Based on the very good medical book of Stone C.K. & Humphries R.L., 'Current Diagnosis and Treatment in Emergency Medicine', McGraw Hill - LANGE, 6th edition, 2008. mcgraw-hillmedical.com

(A) GENERAL ADVICES IN AVOIDING PITFALLS IN EMERGENCY & ACUTE MEDICINE (FOLLOWED ONLY AFTER A SENIOR DOCTOR’S CONSULTANCE)

• AMPLE (Allergy, Medication, Past medical history, Last meal, Environment/Event that brought him/her to the hospital) should be asked in ALL the patients that arrive on the ER (A&E). Medication includes prescribed or over the counter drugs and also the Pill (contraceptives), herbs, aspirin, paracetamol (acetaminophen), ibuprophen and other agents used wrongly as ‘muscle relaxants’ (and have side effects such as interstitial nephritis). Ask also about alcohol and illicit drug abuse, smoking, last menstruation (women). Ask also family members or friends with similar symptoms (exclude bioterrorism if many people arrive on the ER – A&E with the same symptoms). Also, if there is time, ask about hobbies, pets/ animal exposure, family history and child diseases. Environment and event is what happened that brought the patient to the hospital. Ask details about kinetics and biomechanics on a car or motorbike accident (e.g. a spider break of the wind screen shows high energy to the head and neck and necessitates neck protection).

• On last meal exclude also food poisoning, toxins/poisons (e.g. fruits with organophosphates), botulism and paralytic fish/ shellfish poisoning. Consider stomach emptying with NG tube if altered mental status and risk for aspiration (which is great on obese, children, pregnant and pts with reflux or diaphragmatic hernia).

• AVPU (Alert Voice stimuli response, Pain, Unresponsive) for brief neurologic estimation.

• MONA (Morphine, Oxygen, Nitroglycerine NTG, Aspirin 300 mg) on ACS (Acute Coronary Syndrome). Don't give it with the order of MONA, but with the order of OANM (i.e. Oxygen, aspirin, NTG and last morphine)! Contraindications to NTG are Systolic BP <90 (OR > 30 mmHg below baseline), HR < 50 or HR> 100, intracranial bleeding, Aorticstenosis, right ventricular infraction and use of erectile agents and specifically use of Viagra (sildenafil) or Levitra (vardenafil) the past 24 h or Cialis (tadalafil) the past 48 h.

• DOPES (Displacement of the tube – accidental extubation or tube in the right main bronchus, Obstruction of the tube, Pneumothorax, Equipment failure, Stomach distension – especially on children & pregnant) should be checked if respiratory distress occurs on an intubated patient. The first thing is to extubate the patient and ventilate him/her for a while with BMV (Bag Mask Ventilation) until you figure out the reason of the respiratory compromise. About the Equipment failure check O2 bag, ventilator etc.

• On defibrillation don’t forget GEL – JOULE –PADDLES. Remove any oxygen mask or oxygen glasses or oxygen supply to ventilator at least 1 m (40 inches) far away from the patient, before the defibrillation.

• On an emergency exclude poisoning (CHECK ANION GAP!), illicit drug abuse (toxicology), medication overdose or SEs (side effects), electrolyte defects and endocrinological diseases and on women exclude ectopic pregnancy.

• Standard Lab tests include CBC (FBC), U (BUN) & Cr (creatinine), glucose (initially blood finger stick test), LFTs (liver functional tests), blood/ urine cultures, smears/ swabs gram Stain & cultures, coagulation studies (PT, aPTT, D –Dimers, INR), ABGs (!), CK-MB & Troponins, urinalysis, amylase & lipase (!), pregnancy test (!), blood type & crossmatch (ask 4 units packed RBCs), toxicology (e.g. urine drug screen, blood alcohol,

• Special Lab tests to consider include stool occult blood, fecal cultures/ WBCs/ova/ parasites, urine WBCs/ RBCs/ casts/ nitrites/ leukocyte esterase, TFTs (Thyroid Function Tests), peripheral blood smear & reticulocyte (anemia), CK (myopathy, rabdomyolisis), serum lactate, toxicology – blood or urine (elicit drugs), medication levels (acetaminophen (paracetamol), anticonvulsants, digoxin etc), serum cortizol & Cosyntropin test (Addison’s), 24h urine metanephrines & plasma free metanephrines (pheochromocytoma), serum lactate, serum & urine osmolality (SIADH, Diabetes insipidus), PTH (increased or decreased Ca or phosphate), ammonia, urine specific gravity, ADH, urine myoglobulin, HbCO (burns, smoke inhale) and lead/ arsenic (e.g. neurological problems) and serum seruloplasmine & urine cooper (Cu, Wilson’s disease, neurologic or psychiatric problems especially in young, also eye examination).

• Standard emergency procedures include neck/ spine immobilizing (if neck trauma suspected and always in head trauma), 100% O2 (non rebreathing mask with reservoir or bag – with reservoir – mask ventilation), 2 IV lines (warm on trauma 40 degrees C or 104 degress F) 16 G or bigger (initially give saline or RL – don’t give RL in hypothermia), SpO2 (but does not show CO poisoning or methemoglobinemia), GCS, ECG 12 Lead & continue monitoring, ABGs, Lab tests (including lactate), toxicology, CXR (Chest X’ Ray – Face, Profile/ prefer erect, also lateral, supine patient), perhaps AXR (Abdominal X’Ray upright – preferred and/or supine), perhaps spinal X’ Ray studies if trauma suspected (but X’ Rays do not exclude spinal trauma 100%, perform MRI/CT), USS (ultrasound), FAST/DPL (trauma), perhaps TTE (Trans – esophageal Echo, it can show aortic dissection), CT (if decreased GCS and/or head trauma and in other occasions), folley, and perhaps NG tube (Levine).

• On patients with type II respiratory failure you should usually give initally 24 and if no improvement 28% oxygen! These patients have hypoxemia (low oxygen concentrastion) and hypercapnia (increased CO2). An example is the COPD patients. These patients are chronically hypoxic and it is hazardous (with respiratory suppression and even apnoea!) to raise their oxygen concentration to normal. An oxygen saturation around 85% may be adequate! If no improvement, consider doxapram stimulation, or NIPPV (assisted ventilation – Non Invasive Positive Pressure Ventilation) and if still no improvement consider intubation and mechanical ventilation. Seek early an expert’s advice!

Causes of type II respiratory failure include asthma, COPD, pneumonia, pulmonary fibrosis, obstructive sleep apnoea, sedative drugs, CNS (central nerve system) tumour, CNS trauma, cervical cord lesion, diaphragmatic paralysis, polio (poliomyelitis), myasthenia gravis, Guillain Barre, flail chest (trauma) and kyphoscoliosis.

• On a patient with a pacemaker you can’t diagnose cardiac ischemia on the ECG!

• In cardiac problems e.g. acute myocardial infarction the beneficial effect of morphine is due to the release of histamine. For this reason, do not use concomitantly an antiemetic that is antihistamine or phenothiazine drug!!!

• Serotonin syndrome may be caused by many drugs such SSRIs (for depression), tryptophan, triptans (for migraine), buspirone, LSD, MMDA/ecstasy, amphetamine and amphetamine like drugs, sibutramine (for obesity), venlafaxine, TCAs (tricyclic antidepressants), MAO inhibitors, chlorphenamine (antihistamine), pethidine, tramadol (non opiate opioid), levo dopa (for parkinson’s), bromocriptine, lithium and St John’s Wart. It is characterized by rapid onset of hyperactivity, clonus, tremor, shivering, hyper reflexia and increased CPK.

• Drugs or tumours (e.g. small cell lung cancer) or CNS disorders (haemorrhage, infection e.g. meningitis, also vasculitis), chest diseases (e.g. TB pneumonia and also abscess), metabolic problems (e.g. porphyria), head trauma and drugs (chlorpropamide, clofibrate, cyclophosphamide, opioids, tricyclic antidepressants, SSRIs and vincristine) that cause SIADH (syndrome of inappropriate ADH release) may cause hyponatraemia!

• Neuroleptic drugs may cause malignant neuroleptic syndrome with leaden rigidity, bradykinesia, stupor, mutism, increased CPK, hallucinations, fever, anorexia, tachycardia, hyperthermia. Therapy is with cooling, bromocriptine and dantrolene.

• NG (Nasogastral) tube is essential on children and pregnant with decreased GCS/ decreased gag reflex (high aspiration risk) and other patients at risk of aspiration (e.g. stroke, diaphragmatic hernia, bulbar paralysis etc).

• If GCS is equal or less than 8 or respiration rate is more than 30 or less than 10, then intubate the patient or at least use BMV (bag mask ventilation – e.g. Ampu)!

• Avoid opioids in asthma. Also give antiemetic (e.g. metoclopramide) with opioids. Ketamine may be helpful as an anesthetic in status asthmaticus. Ketamine’s CI (contraindications) are head injury, allergy on this agent and also severe hypertension.

• On status epilepticus or coma of unknown etiology, give glucose (50 ml dextrose IV over 5 min), thiamine (in suspected malnutrition/alcoholics 100 mg IV slowly) and naloxone (o,4 – 2mg IV). On convulsion give initially lorazepam 2 – 4 mg (0,1 mg/kg) IV every 3 – 4 min (max 8 mg). The above doses involve adults.

 

• There are many reasons for hyperthermia, including drugs (cocaine, amphetamins, etc), poisoning (salycilates, anticholinergics, TCAs and other antidepressants), alothane (anesthetic), neuroleptics (malignant neuroleptic syndrome), heat stroke, infection/ sepsis, hyperthyroidism, head trauma, status epilepticus/ prolonged seizures, subarachnoid hemorrhage. As antidote think dantrolene (e.g. for halothane or neuroleptics). Do not forget cooling techniques such as using a fan, sponge with cool water (e.g. face, axillae, ingual areas), cold fluids IV/ peritoneal/ pleural or via folley – urinary catheter, extracorporeal circulation (by pass)!

• Rapid (>250 bpm) wide QRS associated with AF (e.g. on WPW syndrome): if patient stable, give IV procainamide or amiodarone (if Congestive Heart Failure, CHF), but DO NOT GIVE digoxin or Ca blockers or β’ blockers, because they may degenerate it to VT/VF. If pt is unstable perform cardioversion!

• Cardioversion should be performed on an unstable patient only with sedation and synchronized (unless VF/ pulseless VT)!

• Administration of medications (such as adrenaline) on peripheral lines on emergencies should be followed immediately by flush with normal saline (at least 20 ml in adults and e.g. 5 ml on children) and elevation of the extremity for 10 - 20 sec to facilitate drug delivery to the central circulation.

• On neurological (and psychiatric) problems exclude Lyme disease, syphilis (VDRL, RPR), sarcoidosis, DM, chronic alcohol abuse (!), opioids and other illicit drugs of abuse, medication overdose or SE (side effects), malnutrition, poisoning (Pb Lead, As Arsenic, organophosphates etc), Wilson disease (inherited disorder of copper metabolism), CO poisoning (headache!), botulism (!), paralytic shell fish poisoning (!), tick paralysis (remove the tick!), malnutrition (thiamin - alcoholics, Vitamin B12), hypokalemic periodic paralysis, amyloidosis, stroke/ cerebral hemorrhage (perform non contrast CT), TIA (amaurosis fugax?), hypoglycemia (!), hepatic/ renal insufficiency (CBC), epilepsy (even without convulsions, or very fine e.g. on a finger, perform EEG), brain tumors, migraine (!), old stroke, delirium (confusional state), endocrinological disorders (esp. thyroid) etc.

• β’ blockers CI (contraindications): heart failure (IV category), bronchospasm/ COPD/ asthma, AV block/ bradycardia, brittle insulin depended DM (IDDM).

• Nesiritide is a new drug, BNP analogue, used in NON compensated CHF(Congestive Heart Failure).

• Amiodarone is an antiarrythmic drug that may cause hypotension. It is preferred in CHF (congestive Heart Failure). As an antiarrhythmic it is used as 1st agent at the ALS/ACLS protocol VT (ventricular tachycardia)/VF (Ventricular Fibrilation).

However, still many books favour lidocaine as 1st agent in Ventricular Tachycardia with pulse!

If you use amiodarone, prefer to use a central or at least a large peripheral vein! The aqueous solution of amiodarone is less possible to cause hypotension! Of course this drug (and all the other antiarrythmic drugs and also phenytoine) administration should be done under continue monitoring (ECG, BP, SpO2 – Oxygen Saturation etc) and resuscitation fascilities. Hypotension and bradycardia may be prevented by slow infusion (e.g. on SVT – supraventricular tachycardia amiodarone should be injected over 20 – 60 min to avoid hypotension).

• On sustained atrial fibrillation or flutter consider anticoagulation before cardioversion.

• Fosphenytoin is safer than phenytoin and can be given more rapidly. Give phenytoin via a large peripheral vein or a central vein (it can cause venous irritation). Phenytoin can cause cardiovascular and CNS depression. Don’t give it on patients with 2nd degree or complete heart block. On status epilepticus give it IV (not IM, its unreliable) 15 mg/kg slowly (less than 50mg /min).

• An alternative drug for rhythm control if there isn’t any structural heart disease (Myocardial Infarction, Heart Failure, structural cardiac abnormality) is flecainide!

• Grape fruit, St John’s Wort (a herb for depression), antifungal (e.g. cetoconazole, these also have liver & renal toxicity!), macrolides (erythromycin, clarithromycine, but not azithromycin), ciclosporine, tacrolimus, simvastatin, atorvastatin, warfarin, Calcium blockers, diazepam, midalozam, antiarrhytmics and some antiviral, HIV protease inhibitors (indinavir, ritonavir, saquinavir) induce hepatic liver Cytochrome P450 and interact with many other drugs. Estrogen consentretion is altered in case of diarrhea and also interacts with many drugs.

• Avoid antifungal imidazole and triazole type on hepatic problems, renal insufficiency and heart failure especially if the patient takes negative inotropic agents such as calcium blockers.

• Avoid estrogens, contraceptives and hormone replacement therapy (HRT) on liver disease, porphyria, uterus fibroids (they may enlarge), pregnancy, history of venous thromboembolism or strong family history (e.g. antiphospholipid syndrome), endometrial or breast cancer (unless used for treatment) and migraine. Drugs that cause diarrhea (e.g. broad spectrum antibiotics) and also a diarrhoeal illness or broad spectrum antibiotics themselves reduce the absorption of contraceptives. Many drugs (carbamazepine, St Johns Wort, rifambicin, griseofulvin and some anti HIV agents) – enzyme inducers reduce the effectiveness of contraceptives.

• Don’t give live vaccines (e.g. BCG, MMR, Polio, Rabies, Yellow Fever, Influenza) on patients taking cytotoxic drugs, radiotherapy, immunosuppressive drugs, corticosteroids (more than 40 mg/day prednisolone equivalents in adults) and patients who received bone marrow transplant the last 6 months or have inherited disorders of cell mediated immunity. HIV patients shouldn’t be offered BCG vaccine and oral typhoid.

• On severe arrhythmia don’t forget to check potassium, magnesium and consider digoxin toxicity! Also consider thyroid function tests.

• Do not give RL (Ringer Lactate) crystalloid fluid on a patient with hypothermia!

• Elevate limb in case of hemorrhage, burns or edema.

• Do not forget on trauma/ burns to remove watch & jewelry!

• Extremity examination (e.g. on trauma or burns) includes pulses, capillary refill (normal less than 2 sec on pressing the nail pulp 5 sec), paresthesias, vibratory sense, pinpoint sense. Also in high suspicion perform Doppler!

• Do not forget Td (tetanus prophylaxis) and perhaps antibiotics for trauma, burns, frost bite, human or animal bites, stings, snake bites, insect bites.

• Orthostatic hypotension is more than 20 mmHg difference on BP, or SBP <90, or HR increasing more than 30 bpm, or dizziness/syncope, on changing post from supine to standing (staying on supine position for 3 min and then changing post to standing for 1 min). On supine hypotension with SBP<90 exclude first hemorrhagic shock!

• On a man with chest pain, ask if he took recently Viagra or other medication for erection (such as tadalafil), because in that case nitrates are contraindicated 24 h after the drug intake.

• CI (contraindication) to ACE Inhibitors is potassium more than 5,5, severe renal failure, creatinine more than 3 mg/dL, bilateral renal artery stenosis (!) pregnancy and allergy.

• Do not give concomitantly Calcium blockers with β’ blockers on CHF because may decrease seriously the HR (heart rate).

• CI (contraindications) to Calcium blockers are AV (atrioventricular) block and perhaps on CHF (congestive heart failure), because of negative inotropic action (especially of verapamil). Give them with caution if LV (left ventricular) dysfunction. Use sustained low acting formula, because short acting increases the risk for ACS/ MI (acute coronary syndrome/ myocardial infarction)!

• Gout is CI (contraindication) to diuretics and aspirin because these agents will worsen it.

• Pneumomediastinum and/or subcutaneous emphysema may be caused by pneumothoraxor rupture of a bleb (e.g. on pts with emphysema/ COPD), or rapture of esophagus (Boerhaaves syndrome) e.g. after vomiting.

CXR (Chest X Ray) will show air in mediastinum! Subcutaneous emphysema (e.g. on the neck) is also a sign (on trauma exclude tracheal or laryngeal rupture).

Hamman’s crunch air sign is a rubbing sound on auscultation of the heart, during systole.

• Extravasation of IV drugs such as barbiturates, phenytoin, vasopressors and chemotherapeutics (e.g. doxorubicin), may cause arterial spasm and tissue necrosis!

• To access a vascular injury (trauma, crash/ compartment syndrome, electrocution, fracture) check the extremity for pulses, murmurs/bruits, paresthesias, cool/pale color and swelling. Use Doppler USS, contrast CT or official angiography (arteriography).

• Vascular injuries of neck include 3 zones that are defined by the clavicle, the cricoids cartilage and the angle of the mandible. In case of rapid expanding hematoma perform intubation.

Zone I trauma needs surgical exploration!

Zone II trauma needs surgical exploration or imaging first!

Zone III trauma needs imaging first. A ENT specialist will decide.

• Testicular pain needs differential diagnosis (Δ/Δ) from an incarcerated hernia (listen for bowel sounds in the scrotum) and urolithiasis (stone). Also for differentiating a torsion from epididimitis use a UUS (ultrasound) and a 99mTc Scintigraphy Scan (in case of Torsion scintigraphy does not show absorption).

• Aortic aneurysm rupture appears with sudden onset of abdominal or flank pain, hypotension, pulsatile abdominal mass! Perform USS (ultrasound), contrast CT (If stable!), AXR and CXR (abdominal & chest X’ Ray). On the X’ Ray you may notice calcification on the wall of the aneurysm.

Patients may have signs of MI (myocardial infarction) or myocardial ischemia! Also may be confused with nephrolithiasis! Hypotension should raise the suspicion! However pain perhaps is on epigastrium, or on the back!

• Superficial thrombophlebitis may appear with pain, tenderness, induration and erythema on the course of an affected vein. Edema doesn’t occur or is slight. It is usually complication of an IV line, but on legs may be a complication of varicose veins, infections, trauma or Burgers disease

• Septic thrombophlebitis has the same signs, but may be with fever/rigor and fluctuance along a superficial vein. It is often on IV drug abusers! Diagnosis is confirmed by aspirating pus from the vein. Therapy is with IV antibiotics and legation or excision of the affected vein.

• IV drug abusers may also have endocarditis (especially in tricuspid valve), osteomyelitis or spinal abscess or deep tissue necrosis! !

• DVT (Deep Vein Thrombosis) may remain unnoticed! Classic appearance involves unilateral leg swelling and pain, erythema (redness), warmth (and perhaps increase in body temperature). Perform Doppler and later perhaps a venography (gold standard). Also ask D’ Dimers (with ELIZA or whole blood agglutination method) that has 100% negative predictive value! Homman’s sign is unreliable and may make a clot remove!

Exclude pelvic DVT! Use a contrast CT and/or Doppler. Therapy is with limb elevation, IV heparin (UH or LMWH). Pregnant women have increased risk for DVD and PE (pulmonary embolism) and some with specific high risk need protective anticoagulation (they should also avoid dehydration and prolonged trips).
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• Other, than aorta, artery aneurysms: e.g. hypogastric or splenic artery. Ruptures are common in pregnancy. Pregnant women have also increased risk for aortic dissection, cardiomyopathy, TTP (thrombotic thrombopenic porpura) and DVT/PE (Deep Vein Thrombosis/Pulmonary Embolism). Symptoms include abrupt diffuse abdominal pain and shock. Perform a contrast CT or (if stable) an angiography.

• Women with history or risk of DVT or with migraine should avoid estrogens in contraceptives or estrogen replacement therapy at menopause (in the last occasion the cardiovascular complications counteract the protective, for the bones, value). Estrogens also increase the risk for breast or endometrial cancer (but if taken with progesterone they decrease only the risk for breast cancer). They should also avoided on migraine.

• For blood transfusion on the ER (A&E) use packed RBCs (red blood cells) or whole blood or FFP (Fresh Frosen Plasma). Be careful not to give the blood cool (especially on trauma), but not warm it on microwave! In massive transfusion calcium may fall.

• Presence of pulse doesn’t rule out a vessel injury!

• Posterior dislocation of the knee or fracture: exclude poplietal artery injury (perform arteriography)! It is often on car accidents.

• Contraindications to LP (Lumbar Puncture) include focal neurological signs & papilledema (on the eye exam), impending or established septic shock (!), GCS <13 (!) or deteriorating, bleeding disorders (first perform replacement therapy), infection at the site of LP (you may do it higher – ask a senior doctor) and signs of increased ICP – Intracranial Pressure (Cushing Triad: decreased HR and increased BP and irregular breathing).

• Avoid NSAIDs on pts with CHF (congestive heart failure) because they cause fluid retention.

• Anesthetic agents may cause severe hypotension and you should be aware of it especially on a patient already in hypotension! Agents such as barbiturates and propofol may decrease BP. Etomidate and midalozame seem safer on (however they can booth cause hypotension) and etomidate is used also in head trauma with increased ICP (intracranial pressure), and in patients with COPD, allergy and shock. It is contraindicated in Addison’s disease. It’s side effect are myoclonies that can be prevented by giving a benzodiazepine or fentanyl 10 min before the anesthesia.

Ketamine may cause dissociative anesthesia, hallucinations, hypertension, involuntary muscle contractions, tachycardia, increased ICP and intraocular pressure, confusion, bad dreams, nausea, vomiting and rarely temporary psychosis.
It may be helpful in status asthmaticus.

It is contraindicated in ischemic cardiac disease (ACS – acute coronary syndrome), hypertension, cardiac failure, neurosurgery, glaucoma, and history of encephalopathy, epilepsy or psychosis. For preventing hallucinations give 10 mg diazepame or 4 mg lorazepame on pronarcosis (before giving the anesthetic).

ENTONOX (NO– O2, 50% – 50%) is useful in small procedures, as analgetic during general anesthesia, in dentistry and on 1st stage of delivery, but is contraindicated in tension pneumothorax, air embolism, middle ear surgery, and long term administration e.g. in ICU.

Halothane contraindicated on shock, liver disease and pregnancy.

Succinylcholine (suxamethonium) is used in RSI (Rapid Sequence Intubation), but its contraindications are hyperkalemia, tetanus, degenerative neuritis, open eye trauma, liver failure, history of malignant hyperthermia, myotonic dystrophy, congenital myotony and non official pseudo – cholinesterase. It may cause bradycardia, hypertension and arrhythmia (especially on children and also on giving halothane as anesthetic) and bradycardia is prevented by giving before atropine 0,6 – 1 mg.

Other agents such as nitrates for ACS (acute coronery syndrome) and duretics such as mannitol and furosemide for increased ICP (intracranial pressure) or furosemide for CHF (congestive heart failure)/pulmonary edema may also worsen hypotension!

• Pneumothorax should be managed with chest a tube before the patient is transferred to the hospital especially with a helicopter.

• Notify the patient to avoid machine manipulation and driving after general anesthesia or during the therapy with sedatives/ hypnotics/ anesthetics/opioids/ TCAs (tricyclic drugs for depression)/ tranquilizers/ neuroleptics/ antiepileptics and antihistaminics!

• PH of venous blood is usually 0,01 – 0,03 lower than the arterial blood PH. Also PCO2 is 6 mmHg higher and bicarbonate is 2 meq/L higher by using venous blood.

• Urinary anion gap on positive value shows renal source of acidosis and on negative value shows GI losses as source of acidosis. It is estimated by urinary [Na] + [K]–[Cl] and determines NH4 excretion.

• Anion gap is ([Na] + [K]) – ([Cl] + [HCO3]) and normal values are 12 – 16 mEq/L (usually 10 -1 2mEq/L).

Increased anion gap occurs on DM (diabetes melitus), alcoholics, starvation, lactic acidosis, renal failure, exogenous toxins metabolized to lactate (cyanide – CN, CO, ibuprofen, strychnine, toluene, iron – Fe and INH - isoniazide), or exogenous toxins metabolized to acids (aspirin, methanol, ethanol, ethylene glucol, paraaldeyde and rarely with isopropanol), severe hypotension, seizures and hypoxemia.

• Increased osmolar gap may occur in DKA, ethylene glycole or methanol or ethanol or isopropanol poisoning. Osmolar gap ΔOsm = measured Osm – Calculated O.

• Delta anion gap is calculated by: anion gap – normal anion gap (normal anion gap is about 10 mEq/L) .

Delta bicarbonate is calculated by: calculated bicarbonate – normal bicarbonate (normal bicarbonate is about 24).

Delta anion gap/ Delta bicarbonate gap equal to 1:1 shows anion gap acidosis.

Delta anion gap < delta bicarbonate gap shows mixed anion gap and non gap acidosis.

Delta anion gap > delta bicarbonate gap shows mixed anion gap acidosis plus metabolic alkalosis.

• What to rule out on a shock:

a)Traumatic blood loss. Check for bleeding in chest. Perform CXR, FAST. Check for pelvic or long bone fracture. If so, do immobilization and consider PAST antishock trousers.

b)Non traumatic blood loss. Rule out abdominal aortic aneurysm (e.g. palsatile abdominal mass). Do USS/ FAST. Is there hematemesis or melena? Is fluid on Levine (NG tube) bloody? Perform endoscopy if high suspected GI bleeding.

c)Dysrhythmia. Perform an ECG.

d)Tension pneumothorax. Are there any decreased unilateral breath sounds, tracheal deviation (away from the pneumothorax), hyper-resonant hemithorax on percussion or distended neck veins (if not hypotensive with blood loss)? Don’t wait CXR. Perform needle decompression and next insert a chest tube.

e)Cardiac Tamponade.Are there distended JVD (jugular veins distension), muffled heart sounds, low ECG voltage and electrical alterance, or pulsus paradoxus? Perform FAST/ USS (ultrasound).

f)Massive pulmonary embolism. Is there hypoxemia with right ventricular strain on ECG?

g)Anaphylaxis. Is there angioedema, laryngeal edema with stridor, wheezing, hives on skin?

h)Spinal Cord Injury – Neurogenic shock with decreased HR. Check for a motor/ sensory level of paralysis and anesthesia. Take cervical spine protections. Check rectal tone and check for blood.

i)Warm skin? If so, consider sepsis, neurogenic shock, anaphylactic shock, medication overdose (e.g.β’ or Ca blockers).

j)Also rule out Poisons/ medication overdose or SEs (Side Effects)/ illicit drug abuse, Sepsis and Adrenal Insufficiency.

• On a patient with diarrhea exclude Gardia lamblia, paralytic shellfish poisoning (clams, oysters, mussels, scallops), scombroid poisoning (tuna, bonito, mahi –mahi and mackerel), clostridium botulism (!), clostridium difficile (antibiotic associated!), Aeromonas hydrophilia (contaminated water, elderly/immunocompromissed), infection (bacterial, viral, parasite, fungus), PID (Pelvic Inflammatory Disease), IBD (Inflammatory Bowel Disease), celiac disease, neurotoxic shellfish poisoning, CO poisoning, medications, nicotine (green tobacco syndrome!), pesticides (organophosphate poisoning), heavy metals, opiate/ alcohol withdrawal, allergy (!), malabsorption, fecal impaction (!), autonomic dysfunction (e.g. DM – diabetes melitus), Hirshsprung disease/ toxic megacolon, hepatitis, pancreatitis, cholecystitis, pyelonephritis, radiation therapy, diverticulitis, GI (gastrointestinal) cancer and all the surgical abdominal cases (appendicitis, ectopic pregnancy etc.) and neurological problems (meningitis, meningo – encephalitis, subdural hematoma, subarachnoid hemorrhage, migraine – perhaps with abdominal pain, etc.) and other conditions.

• A patient with diarrhea caused by Salmonella or Shigella or E Coli enterohemmorrhagic O157:H7 treated with antibiotics(such as ciprofloxacin or TMP – SMX trimethoprime - sulphomethoxasole) or antimotility agents (such as loperamide - imodium) may be implicated with HUS (Hemolytic Uremic Syndrome) which is more often on children and elderly pts. Dysentery may include fever, abdominal pain, bloody diarrhea, anorexia, cephalgia (headache), weight loss, dehydration and myalgia (musclepain).

The main stem of the therapy of any diarrhea is not to give immediately antibiotics (but I think it is better to give them on more than 1 week persistent diarrhea, after a stool culture and stool parasite screening and after excluding all the non microbial cases of diarrhea such as IBD – Inflamatory Bowel Disease – Cronn’s or UC – Ulcerative Colitis), but to prevent or treat dehydration and electrolyte (especially potassium) abnormalities.

• Reactive arthritis (e.g. Reiter’s syndrome) may follow a dysentery, especially on HLA – B27 positive pts.

• Botulism is caused by Clostridium Botulism, from home - canned fruits, vegetables and commercial fish products. Incubation period is 12 – 36 hours, it is rare, and symptoms include gastrointestinal symptoms, diarrhea, weakness, malaise, fatigue, dry mouth (!), diplopia (!), dysphagia (!), muscle incoordination and progressive cranial nerve palsies & muscle weakness that may lead to respiratory failure! Treatment includes GI (gastrointestinal) decontamination, intubation (if needed) & ICU admission and IV trivalent antitoxin!

• Organophosphate poisoning Remember DUMBBELS (Defecation – diarrhea, Urination, Miosis, Bronchospasm, Bradycardia, Emesis, Lacrimation, Salivation). Also sweating, weakness of skeletal or bulbar muscles and respiratory distress. Do not forget decontamination! Antidotes are atropine and pralidoxime!

• On delirium tremens (e.g. on alcoholics) avoid neuroleptics (such as aloperidol or thiorazide), because they may cause seizures.

• CK is increased in myopathy, rabdomyolisis and malignant neuroleptic syndrome. CK – MB is more specific for heart ischemia.

• On orthopedic problems check always temperature, ESR, WBCs, TB (tuberculosis) test (PPD test, CXR), sensory, reflex, and of proximal joints (e.g. examine also hip on back pain). Consider X’ Rays, CT, MRI, scintigraphy, ultrasound and arthroscopy. Exclude with joint aspiration joint/bone infection – septic arthritits/ osteomy.

• On the elderly be aware of renal dysfunction which (because of lower muscular mass) may be not reflected with increased creatinine! Check BUN (blood urea nitrogen).

• PRL (prolactin) is increased after a real epilepsy!

• On DKA (diabetic Ketoacidosis) therapy with bicarbonates may cause cerebral edema! If the patient is on coma, then empty the stomach with NG tube (nasogastral tube – Levine).

• Hypoglycemia may be related with hepatic failure, liver cancer, insulinoma and Addison disease.

• Hypoglycemia or hepatic encephalopathy may be manifested with hemiparesis!

• If you suspect SVC obstruction perform Pemberton’s test on the elevation of the patient’s upper extremities above his/her head for more than 1 min will cause increasing of plethora/ cyanosis of the face, increased JVP (jugular vein pressure) and stridor! Tests include CXR (chest X’ Ray), CT, venography and sputum cytology. Avoid bronchoscopy!

Therapy is with dexamethasone, perhaps venoplasty with balloon and SVC stenting e.g. before the chemo or radiotherapy!

• Sudden shock with decreased volume may be caused by aortic aneurysm rupture or aortic dissection!

• Erythema gangrenosum is caused by Pseudomonas Aeruginosa. Check for neutropenia!

• In generalized erythrodermy (red skin) exclude toxic shock syndrome!

• Addison and myxedema may cause shock.

• Isoproterenol on shock may cause hypotension and arrhythmia.

• Distended jugular neck veins (JVD) may be caused by cardiogenic shock, tension pneumothorax or cardiac tamponade. On the last check for pulsus paradoxus.

• Elderly or alcoholics or uremic pts may have sepsis without fever!

• Sepsis may appear with hypothermia and/or decreased white cells!

• On hyparrahnoid hemorrhage CT may be initially normal so check xanthochromy on CSF (on LP – lumbar puncture)!

• Amaurosis fugax is a form of TIA (transit ischemic attack)!

• On anaphylactic reaction exclude hereditary angioedema (c1 esterase deficiency) or angioedema from ACE Inhibitors. On hereditary angioedema give FFP (Fresh Frozen Plasma) and dalazole.

• Any form of steroids (e.g. oral or inhaled or dia - dermal) may cause cataract or osteoporosis!

• On the initial stage of Polio the patient has constricted neck muscles and increased cells on the CSF (lumbar puncture).

• On RA (Reumatoid arthritis) FELTY syndrome is characterized by splenomegaly and decreased WBCs.

• Dressler syndrome happens 2 – 10 weeks after a MI or after a cardiosurgery and appears with recurrent fever, chest pain, and perhaps pleural and/or pericardiac infusion.

• Mucormycosis is a fungal infection that may be very dangerous and is common on pts with DM (diabetes melitus). It is caused by Rhizopus, Rhizomucor and Cunninghamella. These fungi cause nasal and paranasal sinus infection with low grade fever, dull sinus pain, nasal congestion and thin bloody (!) discharge that progress to double vision, fever, obtundation, blindness (!), unilateral decreased ocular motion, chemosis, proptosis, dusky or necrotic nasal turbinates (on the affected side) and sharply delineated area of necrosis that respects the midline on the hard palate!

Risk factors are DM, organ transplantation, hematologic malignancy, and long term use of deferoxamine (e.g. for iron overload after transfusions)!

There are also other forms of infection such as GI (gastrointestinal), cutaneous & pulmonary. Pulmonary mucormycosis is manifested with progressive severe pneymonia with fever, large infiltrates on CXR – Chest X’ Ray (often with central necrosis & cavitation), hemoptysis (may be fatal if cavities are near hilum!) and hematogenous spread (e.g. to brain). Death on pulmonary form occurs usually within 2 weeks.

Diagnosis is with biopsy of infection sites for histology & cultures (but often cultures are negative), and imaging studies. Therapy is with surgical debridement (!), amphotericin B IV (e.g. liposomal), and also control of diabetes and – if possible – reduction of the immunosuppressive drugs.

• Porphyria (hepatic or erythropoietic) is a condition that may cause abdominal pain and neurologic problems such as neuropathy and altered mental status! Exclude liver insufficiency on hepatic porphyrias (is the patient alcoholic?). On erythropoietic porphyria there is classically cutaneous (skin) photosensitivity!

Acute intermittent porphyria is autosomal dominant and may manifest with colicy abdominal pain (!), vomiting, constipation, port wine colored urine and neuropsychiatric disorders. Photosensitivity does not occur and acute attacks rarely occur before puberty. Manifestations may be caused by drugs (!), the Pill/ estrogens, alcohol and low calorie diet. Check ALA and urine PBG (porphobilinogen) during the attack.

Porpyria cutanea tarda is more common and characterized by cutaneous photosensitivity and usually hepatic disease! It appears with facial pigmentation, increased skin fragility, erythema, vesicular and ulcerative lesions typically on face, forehead and forearms. There aren’t any neurological complications! Precipitating factors are estrogens, excess iron and excess alcohol! Plasma & urine uroporphyrin and 7 – carboxylate porphyrin are increased.

Erythropoietic porphyria is characterized by skin photosensitivity that usually begins in childhood. Vesicular lesions here are uncommon. Redness, swelling, burning and itching develop in few min after sun exposure and may resemble angioedema!

Chronic skin changes include lichenification, labial grooving, nail lesions and leathery pseudo-vesicles. Liver function is normal, however liver disease and gallstones may occur. Protoporphyrin levels are increased in plasma, bile, feces, bone marrow, circulating RBCs, but not in urine!

• Wilson disease is an inherited disorder of copper (Cu) metabolism and manifested with hepatitis, cirrhosis, hepatic failure, neurologic problems (dysarthria, dysphagia, dystonia, incoordination or tremor), psychiatric problems (!), microscopic hematuria, and Fleischer rings on the cornea! Check serum seruloplasmine (often low) and urine copper (elevated). The gold standard test is elevated Cu (copper) on liver biopsy! Exclude Wilson’s disease especially in young patients with neurological and/or psychiatric problems!

• Methemoglobinemia may occur from medication (there are several drugs that may cause it) or poisons! Symptoms include initially asymptomatic (at levels 1,5 g/dL) cyanosis, and on bigger concentrations cyanosis (peripheral & perioral) with dyspnea, headache, weakness, lightheadness, fatigue, severe CNS depression, coma and (if untreated) death.

Patients with anemia, acidosis, COPD and chronic cardiorespiratory disease may be more symptomatic than the expected methemoglobin level! When levels exceed 15% of total hemoglobin, blood appears chocolate brown, when dripped onto a filter paper!

Treatment includes methylene blue and oxygen by mask (5 – 10L/min)! On the ABG (arterial blood gases) the PO2 (oxygen concentration) and the calculated oxyhemoglobin are falsely normal! The pulse oximetry (SpO2) is also unreliable! If the patient is taking nitrite treatment for cyanide poisoning, then do not give methylene blue, because it may cause release of cyanide in toxic levels !

• Intestinal Ischemia happens often in the elderly. It may be occlusive (atherosclerosis or from cardiac mural thrombus) or non occlusive (from hypotension e.g. at arrhythmias or sepsis). It appears with severe poorly localized abdominal pain, perhaps history of intestinal angina (pain after eating), gross or occult intestinal bleeding. Perform contrast CT or (if stable) formal angiography.

Treatment is surgical or (for NON occlusive cases) by infusing vasodilators with a catheter thru the mesenteric artery .

• Thoracic aortic rupture may appear with tearing or retrosternal or interscapular pain; and less frequently with dysphagia, hoarsness, stridor and shortness of breath. There is a difference in upper extremities pulses! Also perhaps there is a harsh systolic murmur on the precardium or the interscapular area. Diagnosis is fast with a TEE (transesophagal Echo), a helical CT or (if stable) with arteriography.

CXR (Chest X ‘Ray) signs are: left apical cap, wide mediastinum, deviation of the trachea to the right, deviation of the Levine (NG – nasogastric or OG – orogastric tube), depression of the left mainstem bronchus, hemothorax and obscuration of the aortic arch. Trauma and the mechanism of the trauma (kinetics) will make the ER doctor suspect this injury
.

• In case of intubation, if GCS is more than 3, perform RSI (Rapid Sequence Intubation) because laryngospasm or bradycardia (especially on children) may occur. If GCS is 3, you don’t need RSI, but you can do immediate intubation, unless there are problems, such as jaw lock and laryngospasm, where RSI is needed. On RSI on children add atropine (0,01- 0,02 mg/kg) before the paralyzing agent and on head trauma add lidocaine (1,5 mg/kg) before the paralyzing agent. Patients with GCS equal or less than 8 need intubation. If there is need for ET (endotracheal intubation) then don’t use succinylcholine in case you suspect increased potassium (peaked T on ECG), because it may worsen hyperkalemia!

• Nasal airway may be useful on patients with trismus (jaw lock) or epilepsy. Use it if the patient isn’t on respiratory arrest. It may be well tolerated even on kids.

• Aortic dissection may mimic heart attack or stroke! It appears with abrupt chest pain with tearing or ripping character and often radiating to the back. One important question is if the patient has hypertension. One sign that should raise the suspicion is the pulse deficit (differential)! Other signs of aortic dissection are murmur of aortic regurgitation (with systolic heart failure) and perhaps neurological deficit and cardiac tamponade!

Neurological deficits may include stroke or spinal cord ischemia with paraplegia or quadriplegia, or anterior cord syndrome. It also may mimic transverse myelitis!

CXR (Chest X ‘Ray) shows on 61% a widened mediastinum! Also on 19% of the pts CXR shows pleural infusion. Aortic dissection is rare. 50% of patients have hypertension, other risk factors include syndromes (Marfan’s, Turner’s, Ehlers – Danlos), cocaine (!), pregnancy (!), trauma, intra –aortic catheterization, aortic valve replacement, bicuspid aortic valve and coarctation of aorta.

Diagnosis is with TEE (Trans – esophageal Echo) or contrast CT. MRI is also helpful. When the dissection involves the ascending aorta (Type A with Stanford system) it needs surgery. In any case, consult a thoracic surgeon.

• Thoracic outlet syndrome is a syndrome that may missed. It consists of the compression of brachial plexus or subclavian or axillary artery or vein. The compression of brachial plexus may include C8 & T1 with ulnar nerve distribution of paresthesias (!), or may include C5 – C7 with paresthesias on ear, neck, upper thorax and lateral aspect of the shoulder and may also include Raynaud’s. Venous compression may cause upper extremity’s pain and swelling with normal pulse. Arterial compression may cause arterial occlusion or embolism.

A sign that the physician may notice is the differential BP and pulse between upper extremities. Patient may notice hand or arm fatigue with overuse (especially abduction) and wasting of the hand muscles. Perform the ‘elevated arm stress which consists of positioning the patient with bilateral 90 degrees shoulder abduction and 90 degrees  elbow flexion and require the patient to open and close his fist for 3 min. Test is positive when the patient reports fatigue and perhaps paresthesias and also has diminished radial pulse on the affected side.

X’ Rays may reveal a cervical rib (!) or deformity on 1st rib or clavicle. Also helpful are USS (ultrasound) and venography/ angiography
.

• ITP (Idopathic Trombopenic Porphyra) may appear with petechia, mild mucosal bleeding (epistaxis, gingival, menorrhagia). Plts (platelets) are decreased. Therapy needed if Plts are less than 20.000 /μL without bleeding, or with less than 50.000/ μL with bleeding or risk factors. Therapy is initially with prednisone and/or immunoglobulin and next – if needed- with Plts transfusion. Also estrogens (25 mg IV once) are used for uterine bleeding. Persistent cases may need splenectomy

• On a patient with bleeding disorder do not do IM injections, do not give aspirin/NSAIDs, do not perform LP (lumbar puncture), do not do ABGs (arterial blood gases) and do not place central lines (including femoral). First give replacement therapy e.g. FFP (fresh frozen plasma). Consult an haematologist.

• HUS (Hemolytic Uremic syndrome) involves especially children (usually 6 months – 4 years) and appears with ARF (acute renal failure), microangiopathic hemolytic anemia (MAHA) and thrombocytopenia. It may occur after an infection e.g. with E.Coli O157:H7 (manifested with bloody diarrhea), and may be induced if antibiotics or antimotility agents (such as loperamide – imodium) are given for the diarrhea! So physicians should be sceptic by using antibiotics or antimotility agents on patients (especially on children or old people) with diarrhea, especially if bloody (and/or with pus). After all, many cases of diarrhea, especially on children, are from viruses (e.g. Rota or Norwalk).

HUS patients may have increased Creatinin and urinalysis show proteins or RBCs (red blood cells) or be normal. ARF (acute renal failure) may be a complication. Treatment is with steroids, plasma – exchange or infusion and hemodialysis on ARF.

• TTP (Thrombotic Thrombopenic Porphyra) is ‘brother’ disease with HUS. It appears with thrombocytopenia, microangiopathic hemolytic anemia (MAHA), and may also include fever, renal problems, high BP and neurologic complications such as seizures and coma! It is induced by autoantibodies. Risk factors are pregnancy (23 – 24 weeks, exclude eclampsia!), HIV, vaccines, drugs and SLE (lupus). Peripheral smear shows schistocytes or helmet cells.

Lab tests show decreased haptoglobin, increased reticulocyte count, increased indirect bilirubin, negative direct Coombs and normal coagulation studies. Therapy is with plasmapheresis, FFP (Fresh Frosen Plasma) or cryoprecipitate and perhaps prednisone. Avoid aspirin, platelet transfusion and heparin
.

• DIC (disseminated intravascular coagulation) is a diagnosis that mustn’t be missed. It may be a complication of many situations such as obstetric complications (retain of gestational products, septic abortion, eclampsia, placenta abruption etc.), sepsis, trauma, fulminant meningitis etc.

Lab tests show prolonged PT, decreased Plts (platelets), and may show decreased fibrinogen. Also shows increased FDPs & D – Dimers, increased LDH and haptoglobin. Peripheral smear shows chistocytes. Clinical appearance includes petechiae, echymosis, GI (gastrointestinal) or GU (genitourinary) bleeding, bleeding from IV sites/ surgical wounds or mucocutaneous sites!

Complications include ARDS (acute respiratory distress syndrome), ARF (acute renal failure), porpura fulminans (in case of bacteremia) and multiorgan failure. Therapy is with cryoprecipitate (to increase fibrinogen), Plts (if < 50.000μL), FFP (fresh frozen plasma), vitamin K & folate, heparin (only if thrombotic complications) – EACA (ε amino caproic acid?) and heparin if hypofibrinogemia
.

• Drugs/agents that may induce hemolysis include sulfonamides (e.g. SMX), antimalarials, urinary drugs (nitrofurantoin, nalidic axid,phenazopyridine), antibiotics (ciprofloxacin, norfloxacin, chloramphenicol), naphthalene (!), vit K analogues, methylene blue, doxorubicin, acetanilide, isobutylnitrate, phenylhydrazine, aspirin, PAS (para amino salycilic acid), phenacetine, mushrooms, probeneside, fave (fava) beans (!) etc. Avoid the above drugs/ agents if thalassemiaor G6PD deficiency.

• G6PD deficiency is an X linked disease (so more often on men), common on patients from Mediterranean, Africa and Asia. Peripheral blood smears show Henz bodies. Lab tests show hemolysis if hemolytic crisis. Also jaundice occurs 1 – 4 days after birth. Hemolytic crisis may occur with drugs (see above), DKA (diabetic Keto – acidosis), renal failure, naphthalene and fave (fava) beans! Complications are gallstones and splenomegaly. Avoid the offending agents.

• Infectious mononucleosis from EBV (Epstein Barr virus) has to be differentiated from streptococcal pharyngitis. It is characterized by fatigue (and may be a reason for chronic fatigue syndrome), pharyngitis – commonly with tonsilar enlargement, low grade fever, spleen tenderness and lymphadenopathy – especially posterior cervical LNs (lymph nodes). Signs also include an early faint maculopapular rash, bilateral periorbital edema and uvular edema (!), hepatitis (!) and splenomegaly. Hemolytic anemia may also occur.

Neurological complications include Bell’s palsy (!), optic neuritis, Guillain Barre (!), transverse myelitis, aseptic meningitis & encephalitis (!) and cranial nerve palsies. Diagnosis is with Mono –spot test.

Patients (especially young) should avoid sports (especially combat ones) because of the risk of splenic rupture. Prednisone is used for enlarged tonsils
.

• Acute transfusion complications include acute intra or extra vascular hemolytic reaction with fever (low grade in extravascular hemolysis), dyspnea, low back pain (!), , increased HR and decreased BP. Check again the blood type (patient’s and donor’s), perform direct and indirect Coombs, check Hb (hemoglobulin, blood and urine), serum haptoglobin, indirect bilirubin. Other reactions include allergic reaction and also febrile reaction. The last one should be differentiated from intravascular hemolysis or infection.

In any of the above reactions stop transfusion, perform Lab tests (CBC/FBC – complete/full blood count, coagulation, biochemistry, renal function), recheck the donor’s and the patient’s blood type and data (name etc) and send patient’s and the donor’s blood sample to the Lab (!), give to the patient fluids and perhaps furosemide and also give the patient FFP (fresh frozen plasma) in case of coagulopat
.

• Coagulation tests include Plts (platelets), PT, aPTT, INR, fibrinogen and D’ Dimers (with enzyme linked immunoassay). Special tests include bleeding time, thrombin clotting time, mixing test, specific clotting factor assays (e.g. VIII, IX, vWF, protein C & S, V Layden) and inhibitor screening (e.g. lupus anticoagulant).

• History for bleeding disorders should include family history, liver or renal disease, drugs (aspirin/NSAIDs, warfarin, heparin and other anticoagulants, antibiotics such as SMX (sulphomethoxasole)/ penicillin/ cephalosporins, quinine, procainamide, phenytoin, valproic acid, digoxin, cimetidine, thiazides, furosemide, SSRIs (for depression) and other psychiatric drugs), opioids (e.g. heroin abuse), choric alcohol abuse, abnormal or unusual bleeding (epistaxis, gingival, uterus) and bleeding history on dental or surgical procedures or traumaa.

• Patients with eye pain or red eye should always asked if they wear contact lenses and if they wash them with plain water, and also if they used any eye drops (especially with corticosteroids).

• Gonorrhea is a STD (Sexual Transmitted Disease).On men may appear with dysuria of acute onset, perhaps with hematuria, inflammation of preputial glands, epididymitis, seminal vasculitis and prostatitis. Men patients have also copious creamy urethral discharge!

On women may be asymptomatic (!), or it may appear with the following: cervicitis/ vaginal discharge, urethritis, Bartholin abscess, salpingitis and pelvic peritonitis.

Also gonorrhea may manifest with proctitis, disseminated arthritis, tenosynovitis, dermatitis (suspect the previous on young pts!), pharyngitis (if oral sex), and conjunctivitis (including the newborn!). Take cultures from urethra/ cervix/ pharynx (if oral sex) and rectum (in all women). Perform Gram stain (Gram – diplococci), smear cultures and consider PCR.

Exclude Chlamydia, syphilis and HIV. Co – infections are common, especially chlamydial! Therapy includes ciprofloxacin and doxycyclin, or azythromycin.

So gonococcal infection should be on the differential diagnosis for patients, especially young, with disseminated arthritis, tenosynovitis (if not any open wound near the involved tendon sheath) and skin lesions (especially pustular).

Disseminated gonococcemia appears with fever, skin lesions (usually on extremities, petechiae/ palpable porpura/ vesiculopustules), septic arthritis (mono or polyarthritis, namely in 1 or more joints), tenosynovitis (25% pts, usually ankles or wrists!).

Perform Gram stain and blood cultures, but 50% will be negative.

• Staphylococcal Scalded Skin Syndrome usually occurs on children. It is characterized from bullaes and exfoliation, that often involve the extremities. Give ceftriaxone 1 g IV or IM every 24h.

• Necrotizing Soft Tissue Infections (NSTI) is life threatening and mustn’t be missed! It may happen from a minor trauma (e.g. insect bite, surgical incision, skin popping/ IV drug abuse) or be spontaneous such as the Fourrier gangrene that involves the perineum and the scrotum! Major risk factor is DM (diabetes mellitus)! Other, than diabetes, risk factors include renal failure, other chronic diseases, and alcoholism!

Most cases are polymicrobial (including GABHS – Game A β’ Hemolytic Streptococcus). More often involves the perineum/scrotum and the extremities! Early signs are cellulitis or small ulcers with redness, warmth and edema of the skin, skin anesthesia (!) and pain out of the proportion of the clinical findings!

Later findings include tense edema, bronze skin discoloration, hemorrhagic bullae, seropurulent foul smelling exudates, and may include crepitus (especially with clostridia), sepsis with hypotension, tachycardia, shock, fever and 10% involves streptococcal toxic shock syndrome.

Key feature is tachycardia and fever out of proportion of the apparent extension of the skin lesion, and also tenderness extending beyond the skin lesion!

Lab tests show increased WBCs, decreased Na, increased BUN & Creatinine and decreased calcium. X’ Rays show subcutaneous emphysema on 50%! CT may be helpful! It may show asymmetric thickening or stranding of the fascial planes.

Needle aspiration, Gram staining and cultures are also needed. Therapy is with penicillinplus clindamycin or with metronidazole plus gentamycin. However it is better to consult a microbiologist.
Surgical debridement is also needed, such as hospitalization in ICU (ITU).

• Toxic Shock Syndrome (TSS) is caused by S. aureus by infection or colonization or vaginal colonization. If menstrual related, it starts during the menses! Ask the woman if she uses tampon or sponges! Other cases are associated with postoperative infection, wound packing (!) and forgotten nasal packing performed for epistaxis!

Toxic Shock Synd. appears with shock and hypotension (SPB Systolic Bp< 80), with fever (>39 degrees C or 102,2 degrees F), multiorgan dysfunction / failure, diffuse blanching macular erythema, pharyngitis, strawberry tongue, conjunctivitis and vaginitis. The rash fades in about 3 days and then desquamation occurs on hands and feet in 5 – 12 days.

Lab may show increased WBCs(white blood cells), decreased Plts(platelets), increased BUN (blood urea nitrogen) & Creatinine, increased PT/ aPTT and INR, acidosis (check for increased lactic acid), decreased CK and calcium, decreased albumin (check also for decreased pro – albumin), and increased LFTs (liver function tests). Check also APACHE II score.

Culture of vagina/ cervix may show S. aureus. Blood cultures are negative on 85% of TSS and 50% of STTS (Staphylococcal TSS)!
Remove any remained vaginal tampon/ sponge or nasal packing or wound packing!

Therapy is with crystalloids or colloids and vasopressors and also vancomycin. Patients need hospitalization in the ICU.

• Toxic shock like syndrome from Group A’ Streptococci. The microbial agent may entry thru the skin or the mucous or via a surgical procedure. Temperature is more than 37,1 degrees C (98,6 degrees F), and patient may have confusion and pain! Pain usually is on an extremity or may be abdominal. Other features are shock with hypotension, respiratory failure, renal dysfunction/ insufficiency, osteomyelitis (!), peritonitis, endophthalmitis or suppurative phlebitis.

Lab may show increased WBCs (white blood cells), decreased Plts (platelets), decreased Hematocrit (on 48 – 72 h), increased creatinine (!) with microscopic hematuria, increased CK, decreased calcium and decreased albumin (check also for decreased pro – albumin). Take cultures of blood/ body fluids/ tissues. Therapy includes surgical debridement, ICU (ITU) hospitalization with CVP or PCWP and administration of IV penicillin or cephalosporin.

• Septic arthritis is also a condition that, as osteomyelitis, shouldn’t be missed (especially on children). Do not attribute a joint effusion or a painful joint to degenerative arthritis (osteoarthritis) without ruling out septic arthritis. Septic arthritis is common on small children, so adults and especially the elderly are diagnostic traps. The key is to perform a arthrocentesis (joint aspiration).

The symptoms of septic arthritis are fever (!), painful joint, joint effusion. Perform arthrocentesis and blood cultures. Lactic acid in synovial fluid has 97% negative predictive value. On sexually active pts note the Lab to rule out gonorrhea and take cultures from smears from cervix, urethra (especially men), pharynx (if oral sex) and rectum.

It is more often on children < 3 years old (boys> girls) and risk factors include prosthetic joint, Reumatoid Arthritis (!), orthopedic surgery, IV drug abuse (!), hemodialysis (!) and sexual transmitted diseases (gonococcus – poly or mono articular artritis). Treatment is with joint aspiration and antibiotics.

• Osteomyelytis is a disease that, as with septic arthritis, shouldn’t be missed. Symptoms include pain, tenderness and swelling of a bone and increased ESR (!) and may involve vertebra (with back pain!) or the cranium! WBC is increased (!), but may not if chronic. Patients with DM (diabetes mellitus) may not have pain!

Microbial culprits are usually bacteria (esp. S. aureus, also TB - tuberculosis!), or fungi. Perform MRI and Bone Scan. Infection occurs hematogenous (via blood), or with orthopedic procedure/ surgery, or after a wound (!), or performing IO (intraosseal) rout on children (rare) and also on pts with vascular insufficiency (DM or peripheral vascular disease).

• Catecholamine crisis may be caused by pheochromocytoma, MAO Inhibitors and sympathomimetics such as cocaine. It is characterized with DBP (Diastolic BP) equal or more than 120!

• Pheochromocytoma can be manifested with headache, palpations, flushing (!), diaphoresis (sweating), hypertension (may be severe with DBP (diastolic BP) equal or more than 120), pallor, nausea, vomiting, abdominal pain (!) and nervousness.

Pheochromocytoma has to be considered in the differential diagnosis of hypertension (especially severe and/or paroxysmal).
Complications include abdominal or chest pain (!), aortic dissection (!), encephalopathy (!), cardiomyopathy, pulmonary edema (!), fever, anion gap metabolic acidosis.

Lab tests should include 24 h urine and plasma free metanephrines. Imaging with CT/ MRI/ Scan may manifest a adrenal tumor (but 10% are extradrenal). Treatment is with phentolamine (an a’ blocker) 1 – 2 mg every 5 min IV. Other options include nitroprusside (but Side Effect is CN – cyanide toxicity), fenoldopam (DA1R agonist), nicardipine (Calcium blocker), lorazepam (1-2 mg IV) and β’ blockers – especially labetalol 10 – 20mg IV bolus, every 10min. Give labetalol only after giving phentolamine and also use it if severe tachyarrhythmia.

• Diabetic Keto – Acidosis (DKA) has the risk of hypokaleamia. You have to correct the potassium before you give insulin! If you don’t, then potassium will fall. Sodium is also decreased (the deficit may be 7- 10 mEq/kg) but DON’T correct it fast because you may cause cerebral edema! However sodium may be factitiously low.

Phosphate may be also decreased. If very decreased it then correct it by using potassium phosphate as 1/3 of the replacement of potassium. Do not forget to put a urinary catheter (folley) before potassium replacement and to establish urine output.

DKA is more often in DM (diabetes mellitus) type (1) and characterized by Kussmaul’s respiration (don’t confuse it with asthma!), fatigue, polydipsia (thirsty), polyuria, tachycardia, altered mental status, abdominal pain (!), vomiting and tests show PH less than 7,3, serum glucose equal or more than 250 mg/dl, serum bicarbonate equal or less than 15 mEq/L.

Precipitating factors for DKA should be recognized and are: infection, ACS/MI (heart attack), TIA (transit Ischemic attack)/ CVA (stroke), medicines, trauma, corticosteroids, thiazides, pancreatitis, alcohol, drug abuse and sympatheticomimetic drugs. The main stem of the DKA therapy is fluid resuscitation.

• Hyperosmolar Hyperglycemic State (HHS) is characterized by severe dehydration (!), absence of acidosis (!), small or no ketones, glucose usually equal or more than 600 mg/dl (!), bicarbonate > 15 mEq/L, PH>7,3 (!), anion gap usually equal or less than 10 (!), serum osmolarity equal or more than 320 mOsm/Kg (!), potassium normal or decreased (unless ARF) with the total body deficit often 4 – 6 mEq/L, BUN (blood urea nitrogen) increased (exclude GI – gastrointestinal bleeding!), sodium usually decreased (125 – 130 mg/dL), but may be factitiously low. Kussmaul’s respiration and abdominal pain are unusual!

Tests: ECG (!), troponins (!) & CK-MB, abdominal & head CT (!), USS (ultrasound) and endoscopy to exclude gastrointestinal bleeding! Don’t give Sc (subcutaneus) insulin and also don’t give bolus insulin in children. If there is need for ET (endotracheal intubation) then don’t use succinylcholine in case you suspect increased potassium (peaked T on ECG), because it may worsen hyperkalemia!

If cardiorespiratory shock or ARF (acute renal failure) then check urine output and exclude CHF and pulmonary oedema! If there is hypoxia then exclude aspiration, pulmonary oedema and pneumonia!

Do not correct osmolarity more than 3 mOsm/kg/h because you may cause cerebral edema! Correct potassium, but first confirm that there is urine output and check potassium levels! In case potassium is very increased (more than 6 mEq/L) give regular insulin bolus 8 – 12 Units! In severe acidosis (PH<6,9) give bicarbonate.

Check also for decreased phosphates. If so, then on the potassium replacement give 2/3 KCl (potassium chloride) and 1/3 potassium phosphate, otherwise give 40 mEq KCl IV. A safer way is to give 40 mEq KCl PO (orally) or via NGT (Nasogastral tube, Levine).

Perform smears, Gram stain & cultures (blood, sputum, urine & CSF – with lumbar puncture) and give empirically antibiotics. Exclude infection (exclude especially cellulitis, perform wound & pelvic examination). The main stem of HHS therapy is fluid resuscitation.

• Thyroid storm has to be suspected on patients with stigmata of hyperthyroidism such as thyromegaly (enlarged thyroid), ophthalmopathy, diaphoresis (sweating), tremor, lid – lag, agitation, proptosis, weakness, coarse hair, myopathy (! especially proximal muscles), think & dry skin, fever (! may be more than 40 degrees C or 104 degrees F!), tachycardia (out of proportion to fever!), arrhythmias (!SVT (supraventricular tachycardia), AF(atrial fibrillation), atrial flutter, MI (Myocardial infarction!), mental status changes (confusion to coma!), GI symptoms (nausea, D&V Diarrhea and Vomiting, abdominal pain!).

Lab shows increased fT4 and decreased TSH. For hyperpyrexia give cool IV fluids, antipyretics and use cooling blankest (a simple way of cooling). Treatment is with 1 L N/S (normal saline) or RL (Ringer’s) in the 1st hour, Phenobarbital (induces hepatic enzymes), PTU (propylthiouracil), Iodine . Give iodine only 2 h after PTU!!! Give KI (potassium iodine) 5 drops (35mg/drop) PO (orally) every 6 h or 10 drops Lugol every 8 h. Give also propranolol (CI is bronchospasm) and dexamethazone (!) 0,1 mg/kg IV every 8h.

• Myxedema Coma has to be suspected in patients with stigmata of hypothyroidism such as coarse dry skin, cold intolerance, constipation, angina (!), hyperlipidaemia, periorbital oedema (!), half cut eye brows, absent/irregular menses, cramps, weakness, oedema (!), transverse scar across the anterior neck (surgery), macroglossia (big tongue, exclude also amyloidosis), bradycardia (!), altered mental status ! (however coma is rare), hypothermia (less than 35,5 degrees C or 95,9 degrees F ! 80% pts!) and perhaps hypotension. Men to women rate is 1:4!

Lab shows decreased fT4 & T3 and increased TSH. Check for increased CK. If so exclude rabdomyolysis or MI –Myocardial Infarction (Check ECG, CK-MB and Troponins)! Sodium and glucose may be also decreased!

Treatment is with isotonic crystalloids (if hypotension), rewarming for hypothermia (prefer only warming blankets), electrolyte abnormalities treatment and treatment of hypoglycemia. If sodium is decreased give carefully 3% saline, in case of decreased mental status. Therapy is with T4 (levothyroxine). Before T4 give dexamethasone 2 – 4 mg IV every 6h! Use lower dose of T4 if risk for MI! Start cardiac monitoring! Give also empirically antibiotics and use specific therapy for causes e.g. for pneumonia. Vasopressors should be avoided!

• Addisonian crisis has to be suspected in pts with hypotension refractory to fluids or acutely ill pts with stigmata of chronic corticosteroid use (moon face & buffalo hump) (and usually abrupt cessation of corticosteroids or not increasing them in case of a disease or shock) and/or stigmata of Addisson’s such as orthostasis (orthostatic hypotension), decreased weight, anorexia, nausea, D&V (diarrhea and vomiting), lethargy, abdominal cramps (!), mental status changes (!), generalized aches, amenorrhea, decreased body hair, pigmentation of axilla & other skin folds (e.g. palm creases, mouth), hyponatremia (!) & hyperkalemia (!) (but potassium is nit increased if secondary disease).

Causes are autoimmune, infections (TB - tuberculosis!, AIDS, CMV, histoplasma), metastatic cancer, hemorrhage, SIRS, drugs, N.meningititis or S.pneumonia septicemia (Waterhouse – Friderichsen syndrome, high mortality!), anticoagulants (!), coagulopathy, thromboembolism, or may be secondary from chronic steroid use (by stopping them abruptly or by not increasing them in situations of diseases or shock) or pituitary/ hypothalamus mass (e.g. tumor).

Tests include cranial MRI, abdominal CT, serum cortisol (if more than 20 mg/dL perform the official Cosyntropin test for ACTH). In case you suspect addisonian crisis give dexamethasone 0,1 mg/kg every 8 h (hours) which does not affect the results of the Cosyntropin test! If the diagnosis has been established give 100 mg hydrocortisone IV every 8 hours.

• Pituitary apoplexy is rare. Suspect it if the patient has sudden severe headache (retro-orbital / bifrontal) with sudden onset, N&V (nausea & vomiting), meningeal irritation, decreased V (visual acuity), decreased mental status, hemiparesis, cranial nerve palsies/ deficits, bitemporal hemianopsia and ophthalmoplegia and perhaps seizures!!! Ask the patient or the relatives or the GP if there is any pre-existing pituitary adenoma. Lab tests include TFTs (Thyroid Function Tests), serum cortisol, GH, PRL (prolactin). Sodium (Na) may be increased or decreased. Check CSF for xanthochromia or blood.

Perform MRI!!! Its superior of CT. Treatment is with 100 mg hydrocortisone IV and neurosurgeon consultance!

• Orbital cellulitis is characterized by periorbital swelling and redness of the eye lids and periorbital tissues, chemosis (of the conjunctiva), limitation of orbital movement, exophthalmos, and also often maxillary and/or ethmoid sinusitis (!) and palatal or nasal mucosa ulceration. Fever is common! There may be history of sinusitis (!) or periorbital injury!

X’ Ray shows sinusitis with or without soft tissue infiltration of the orbit. A very dangerous complication is cavernous sinus thrombosis and patients with DM (diabetes mellitus) or immunosupression are at great risk!

• Cavernous sinus thrombosis is a complication from sinus or facial (e.g. orbital cellulitis) infections. It appears with decreased vision, headache, nausea, vomiting, fever & chills (!), lethargy (!) and signs of systemic illness, unilateral or bilateral exophthalmos (!), papilledema and absent papillary reflexes! Also may have limitation of ocular movements and decrease in corneal sensation.

Perform CT of head & orbits (!), obtain blood cultures (!), admit and give antibiotics parenteraly. It often spreads and involves and the other cavernous sinus! Consider heparin if the patient is deteriorating, but first exclude intracranial hemorrhage with a CT.

• Corticosteroid eye drops may be dangerous on eye problems and may cause severe complications when used in herpes simplex keratitis, fungal infection, cataract and open angle glaucoma. Especially on herpes simplex Keratitis there may be severe corneal destruction. So corticosteroids have specific indications (such as iritis, uveitis, some types of Keratitis and also in allergy), contraindications and need frequent follow up by a specialist. In my opinion, only an ophthalmologist should prescribe corticosteroids (eye drops or systemically) after, a thorough examination of the eye.

• Never give the patient with eye pain to take home eye drops with anesthetics, because their abuse may cause severe corneal abrasions!

• On a painful or red eye exclude cluster headache, glaucoma (increased intra ocular pressure, mid dilated pupil) , uveitis (constricted eye), corneal ulcer/ abrasion, keratitis, conjunctivitis (bacterial or chlamydial!), foreign body (!), actinic kereatitis (sun/ UV exposure), chemicals, ocular burn.

• DM (diabetes mellitus) may cause on the eye retinal detachment or vitreous hemorrhage or productive retinopathy.

(B) EMPIRICAL ADVICES IN AVOIDING PITFALLS IN EMERGENCY & ACUTE MEDICINE (FOLLOWED ONLY AFTER A SENIOR DOCTOR’S CONSULTANCE)

• A speechless patient may suffer from aphasia – stroke, TIA (transit ischemic attack), seizure – epilepsy, or a psychiatric, or other diseases, but may be just deaf and/or mute (!) or have done surgery for larynx cancer or have a tracheostomy or have vocal cords palsy!

• Kids may take poisons or medicine (ask parents for drugs in home). Often a foreign body may obstruct their air.

• History taking should include medication (including herbs, over the counter, the Pill/ contraceptives, and aspirin), illegal drugs or others (such as glue sniffing or mushrooms), alcohol abuse, past medical and family history, same complaints recently, same complaints in the family, occupation, hobbies, sexual practices and recent travel abroad (especially on tropic/ endemic area).

• Burns may cause respiratory suppression. If suspected, intubate early. Also check for CO (carbon monoxide) (SpO2 - Oxygen Saturation may be misleading, perform official HbCO carboxy haemmoglobulin levels) or cyanide (plastic/ synthetic material burning) poisoning, especially if the victim was in a closed room. Circumferal burns of the chest may compromise respiration and need escharotomy. Inhalational burns may compromise airway so consider early intubation!

• Alcoholics may have a hidden head trauma. They may also have Wernick – Korsakoff encephalopathy from thiamine deficiency (and be even in coma), have malnutrition with electrolytes (such as magnesium) and glucose deficiency, may suffer from withdrawal syndrome and the very dangerous ‘delirium tremens’ etc. Ask the alcoholic if he/she is taking other substances of abuse or medication (especially sedatives).

• Alcoholics and illicit drug addicts are the biggest trap is the ER. Concomitant conditions may be misse.

• However, in the ER a minor case may be the trap of malpractice e.g. in a busy ER with multi-injury patients a patient with a trauma on his small finger may be undertreated and this may cause a permanent functional disability on his hand and eventually press charges for malpractice.

• On a coma or seizures (status epilepticus) of unknown etiology, give empirically thiamine, glucose and naloxone.

• A patient may be a smuggler. Check his/her rectum and her vagina, perform a AXR (abdominal X Ray) and from suspect smuggling from his/her history (e.g. a prisoner).

• Do not forget a Td (Tetanus prophylaxis) in any trauma, burn, laceration, bite (animal, man). Also consider prophylactic antibiotics (especially on bites).

• Do not also forget Rh Ig (rhesus immunoglobulin) in a Rh negative pregnant with bleeding, abortion, chorionic sampling/ amniocentisis or manipulations to bring the fetus on its proper place in the uterus.

• All women in reproductive age need a pregnancy blood/ urine test (prefer blood test). On abdominal/ pelvic pain exclude ectopic pregnancy.

• Clavicle (sternoclaviclal) dislocation may press the trachea and should be removed with a special clamp.

• In an emergency suspect the following: poisoning, illicit drugs/ alcohol, head trauma, medicine (side effects, overdose), meningitis, subarachnoid hemorrhage.

• On patients with stroke, seizure or patients that passed out exclude a head trauma from the ptosis (falling).

• Do never forget that drugs have indications, contraindications, side effects and reactions when taken concomitantly with other medicines. Especially when giving sedative drugs or anaesthetics do not forget to give written instructions about not to drive and also to avoid handling machines.

• In patients with dyspnea (short breathing) exclude pulmonary hypertension.

• On COPD and asthma patients exclude pneumothorax.

• On COPD patients initially avoid more than 28% oxygen (ask a senior doctor for it).

• On smokers for years exclude COPD.

• On ischemic stroke the patient may be treated with thrombolysis, if the patient arrives within 3 hours from the onset of the symptoms. Check for CI (contraindications) for thrombolysis. First do a non contrast CT.

• Check for pacemaker/ ICD (implantable cardiac device) before a defibrillation/ cardioversion (see for scars, ask the attendants/ relatives) in order to avoid the area of the device during defibrillation which may burn the heart!

• Initially, check glucose (initially with a blood stick) and pupils. Always check electrolytes, CBC/ FBC (Complete /Full Blood Count), ABGs (arterial blood gases) and also perform clotting tests.

• A coma pretending may be revealed with tricks such as inserting (gently) an ear pad in the patient’s nose.

• Consider irrelevant causes of a clinical presentation e.g. necrotizing fasciitis on a fireman with hypotension and minor burns, but without history of burning or smoke inhalation.

• Exclude poisoning from herbs, mushrooms, insecticides, organophosphates etc.

• Empirically, thousands of thorns on the body (e.g. from a cactus) can be removed by waxing (such as on depilation).

• Persistent headache may indicate CO (carbon monoxide) poisoning e.g. from an old car in which gases came into the cabin, or a brazier. Ask for symptoms in other family members or colleagues.

• Except illicit drug addicts and alcoholics, another big trap, and common malpractice, is a compression syndrome on a multi-injured patient (especially comatose), or after an electrocution or crushing/ squeezing of body parts under rubble.

• Tranfusing is also a major trap for malpractice. Check, when transfusing (e.g. on trauma, anemia etc.) if the worsening of patient’s condition is due to intra or extra vascular hemolysis (Stop transfusion and check CBC/FBC (complete/full blood count), urine Hb (hemoglobuline), LDH, direct and indirect bilirubin etc).

• Paralysis, paraplegia and generally muscle palsies (bulbar or peripheral) may be caused by botulism, toxins (Arsenic – As, Lead – Pb, mercury- Hg), Guillain Barre (ask for recent ‘fly’ like symptoms or gastroenteritis), or hypokalemic periodic paralysis.

• Big raise on the BP may happen from illicit drugs (such as cocaine and amphetamins), pheochromocytoma etc. These may also cause extreme pyrexia with high temperature.

• Ask the patient about his/her diet and also parents about their children’s (especially babies) diet/ nutrition. Many people suffer from malnutrition and/or vitamin/ electrolytes (e.g. potassium K and magnesium Mg) deficiency e.g. Fe – iron (sideropenic – iron deficiency anemia – common in children), thiamin deficiency (alcoholics), pyridoxine deficiency (need it especially if taking isoniazid for TB - tuberculosis) etc. Extreme ages, alcoholics, homeless and drug addicts are in higher risk.

• A child with sudden respiratory distress may have an airway obstruction from foreign body. Also exclude croup and epiglottitis.

• A patient with abdominal pain for prolonged time may have a mesenteric ischemia (especially if old). Ask about deteriorating after food (intestinal angina) that may imply mesenteric ischemia (or a gallbladder disease that rather be on Right Upper Quadrant). Perform a CT.

• Increased ICP (intracranial pressure) and neurological deterioration (e.g. focal signs, convulsion, obtunation) may be ought to drugs such as cocaine and ecstasy.

• Headache and/or neurological symptoms may need a LP (lumbar puncture) to exclude meningitis. However, if focal neurological symptoms or signs of increased ICP (increased intracranial pressure) occur, then perform a CT first. LP has contraindications such as local infection and bleeding dyscrasias. Ask your senior doctor about these. Also, in suspected meningitis, if a LP may be delayed (e.g. for performing a CT), then give antibiotics, otherwise it would be a malpractice.

• Non contrast CT is the initial image test to exclude an ischemic or hemorrhagic stroke (CVA – Cerebrovascular Accident).

• A child with abdominal pain may have DKA (diabetic Ketoacidosis)! Also exclude porphyria and poisoning.

NOTE

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor's consultancy. Some information in this text is empirical and its reliability can't be ascertained. It is suggested to search official medical articles, books and guidelines in order to ascertain the medical information of this text.

 

 

NOTE

About PE (pulmonary embolism), negative D - Dimers are helpful and may rule out only low risk patients. On high risk patients perform a spiral CT or V/Q scan.

REFERENCE – RECOMMENDED BIBLIOGRAPHY FOR EMERGENCY & ACUTE MEDICINE

1)Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw Hill - LANGE, 6th edition, 2008.

2)Wyatt J.P., Illingworth R.N., Graham C.A., Clancy M.J., Robertson C.E., Oxford Handbook of Emergency Medicine, Oxford Medical Publications, 3rd edition, 2006.

3)Ramrakha P., Moore K., Oxford Handbook of Acute Medicine, Oxford Medical Publications, 2nd edition, published 2004, reprinted 2005.

4)ALS (Advanced Life Support), European Resuscitation Council, 5th edition, The Image Factory, Belgium,2006.

5)EPLS (European Paediatric Life Support), European Resuscitation Council, 3rd edition, The Image Factory, Belgium, 2006.

6)Llewelyn H., Aun Ang H., Lewis K., Al – Abdulla A., Oxford Handbook of Clinical Diagnosis, Oxford Medical Publications, 2006.

7)Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

8)Richards D., Aronson J., Oxford Handbook of Practical Drug Therapy, Oxford Medical Publications, 2008.

9)ATLS (Advanced Trauma Life Support), American College of Surgeons – Committee on Trauma, Students Course Manual, First Impression, 7th edition, 2002.

10)PHTLS (Prehospital Trauma Life Support, basic & advanced), Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in association with The Committee of Trauma of the American College of Surgeons, 5th edition (revised), Mosby, inc, 2003.

11)ALSO (Advanced Life Support in Obstetrics), American Academy of Family Physicians, 4th edition (revised), 2006.

12)Kasper D.L., Braunwald E., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Harrison’s Manual of Medicine, McGraw – Hill, 16th edition, 2005.

13)Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

14)Longmore M., Wilkinson I., Turmezei T., Kay Cheung C., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 7th edition, 2008.

15)Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.