Manual of Emergency Medicine 6th Edition

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 Contents
Contributors xi
Preface xiii
Editor’s Note xiv
Acknowledgment xiv

Part I Cardiopulmonary Resuscitation 1

1 Cardiopulmonary Resuscitation 1

2 Rapid Sequence Intubation 18

Part II Trauma 27

3 Initial Assessment of the Multiple

Trauma Patient 27
4 Head, Neck, and Facial Trauma 40

5 Eye and Periorbital Trauma 58

6 Chest Trauma 64

7 Abdominal Trauma 78

8 Pelvic Trauma 82

9 Genitourinary Trauma 84

10 Extremity Trauma 87

11 Trauma in Pregnancy 124

iv

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 CONTENTS v

Part III Eye, Ear, Nose, and Throat Disorders 129

12 Ear Pain 129

13 Epistaxis 139

14 Facial Pain—Atraumatic 142

15 Hoarseness 146

16 Sore Throat 149

17 Red Eye 156

18 Visual Disturbances 164

Part IV Respiratory Disorders 173

19 Cough 173

20 Hemoptysis 182

21 Shortness of Breath 187

22 Mechanical Ventilation 205

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 vi CONTENTS

Part V Cardiovascular Disorders 211

23 Chest Pain 211

24 Hypertension 230

25 Palpitations 234

Part VI Gastrointestinal Disorders 243

26 Abdominal Pain 243

27 Constipation and Diarrhea 260

28 Gastrointestinal Bleeding 270

29 Hiccups (Singultus) 275

30 Jaundice 276

31 Nausea and Vomiting 282

Part VII Genitourinary and Pregnancy-Related Disorders 287

32 Hematuria 287

33 Sexually Acquired Disorders 291

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 CONTENTS vii

34 HIV Disease and AIDS 301

35 Sexual Assault 317

36 Testicular, Scrotal, and Inguinal Pain or

Swelling 322

37 Vaginal Bleeding 327

38 Childbirth and Emergency Delivery 334

Part VIII Neurologic Disorders 339

39 Coma, Seizures, and Other Disorders of

Consciousness 339

40 Stroke and Syncope 354

41 Dizziness 367

42 Headache 372

43 Weakness 382

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 viii CONTENTS

Part IX Musculoskeletal and Soft-Tissue Disorders 395

44 Abscesses 395

45 Back Pain 398

46 Extremity Pain and Swelling—

Atraumatic 409
47 Joint Pain—Atraumatic 436

48 Abrasions, Avulsions, Lacerations, and

Puncture Wounds 447

Part X Environmental Emergencies 467

49 Diving Accidents 467

50 Near Drowning 471

51 Electrical and Lightning Injuries 474

52 High-Altitude Illness 480

53 Radiation Injury 486

54 Smoke Inhalation 499

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 CONTENTS ix

55 Burns 503

56 Heat Illness and Cold Exposure 511

57 Bites and Stings 521

Part XI Selected Pediatric Emergencies 537

58 Child Abuse 537

59 Fever 541

60 Pediatric Sedation 544

Part XII Other Emergencies 551

61 Foreign Bodies 551

62 Oncologic Emergencies 559

63 Pain Management 566

64 Poisoning and Ingestions 569

65 Rashes 624

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 x CONTENTS

Part XIII Psychiatric Emergencies 643

66 Evaluation of Psychiatric Patients in the

Emergency Department 643

67 Managing Agitation and Aggression in the

Emergency Department 655

68 Evaluating the Suicidal Patient in the

Emergency Department 658

69 Evaluation and Management of Drug

and Alcohol Problems in the Emergency
Department 665
Index 679

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 Contributors
Jeanne Basior, MD, FACEP Christopher L. DeFazio, MD
Associate Professor of Clinical Emergency (Deceased)
Medicine Clinical Instructor
Assistant Residency Director Emergency Medicine
Department of Emergency Medicine Tufts Medical School
School of Medicine and Biomedical Sciences Boston, Massachusetts
University of Buffalo Chairman of Emergency Medicine
Buffalo, New York Melrose Wakefield Hospital
Chapters 24 and 25 Melrose, Massachusetts
Chapters 1, 3, 4, 5, 6, 7, 8, 9, 10, 21, 23
G. Richard Braen, MD, FACEP
Professor and Chair David G. Ellis, MD, FACEP
Department of Emergency Medicine Associate Professor of Clinical Emergency
Assistant Dean of Graduate Medical Medicine
Education Chief of Division of Tele-Informatics
School of Medicine and Biomedical Sciences Department of Emergency Medicine
University of Buffalo School of Medicine and Biomedical Sciences
Buffalo, New York University of Buffalo
Chapters 12 to 20, 24 to 51, 54 Buffalo, New York
to 61 and 65 Chapter 2
Samuel Cloud, DO, FACEP Christopher D. Gordon, MD
Assistant Professor of Clinical Emergency Medical Director and Vice President
Medicine Behavioral Health Advocates, Inc.
Assistant Residency Director Framingham, Massachusetts
Department of Emergency Medicine Assistant Clinical Professor
School of Medicine and Biomedical Sciences Department of Psychiatry
University of Buffalo Harvard Medical School
Buffalo, New York Boston, Massachusetts
Chapters 1, 8, 9, and 11 Chapters 66, 67, 68, 69
Christian DeFazio, MD, FACEP Christopher Jaksa, MD
Assistant Professor of Clinical Emergency Attending Physician
Medicine Walnut Creek Medical Center
Residency Director Walnut Creek, California
Department of Emergency Medicine
Chapter 22
School of Medicine and Biomedical Sciences
University of Buffalo
Buffalo, New York
Chapter 23

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 xii CONTRIBUTORS

Jon L. Jenkins, MD, FACEP Robert McCormack, MD, FACEP

Editor Emeritus Associate Professor of Clinical Emergency
Manual of Emergency Medicine Medicine
Former Chairman Department of Emergency Medicine
Department of Emergency Medicine School of Medicine and Biomedical Sciences
Wakefield Hospital University of Buffalo
Melrose, Massachusetts Buffalo, New York
Chapters 12 to 20, 24 to 51, 54 Director
to 61 and 65 Department of Emergency Medicine
Buffalo General Hospital
Richard S. Krause, MD, FACEP Buffalo, New York
Associate Professor of Clinical Emergency Chapter 18 and 19
Medicine
Department of Emergency Medicine Bruce Shannon, MD (Deceased)
School of Medicine and Biomedical Sciences Chapter 52, 53, 65
University of Buffalo
Buffalo, New York Alexander Walker, MD, FACEP
Chapter 62 Attending Physician
Department of Emergency Medicine
Jonathan T. Lineer, MD Hallmark Health System
Attending Physician Melrose-Wakefield Hospital
Fairview Southdale Hospital Melrose, New York
Minneapolis, Minnesota Chapter 3
Chapter 63

Deborah J. Mann, MD
Assistant Professor of Emergency Medicine
Department of Emergency Medicine
SUNY-Syracuse
Syracuse, New York
Chapter 34

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 Preface
Since publishing the first edition of Manual of Emergency Medicine in 1986, we have
consistently revised the text based on scientific and clinical advances in emergency
medical care and changing patterns of practice. The current edition has been carefully
reviewed and revised.
We believe the Manual provides a practical guide for the initial evaluation and
management of both common and potentially life-threatening or limb-threatening
conditions encountered in emergency medicine. We attempted to write and organize
the Manual in a style and format that would be valuable to physicians at every level
of training and experience.
This manual, because of size limitations inherent to the series, cannot provide the
comprehensive or definitive standard of care for all patients. Additionally, the authors
acknowledge that for many clinical problems in emergency medicine, there exist
several, differing, acceptable, and appropriate management strategies, that medical
opinions among experienced and thoughtful emergency physicians often diverge, and
that few absolutes exist in medicine. Recommendations made in this edition, as well
as in previous editions, must be interpreted in this context.
We are indebted to the many authors who contributed to this and past editions.
Also, we are grateful for the numerous readers and reviewers who, over the years,
have shared their comments and thoughts with us. We invite and appreciate your
comments, thoughts, and suggestions.

G. Richard Braen

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 Editor’s Note
In 1984, Drs. Jon Jenkins and Joseph Loscalzo felt that there was a need for a manual
for emergency physicians, residents, and anyone who wanted to have a better knowl-
edge of emergency medicine. The manual that they conceived was problem based,
reflecting the chief complaints of patients who come to an ED for evaluation and care.
The chapter headings for the medical problems included “shortness of breath,” “chest
pain,” and “abdominal pain” as examples, instead of chapters on “congestive heart
failure,” “myocardial infarction,” and “appendicitis.” The authors wanted the manual
to directly reflect the problems and thought processes that a practicing emergency
physician would encounter and utilize. In 1986, the Manual of Emergency Medicine
was first published. In addition to Drs. Jenkins and Loscalzo, there was one author,
Dr. Bruce Shannon, who contributed multiple chapters. The book had 455 pages of
text. In subsequent editions, additional authors were added. Dr. Loscalzo left the book
after a few editions to become an editor for the New England Journal of Medicine.
For the third edition of the Manual of Emergency Medicine, Dr. Richard Braen
was added as an author/editor. In the fourth and fifth editions, additional contribu-
tors were added, and now, in the sixth edition, four new assistant editors are added.
The four are practicing and teaching emergency physicians and include Drs. Basior,
Cloud, DeFazio, and McCormack.
Dr. Joseph Loscalzo is currently the physician and chief of Internal Medicine
at the Brigham and Women’s Hospital and is on the faculty of the Harvard Medical
School. Dr. Jon Jenkins is a clinical instructor at Tufts University School of Medicine
and is the president of Medical Reimbursement Systems, Inc., a specialized coding
and billing company working with emergency physicians and hospitals.

Acknowledgment
Thanks to those from Lippincott Williams & Wilkins who made this book possible:
Franny Murphy, Chitra Subramaniam, and Julia Seto.

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 PART 1
Cardiopulmonary
Resuscitation

Cardiopulmonary
1 Resuscitation

The techniques and strategies of cardiopulmonary resuscitation (CPR) have evolved

over the years into an organized framework for the evaluation and treatment of
patients with respiratory or cardiac arrest. It is reasonable for the emergency physician
to consider these recommendations, based on currently available data, to be the best
initial approach to most patients presenting with cardiorespiratory arrest; however,
one understands that the recommendations evolve continuously and often dramati-
cally change, suggesting that our understanding of the pathophysiology of this illness
is partial at best and certainly not optimal. In the emergency department, basic CPR
must proceed simultaneously with advanced resuscitation, the latter using medica-
tion and electrotherapy. This chapter thus deals with resuscitation by an emergency
department team and does not cover the details of layperson and healthcare provider
out of hospital CPR/advanced resuscitation.

BASIC CPR

• Focuses on the “ABCs,” ensuring first that the airway is patent and adequate; sec-
ond, that breathing is effective and results in appropriate air exchange within the
chest; and third, that the circulation is restored.
• Recently minimally interrupted chest compressions have been emphasized as the
most important aspect of CPR.

Airway
• In the obtunded or unconscious patient, the upper airway may become obstructed
because of relaxation of muscle groups in the upper respiratory tract.
• Should upper airway obstruction by a foreign body be suspected, the airway should
be cleared manually.
• When respiratory effort exists, airway patency can often be obtained by a variety of
simple mechanical maneuvers that involve the mouth, chin, and mandible.

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 2 CARDIOPULMONARY RESUSCITATION

• When injury to the cervical spine is not present, simply tilting the head backward
may be dramatically effective in opening the airway, and if so, signs of respiratory
obstruction, such as stridor, may disappear.
• In some patients, the insertion of an oral or a nasal airway, provided that the former
does not result in gagging or vomiting, followed by bag-valve–mask (BVM) ventila-
tion as required, may provide adequate oxygenation while the physician attends to
other aspects of CPR.
• In other patients with respiratory effort, the jaw thrust (which involves placing
the fingers bilaterally behind the mandibular angles and displacing the mandible
forward or anteriorly) or the chin lift may provide complete control of the upper
airway.
• The jaw thrust, which results in little or no movement of the neck, is the preferred
initial maneuver in patients with possible injury to the cervical spine.
• In all patients, supplemental oxygen should be administered.
• Despite respiratory effort by the patient, the use of supplemental oxygen, and the
application of techniques to open the airway, the patient with persistent inadequate
oxygenation will require establishment of a definitive airway.
• Rapid sequence endotracheal intubation is the preferred maneuver; relative con-
traindications include potential injury to the cervical spine, mechanical upper
airway obstruction, severe restriction of cervical spine mobility, or severe perioral
trauma.
• In some cases, nasotracheal intubation remains a valuable technique that may safely
be used in the presence of contraindications to endotracheal intubation.
• Nasotracheal intubation should be avoided in patients with significant maxillofacial
trauma, because intracranial penetration along fracture lines has been reported.
• Because of a variety of factors, in some patients, it may not be possible to obtain an
airway by endotracheal or nasotracheal intubation. In these patients, BVM ventila-
tion using an oral or a nasal airway (during which time the adequacy of oxygenation
should be ensured by continuous pulse oximetry) should occur while one considers
alternative techniques for airway control, including use of the laryngeal mask airway
(LMA), or needle or surgical cricothyrotomy.
• The deflated LMA is inserted blindly into the hypopharynx, where cuff inflation
produces an effective proximal and distal seal, with airflow then directed into the
trachea. There is somewhat less airway protection from aspiration with the LMA;
however, there is enthusiastic support for this device, particularly in settings associ-
ated with limited access to the patient, when possible injuries to the cervical spine
preclude or complicate patient positioning for endotracheal intubation, or in situ-
ations in which early responders are untrained in endotracheal intubation. There
is also significantly less risk of the “fatal error” associated with tracheal intubation
(continuing to “ventilate” the patient after intubation of the esophagus).
• In patients without respiratory effort, immediate intervention is required to estab-
lish an airway and provide oxygenation. This should not interrupt chest compres-
sion whenever possible.
• Begin with BVM ventilation and 100% supplemental oxygen with the assistance
of an oral or a nasal airway. When possible, evaluate oxygenation with pulse oxim-
etry. Endotracheal intubation (or consideration of the alternative airway techniques,
depending on the specific situation), as discussed, is then indicated, with needle or
surgical cricothyrotomy considered alternatives for the patient who can be neither
oxygenated nor endotracheally intubated.

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 Chapter 1 • Cardiopulmonary Resuscitation 3

Breathing
• Once airway patency is established, patients without adequate spontaneous respira-
tory effort require artificial ventilation.
• When available, a BVM with an oral or a nasopharyngeal airway and supplemental
oxygen (100% FiO2) is preferred to barrier devices and mouth-to-mouth ventila-
tion, and it is more effective.
• Effective, sustained BVM ventilation is also preferable to the interrupted ventilation
that can occur during multiple failed attempts at endotracheal intubation.
• The adequacy of ventilation is assessed by determining that breath sounds are pres-
ent bilaterally, that an inspiratory increase in chest volume occurs with each inspira-
tion, that skin color improves, and that arterial blood gases or pulse oximetry reflect
appropriate oxygenation.
• It is also recommended that endotracheal tube (ET) placement be confirmed
by nonphysical examination criteria such as capnography or color change CO2
detectors.

Circulation
• The initial pulse check should take no longer than 10 seconds before initiating chest
compressions.
• Precordial thumps are no longer recommended but are not discouraged in the
patient with pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF).
• Chest compressions should begin simultaneously with the establishment of an air-
way and the initiation of ventilation.
• Interruptions in chest compressions should be minimized at all costs.
• With the patient placed in a supine position on a hard surface, external cardiac
compressions are initiated by placing the heel of one hand over the lower half of the
sternum and the heel of the second hand on top of the first hand.
• Pressure over the xiphoid process should be avoided.
• With the elbows extended, rhythmic compressions should be provided by depress-
ing the sternum 1.5 to 2.0 inches posteriorly in adults.
• Compressions should be smooth and should be performed at the rate of approxi-
mately 100/min.
• The efficacy of external compressions can be checked by palpating the carotid or
femoral pulse.
• CPR cycles of 30 compressions to 2 breaths via a BVM should continue until the
patient is connected to the defibrillator and an advanced airway is established.
• Ventilations should be given at a rate of 8 to 10/min during chest compressions once
an advanced airway is established.

ADVANCED CARDIOPULMONARY RESUSCITATION

Early identification of the pulseless rhythm, minimally interrupted chest compres-
sions, and early defibrillation of pulseless VT and VF are the initial goals of emergency
department resuscitation in cardiac arrest.

Intravenous Access
• Initial venous access should be sought in a peripheral vein if possible (e.g., using
veins in the antecubital fossa, generally the most accessible peripheral veins).

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 4 CARDIOPULMONARY RESUSCITATION

• Intraosseous (IO) access is an increasingly utilized modality in adults and should be

considered in any patient in whom large bore peripheral venous access is difficult.
This approach involves the use of a specially designed IO needle that is inserted into
the proximal anterior tibial bone marrow; the distal femur, the proximal humerus,
and distal tibia can also be used. If rapid volume expansion is needed, then fluids can
be administered under pump pressure. The major complications of this procedure
are tibial fractures, lower extremity compartment syndromes in the case of dislodged
needles, and osteomyelitis.
• Central venous sites are avoided because of the increased time associated with their
placement and the unavoidable interruption of CPR; hand and wrist peripheral IV
sites are also less useful, as is femoral venous catheterization.
• One must remember that 1 to 2 minutes is required for medications administered at
a peripheral site to reach the heart; this is true even when CPR is adequate.
• Drugs should be administered by rapid bolus and followed by a 20-mL bolus of
fluid.
• When venous access is unobtainable, the following medications can be adminis-
tered via ET tube: lidocaine, epinephrine, atropine, and narcan (LEAN), which are
administered in approximately 2- to 2.5-times the recommended dose, first diluted
in 10 mL of normal saline and then injected by passing a catheter beyond the tip
of the ET.
• After injecting the medication, three to four forceful ventilations are provided.
Additional Recommendations
• In the past, the use of sodium bicarbonate was encouraged to treat acidosis asso-
ciated with cardiac arrest; the use of sodium bicarbonate is now discouraged in
routine CPR. The rationale for this change involves the lack of evidence supporting
the use of this alkali in changing the outcome of routine CPR as well as a number
of factors suggesting a negative effect. For example, bicarbonate (1) does not facili-
tate defibrillation or improve survival in laboratory animals in VF; (2) shifts the
oxyhemoglobin saturation curve to the left, inhibiting the release of oxygen to the
tissues; (3) produces a paradoxical acidosis in cells, which results from the ability
of carbon dioxide, released from sodium bicarbonate, to diffuse freely into cells,
depressing cellular function; (4) may inactivate administered catecholamines; and
(5) induces a number of other adverse effects caused by systemic alkalosis produced
from overvigorous administration. Bicarbonate is therefore not recommended in
routine CPR.
• In certain specific circumstances, bicarbonate may be of use, but only when the
diagnosis on which such therapy is based has been clearly defined. For exam-
ple, patients with pronounced systemic acidosis associated with renal failure,
patients with tricyclic antidepressant overdose, and patients with hyperkalemia
documented before arrest may benefit from the prompt administration of
bicarbonate.
• Bicarbonate can also be considered in patients with prolonged resuscitations, pro-
vided tracheal intubation and adequate ventilation have been provided (the admin-
istration of bicarbonate to patients with hypercarbic acidosis is harmful), and in
patients with restoration of normal circulation after prolonged arrests.
• The routine administration of bicarbonate should otherwise, however, be
avoided.
• Calcium should be used only in arrests associated with hyperkalemia, hypocalcemia,
or calcium channel blocker toxicity.

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 Chapter 1 • Cardiopulmonary Resuscitation 5

• If possible, particularly in profoundly hypotensive patients who have regained pulses,

bedside US may provide a clue as to the etiology of the shock (i.e., cardiac tampon-
ade, free fluid in the abdomen suggesting intraabdominal aneurysm rupture, etc.).
Treatment of Rhythm Disturbances
Ventricular Fibrillation/Pulseless Ventricular Tachycardia
• The newest guidelines emphasize minimally interrupted CPR.
• Once diagnosed, it should be treated with immediate defibrillation using 120 to
200 J (biphasic device specific, 360 J monophasic device).
• Rhythm checks after defibrillation and stacked shocks are no longer recommended.
• Compressions should immediately follow defibrillation without a rhythm check for
2 minutes.
• After 2 minutes of CPR, the rhythm should be checked.
• If the VT/VF persists, then epinephrine (10 mL of a 1:10,000 solution or 1 mg)
should be administered, either intravenously or, if venous access has not been
obtained, by ET (2–2.5 mg is a reasonable adult dose).
• Then, the patient should be defibrillated again and CPR continued for another
2 minutes.
• If unsuccessful, the dose of epinephrine is repeated at 3- to 5-minute intervals, fol-
lowed by repeated defibrillations at maximum joules, followed by 2 minutes of CPR
as long as the patient remains in VT/VF.
• Vasopressin is an alternative to epinephrine in this setting; vasopressin is adminis-
tered as a one-time intravenous (IV) dose.
• If these maneuvers fail, amiodarone should be administered in a 300-mg IV dose,
followed by defibrillation and 2 minutes of CPR.
• A dose of amiodarone, 150 mg, may be repeated in 3 to 5 minutes.
• Lidocaine (1.5 mg/kg) is an alternative to amiodarone and is administered intra-
venously (or IO), after which defibrillation is repeated; additional doses of 0.5 to
1.5 mg/kg are administered up to a total dose of 3 mg/kg.
• Magnesium sulfate (1 to 2 g IV or IO) may be useful in torsade de pointes or in
suspected hypomagnesemia.
Pulseless Electrical Activity
• In this disorder, there is ECG evidence of organized electrical activity but failure of
effective myocardial contraction (absent pulses and heart sounds).
• Causes of pulseless electrical activity (PEA) to consider include the “5 Hs and 5 Ts”:
hypovolemia, hypoxia, hydrogen ion (acidosis), hyperkalemia, hypokalemia, hypo-
thermia, tablets (overdose), tamponade (cardiac), tension pneumothorax, thrombo-
sis (coronary), and thrombosis (pulmonary embolus).
• Treatment includes oxygenation; volume repletion; CPR; epinephrine (1 mg
IV push every 3–5 minutes); atropine (1 mg intravenously, every 3–5 minutes up
to a total of 0.04 mg/kg); rapid, empiric fluid challenge (in adults, 500 mL of nor-
mal saline recommended by some authorities); and consideration and correction of
other causes of PEA.
• Bedside cardiac US can be very useful to confirm the absence of cardiac output and
help to determine a correctable cause (cardiac tamponade, etc.).
Asystole
• Potential asystole may represent any one of three possible electrophysiologic
events: extremely fine VF, pronounced bradycardia (supraventricular, junctional, or
idioventricular), or true asystole.

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