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ER18 Emergency Medicine
Approach to Common ED Presentations Toronto Notes 2019
• physicalexam
■ think about underlying anatomy
■ examine tendon function actively against resistance and neurovascular status distally
■ clean and explore under local anesthetic; look for partial tendon injuries
■ x-ray or U/S wounds if a foreign body is suspected (e.g. shattered glass) and not found when
exploring wound (remember: not all foreign bodies are radioopaque), or if suspect intra-articular
involvement • management
■ disinfect skin/use sterile techniques ■ irrigate copiously with normal saline ■ analgesia ± anesthesia
■ maximum dose of lidocaine
◆ 7 mg/kg with epinephrine
◆ 5 mg/kg without epinephrine
• inchildren,topicalanestheticssuchasLET(lidocaine,epinephrine,andtetracaine),andinselected
cases a short-acting benzodiazepine (midazolam or other agents) for sedation and amnesia are useful • securehemostasis
• evacuate hematomas, debride non-viable tissue, remove hair and foreign bodies
• ±prophylacticantibiotics(considerforanimal/humanbites,intra-orallesion,orpuncturewoundsto
the foot)
• sutureunless:delayedpresentation(>6-8h),puncturewound,mammalianbite,crushinjury,or
retained foreign body
• takeintoaccountpatientandwoundfactorswhenconsideringsuturing • advisepatientwhentohavesuturesremoved
• cellulitisandnecrotizingfasciitis(seePlasticSurgery,PL15)
Approach to Common ED Presentations
Early wound irrigation and debridement are the most important factors in decreasing infection risk
Alternatives to Sutures
• Tissue glue • Steristrips® • Staples
Abdominal Pain
Table 12. Selected Differential Diagnosis of Abdominal Pain
Be vigilant: very young, elderly, alcoholics, immunosuppressed patients often present atypically
Old age, pregnancy (T3), and chronic corticosteroid use can blunt peritoneal findings, so have an increased level of suspicion for an intra-abdominal process in these individuals
Unstable patients should not be sent for imaging
GI
Hepatobiliary Genital
Urinary CVS Respirology Metabolic Other
Emergent
Perforated viscus, bowel obstruction, ischemic bowel, appendicitis, strangulated hernia, IBD flare, esophageal rupture, peptic ulcer disease
Hepatic/splenic injury, pancreatitis, cholangitis, spontaneous bacterial peritonitis
Female: Ovarian torsion, PID, ectopic pregnancy Male: Testicular torsion
Pyelonephritis
MI, aortic dissection, AAA
PE, empyema
DKA, sickle cell crisis, toxin, Addisonian crisis Significant trauma, acute angle closure glaucoma
Usually Less Emergent
Diverticulitis, gastroenteritis, GERD, esophagitis, gastritis, IBS
Biliary colic, cholecystitis, hepatitis
Female: tubo-ovarian abscess, ovarian cyst, salpingitis, endometriosis
Male: epididymitis, prostatitis
Renal colic, cystitis
Pericarditis
Pneumonia
Lead poisoning, porphyria
Abdominal wall injury, herpes zoster, psychiatric, abscess, hernia, mesenteric adenitis
If elevated AST and ALT
Think hepatocellular injury AST > ALT: alcohol-related ALT > AST: viral, drug, toxin
If elevated ALP and GGT
Think biliary tree obstruction
• differentialcanbefocusedanatomicallybylocationofpain:RUQ,LUQ,RLQ,LLQ,epigastric, periumbilical, diffuse
History
• pain: OPQRST
• reviewsymptomsfromGU,gynecological,GI,respiratory,andCVsystems • abdominaltrauma/surgeries,mostrecentcolonoscopy
Physical Exam
• vitals,abdominal(includingDRE,CVAtenderness),pelvic/genital,respiratory,andcardiacexamsas indicated by history
Investigations
• ABCs,donotdelaymanagementandconsultationifpatientunstable
• labs:CBC,electrolytes,glucose,BUN/Cr,U/A±liverenzymes,LFTs,lipase,β-hCG,ECG,troponins,±
VBG/lactate
• AXR:lookforcalcifications,freeair,gaspattern,airfluidlevels
• CXRupright:lookforpneumoperitoneum(freeairunderdiaphragm),lungdisease
• U/S:biliarytract,ectopicpregnancy,AAA,freefluid
• CT:trauma,AAA,pancreatitis,nephro-/urolithiasis,appendicitis,anddiverticulitis