’s Hospital Mt. Sinai Hospital St. Michael’s Hospital Mary Ann Badali, M.D. Sara Gray, M.D. Shauna Martiniuk, M.D. Sunnybrook Health Sciences St. Michael’s Hospital Mount Sinai Hospital Centre Paul Hannam, M.D. Laurie Mazurik, M.D. Glen Bandiera, M.D. Toronto East General Hospital Sunnybrook Health Sciences St. Michael’s Hospital Centre Laura Hans, M. D. Mike Brzozowski, M.D. St. Michael’s Hospital Nazanin Meshkat, M.D. Sunnybrook Health Sciences University Health Network Centre Leah Harrington, M.D. Hospital for Sick Children Andrew McDonald, M.D. Alan Campbell, M.D. Sunnybrook Health Sciences Trillium Health Centre- Anton Helman, M.D. Centre Mississauga Site Toronto East General Hospital Maria McDonald, LLB David Carr, M.D. Walter Himmel, M.D. University Health Network North York General Hospital Howard Ovens, M.D. Mount. Sinai Hospital Dan Cass, M.D. Matthew Hodge, M.D. St. Michael’s Hospital Univeristy Health Network Rick Penciner, M.D. North York General Hospital Jordan Chenkin, M.D. Martin Horak, M.D. Sunnybrook Health Sciences St. Michael’s Hospital Sev Perelman, M.D. Centre Mount. Sinai Hospital Cheryl Hunchak, M.D. Anil Chopra, M.D. Mount. Sinai Hospital Sara Pickersgill, M.D. University Health Network Credit Valley Hospital Santosh Kanjeekal, M.D. Jennifer Devon, M.D. Toronto East General Hospital George Porfiris, M.D. Scarborough Hospital Toronto East General Hospital Tom Kaul, M.D. Sheila Dunn, M.D. St. Michael’s Hospital Jessica Potvin, R.N. Women’s College Hospital Women's College Hospital Simon Kingsley, M.D. Sexual Assault and Domestic Heather Farina, R.N. St. Michael’s Hospital Violence Care Centre Hospital for Sick Children Kate Lazier, M.D. Tim Rutledge, M.D. Steven Friedman, M.D. University Health Network North York General Hospital University Health Network Shirley Lee, M.D. Suzan Schneeweiss, M.D. Lynne Fulton, M.D. Mount Sinai Hospital Hospital for Sick Children Sunnybrook Health Sciences Centre Eric Letovsky, M.D. Suzanne Schuh, M.D. Credit Valley Hospital Hospital for Sick Children Peter Glazer, M.D. University Health Network Joel Lexchin, M.D. Brian Schwartz, M.D. University Health Network Sunnybrook Health Sciences Centre All contents copyright ©2015, University of Toronto. All rights reserved. Debbie Selby, M.D. Kasia Stefanska, M.D. Rajani Vairavanathan, M.D. Sunnybrook Health Sciences Toronto East General Hospital Toronto East General Hospital Centre Heather Sues-McKay, M.D. Jeff Tyberg, M.D. Dominick Shelton, M.D. Mount Sinai Hospital St. Michael’s Hospital Sunnybrook Health Sciences Centre Peter Switakowski, M.D. Rick Verbeek, M.D. University Health Network Sunnybrook Health Sciences Kevin Skarratt, M.D. Centre Sunnybrook Health Sciences Fernando Teixeira, M.D. Centre St. Michael’s Hospital Natalie Wolpert, M.D. St. Michael’s Hospital Telisha Smith Gorvie, M.D. Caroline Thompson, M.D. University of Toronto Scarborough Hospital Joel Yaphe, M.D. University Health Network Margaret Thompson, M.D. Leeor Sommer, M.D. North York General Hospital St. Michael’s Hospital All contents copyright ©2015, University of Toronto. All rights reserved. PREFACE Welcome to your Emergency Medicine common medical problems, participate in the Experience! resuscitation of acutely unwell and become more comfortable with the ill, undifferentiated patient. We are pleased to present you with the ABC’s of Emergency Medicine. This manual has been We thank all the authors and chapter editors who authored by many of the Emergency physicians have contributed their time and expertise. We are with whom you will be working during your core fortunate to have contributions from so many rotation and longitudinal shifts. leaders in our community. Special thanks to our student editors Emily Stewart and Alyx Holden, The manual is meant to accompany you on your who took on the large task of looking at each shifts, to be a guide for your rotation, your shifts chapter in the manual and to Nancy Medeiros for throughout the year and be a future resource. her ongoing commitment to Undergraduate While this is not a comprehensive review of the Emergency Medicine at the University of listed topics, it will outline key issues, Toronto. controversies and current practice for each topic. Enjoy your core Emergency rotation! In the Emergency Department, you will see a broad variety of patients across all spectrums of Laura Hans, Director, Undergraduate Emergency ages from stable to critically ill. You will have a Medicine and the EM Undergraduate Committee unique opportunity to see first presentations of Every effort has been made in preparing this manual to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors and editors can make no warranties that the information contained herein is totatlly free from error, not least because clinical standards are constantly changing through research and regulation. The authors and editors therefore disclaim all liability for direct or consequential damages resulting from the uses of material contained in this manual. Readers are strongly advised to pay careful attention to information provided by the manuafacturer of any drugs or equipment that they plan to use. This manual is intended for use by medical students. It is expected that the intended reader will consult with a supervising physician prior to initiation of treatment or management of a patient. All contents copyright ©2015, University of Toronto. All rights reserved. TABLE OF CONTENTS Section One RESUSCITATION 1 Airway Bryan Au 1 2 Breathing Heather Sues McKay, Martin Horak 4 3 Circulation Joel Yaphe 8 Section Two THE SYMPTOM PURSUIT APPROACH 4 Altered Mental Status & Coma Brian Schwartz, Sara Pickersgill 12 5 Syncope Eric Letovsky 15 6 Headache Dan Cass, Tom Kaul 20 7 Chest Pain Steven Friedman, Telisha Smith Gorvie 25 8 Abdominal Pain Rick Penciner 29 9 Back Pain Anton Helman 34 10 Pain Brian Goldman 37 Section Three SELECTED MEDICAL EMERGENCIES 11 Myocardial Infarction Eric Letovsky 43 12 Congestive Heart Failure Dominick Shelton 52 13 Cardiac Dysrythmias Laurie Mazurik, Peter Switakowski 57 14 Vascular Emergencies Paul Hannam 74 15 DVT & Pulmonary Embolus Anil Chopra 79 16 Asthma and COPD Rick Verbeek, Kasia Stefanska 85 17 Gastrointestinal Bleeding Rajani Vairavanathan 90 18 TIA & Stroke Jennifer Devon 94 19 Status Epilepticus Heather Sues-McKay, Cheryl Hunchak 100 20 The Agitated & Violent Patient Matthew Hodge 104 21 Diabetic Emergencies David Carr 110 All contents copyright ©2015, University of Toronto. All rights reserved. 22 ENT Emergencies Bryan Au 115 23 Eye Emergencies George Porfiris 119 24 Hyperkalemia Santosh Kanjeekal 123 25 Sepsis Kate Lazier 125 26 Anaphylaxis Leeor Sommer 128 27 Adverse Drug Reactions Caroline Thompson 133 Section Four UROGYNECOLOGICAL EMERGENCIES 28 Vaginal Bleeding Sev Perelman 137 29 The Pregnant Patient in the ED Shauna Martiniuk 144 30 Urological Emergencies Shirley Lee, Natalie Wolpert 150 31 Renal Colic Peter Glazer 153 Section Five PEDIATRIC EMERGENCIES 32 Pediatric Cardiopulmonary Resuscitation Suzan Schneeweiss 156 33 Pediatric Respiratory Emergencies Suzanne Schuh 161 34 Fever in Infants & Children Leah Harrington 164 35 Abdominal Pain in Infants & Children Leah Harrington 167 Section Six ENVIRONMENTAL INJURIES 36 Animal Bites Tim Rutledge 172 37 Heat Emergencies Joel Lexchin 177 38 Burns Laura Hans 182 39 Hypothermia & Cold Injuries Joel Lexchin 186 40 Near Drowning Andrew McDonald 193 Section Seven TOXICOLOGY 41 Toxicology Margaret Thompson 196 42 Alcohol Related Illnesses Brian Goldman, Simon Kingsley 201 All contents copyright ©2015, University of Toronto. All rights reserved. Section Eight TRAUMA 43 Trauma Resuscitation Dave MacKinnon 206 44 The Secondary Trauma Survey Mike Brzozowski, Laura Hans 212 45 Head & Neck Trauma Nazanin Meshkat 215 46 Facial Trauma Glen Bandiera 222 47 Common Orthopedic Injuries Laurie Mazurik, Fernando Texiera 228 48 Wound Care Kevin Skarratt 234 Section Nine MISCELLANEOUS 49 Communication Howard Ovens 238 50 End of Life Issues Howard Ovens, Debbie Selby 243 51 Domestic/Intimate Partner Violence Sheila Dunn, Jessica Potvin 248 52 Sexual Assault Sheila Dunn, Jessica Potvin 251 53 Medico-legal Issues Andrew McDonald, Maria McDonald, Mary 255 Ann Badali 54 Pre-hospital Care Brian Schwartz, Jordan Chenkin 261 All contents copyright ©2015, University of Toronto. All rights reserved. NOTES All contents copyright ©2015, University of Toronto. All rights reserved. 1: AIRWAY Bryan Au OBJECTIVES o 2 fingers-distance from thyroid cartilage notch to floor of mandible 1. To review basic airway management 2. To review indications for definitive airway A = Atlanto-occipital (neck) extension management o Normal = 35 degrees or more; inability to 3. To review rapid sequence intubation extend the neck=difficult laryngoscopy P = Pathologic conditions o Tumour, hematoma, trauma, etc. may make INTRODUCTION intubation difficult In the resuscitation of any patient, assessment and Other mneumonics that you may see in management of the airway is the first priority. One airway assessment are: cannot continue managing breathing or circulation LEMON: Anticipation of a difficult
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