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Toronto Notes 2019 Approach to Common ED Presentations
History
• gatherdetailsfromwitnesses,andclarifypatient’sexperience(e.g.dizziness,ataxia,ortruesyncope) ■ two key historical features: prodrome and situation (setting, patient posture)
• distinguishbetweensyncopeandseizure(seeNeurology,N19)
■ some patients may have myoclonic jerks with syncope – NOT a seizure ◆ signs and symptoms during presyncope, syncope, and postsyncope
◆ past medical history, drugs
◆ think anatomically in differential; pump (heart), blood, vessels, brain • syncopeiscardiogenicuntilprovenotherwiseif
■ there is sudden loss of consciousness with no warning or prodrome ■ syncope is accompanied by chest pain
Physical Exam
• posturalBPandHR
• cardiac,respiratory,andneurologicalexams
• examineforsignsofsecondaryinjurycausedbysyncopalepisode(e.g.headinjury)
Investigations
• ECG(tachycardia,bradycardia,blocks,Wolff-ParkinsonWhite,longQTinterval,BrugadaSyndrome, RV strain), bedside glucose
• consider blood work: CBC, electrolytes, BUN/Cr, ABGs, troponin, Ca2+, Mg2+, β-hCG, D-dimer
• consider toxicology screen
Management
• ABCs, IV, O2, monitor
• cardiogenicsyncope:admittomedicine/cardiology
• low risk syncope: discharge with follow-up as indicated by cause (non-cardiogenic syncope may still be
admitted)
Disposition
• decisiontoadmitisbasedonetiology
• mostpatientswillbedischarged
• ondischarge,instructpatienttofollow-upwithfamilyphysician
■ educate about avoiding orthostatic or situational syncope
■ evaluate the patient for fitness to drive or work
■ patients with recurrent syncope should avoid high-risk activities (e.g. driving)
Sexual Assault
Epidemiology
• 1in5womenand1in71menwillbesexuallyassaultedintheirlifetime;only7%arereported
General Approach
• ABCs,treatacute,seriousinjuries;physicianpriorityistotreatmedicalissuesandprovideclearance • ensurepatientisnotleftaloneandprovideongoingemotionalsupport
• obtainconsentformedicalexamandtreatment,collectionofevidence,disclosuretopolice(notify
police as soon as consent obtained)
• SexualAssaultKit(documentinjuries,collectevidence)if<72hsinceassault • labelsamplesimmediatelyandpassdirectlytopolice
• offercommunitycrisisresources(e.g.shelter,hotline)
• donotreportunlessvictimrequestsorif<16yrold(legallyrequired)
History
• ensureprivacyforthepatient–othersshouldbeaskedtoleave
• questionstoask:who,when,wheredidpenetrationoccur,whathappened,anyweapons,orphysical
assault?
• post-assaultactivities(urination,defecation,changeofclothes,shower,douche,etc.)
• gynecologichistory
■ gravidity, parity, last menstrual period
■ contraceptionuse
■ last voluntary intercourse (sperm motile 6-12 h in vagina, 5 d in cervix)
• medicalhistory:acuteinjury/illness,chronicdiseases,psychiatrichistory,medications,allergies,etc.
Physical Exam
• neverre-traumatizeapatientwiththeexamination • generalexamination
■ mental status
■ sexual maturity
■ patient should remove clothes and place in paper bag
■ document abrasions, bruises, lacerations, torn frenulum/broken teeth (indicates oral penetration)
Emergency Medicine ER27
Causes of Syncope by System
HEAD, HEART, VeSSELS Hypoxia/Hypoglycemia Epilepsy
Anxiety
Dysfunctional brainstem Heart attack
Embolism (PE)
Aortic obstruction Rhythm disturbance Tachycardia
Vasovagal
Situational
Subclavian steal
ENT (glossopharyngeal neuralgia) Low systemic vascular resistance Sensitive carotid sinus
San Francisco Syncope Rule: High risk of adverse outcomes in syncope patients if:
CHESS
CHF: Hx of CHF
Hct: Low
ECG: Abnormal
SOB: Hx of dyspnea SBP: sBP <90 at triage
Interprofessional teams are key; many centres or regions have sexual assault teams who specialize in the assessment and treatment
of sexual assault victims, leaving emergency physicians responsible only for significant injuries and medical clearance