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Toronto Notes 2019 Approach to Common ED Presentations Table 13. Toxic-Metabolic Causes of Fixed Pupils
Emergency Medicine ER21
Dilated
Anoxia
Anticholinergic agents (e.g. atropine, tricyclic antidepressants)
Methanol (rare)
Cocaine
Opioid withdrawal
Amphetamines
Hallucinogens
Serotonin syndrome (MAOI + SSRI)
Disposition
Dilated to Normal
Hypothermia Barbiturates Antipsychotics
Constricted
Cholinergic agents (e.g. organophosphates) Opioids (e.g. heroin), except meperidine
• admission:ifongoingdecreasedLOC,admittoservicebasedontentativediagnosis,ortransferpatient if appropriate level of care not available
• discharge:readilyreversiblealterationofLOC;ensureadequatefollow-upcareavailable
Chest Pain
Table 14. Differential Diagnosis for Chest Pain
Emergent
CVS MI, unstable angina, aortic dissection, cardiac tamponade, arrhythmia
Respirology PE, pneumothorax
GI Esophageal rupture, pneumomediastinum
MSK Other
History and Physical Exam
Usually Less Emergent
Stable angina, pericarditis, myocarditis
Pneumonia, pleural effusion, malignancy
Peptic ulcer disease, esophagitis, GERD, esophageal spasm, pancreatitis, cholecystitis
Rib fracture, costochondritis
Herpes zoster, psychiatric/panic attack
Life-Threatening Causes of Chest Pain
PET MAP
PE
Esophageal rupture Tamponade MI/angina
Aortic dissection Pneumothorax
Imaging is necessary for all suspected aortic dissections, regardless of BP
Angina Characteristics
1. Retrosternal location
2. Provoked by exertion
3. Relieved by rest or nitroglycerin
Risk for Coronary Artery Disease
3/3 = “typical angina” - high risk
2/3 = intermediate risk for women >50 yr,
all men
1/3 = Intermediate risk in men >40 yr,
women >60 yr
• OPQRST,previousepisodesandchangeinpattern
• cardiacriskfactors(HTN,DM,dyslipidemia,smoking,FHx)
• vitals, cardiac, respiratory, peripheral vascular, abdominal exams
Investigations
• CBC,electrolytes,Cr,BUN,glucose,PTT/INR,cardiacbiomarkers(troponins,CK)
• ECG:alwayscomparewithprevious;maybenormalinupto50%ofPEandacuteMI • CXR:comparewithprevious
• CT:ifindicated(e.g.aorticdissection,PE)
Management and Disposition
• ABCs,O2,cardiacmonitors,IVaccess
• treatunderlyingcauseandinvolveconsultantsasnecessary
• considerfurtherobservation/monitoringifuncleardiagnosisorriskofdysrhythmia
• discharge:patientswithalowprobabilityoflife-threateningillnessduetoresolvingsymptomsand
negative workup; arrange follow-up and instruct to return if SOB or increased chest pain develops