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Challenging Concepts in Emergency Medicine
Published and forthcoming titles in
the Challenging Concepts in series

Anaesthesia (Edited by Dr Phoebe Syme, Dr Robert Jackson, and

Professor Tim Cook)
Cardiovascular Medicine (Edited by Dr Aung Myat, Dr Shouvik
Haldar, and Professor Simon Redwood)
Emergency Medicine (Edited by Dr Sam Thenabadu, Dr Fleur Cantle,
and Dr Chris Lacy)
Infectious Disease and Clinical Microbiology (Edited by Dr Amber
Arnold and Professor George Griffin)
Interventional Radiology (Edited by Dr Irfan Ahmed, Dr Miltiadis
Krokidis, and Dr Tarun Sabharwal)
Neurology (Edited by Dr Krishna Chinthapalli, Dr Nadia Magdalinou,
and Professor Nicholas Wood)
Neurosurgery (Edited by Mr Robin Bhatia and Mr Ian Sabin)
Obstetrics and Gynaecology (Edited by Dr Natasha Hezelgrave,
Dr Danielle Abbott, and Professor Andrew Shennan)
Oncology (Edited by Dr Madhumita Bhattacharyya, Dr Sarah Payne,
and Professor Iain McNeish)
Oral and Maxillofacial Surgery (Edited by Mr Matthew Idle and
Dr Andrew Monaghan)
Respiratory Medicine (Edited by Dr Lucy Schomberg and
Dr Elizabeth Sage)
Challenging Concepts in
Emergency Medicine:
Cases with Expert Commentary

Edited by

Dr Sam Thenabadu
Consultant Adult & Paediatric Emergency Medicine, Princess Royal University Hospital, King’s
College Hospital NHS Foundation Trust Kent, UK

Dr Fleur Cantle
Consultant in Adult and Paediatric Emergency Medicine, King's College Hospital NHS Foundation
Trust, London, UK

Dr Chris Lacy
Consultant Emergency Medicine, King’s College Hospital, London, UK

Series editors

Dr Aung Myat BSc (Hons) MBBS MRCP

BHF Clinical Research Training Fellow, King’s College London British Heart Foundation Centre of
Research Excellence, Cardiovascular Division, St Thomas’ Hospital, London, UK

Dr Shouvik Haldar MBBS MRCP

Electrophysiology Research Fellow & Cardiology SpR, Heart Rhythm Centre, NIHR Cardiovascular
Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, Imperial College
London, London

Professor Simon Redwood MD FRCP

Professor of Interventional Cardiology and Honorary Consultant Cardiologist, King’s College London
British Heart Foundation Centre of Research Excellence, Cardiovascular Division and Guy’s and
St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK

1
3
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For Richard, Martha and Barnaby
Fleur Cantle

For Molly and Reuben

Sam Thenabadu
FOREWORD

The publication of this book is a timely reminder of the maturity of the specialty of
emergency medicine. The chapters, each written by an experienced EM physician
and added to by renowned national and international experts, explore in depth the
clinical challenges and conundrums that begin each chapter.
The diligent reference to key studies, not just via a simple citation but by use
of a brief summary of the relevant findings, ensures that the reader is not only
informed by the text but achieves a level of familiarity with a good deal of the
academic literature.
The reader is guided through a series of questions and answers as the
clinical path of each patient progresses and this interaction greatly increases
the readability of the text. The other engaging feature is the inclusion of expert
comments and opinions at various points in each chapter. The effect created is
similar to that experienced in a small tutorial group overseen by a learned and
experienced mentor. Key learning points assist in emphasizing the issues most
relevant to patient outcomes. Finally each chapter concludes with an extensive and
up to date reference list to ensure ease of access to the source literature.
For those EM physicians who are increasingly familiar with the use of
ultrasound in the ED there are numerous excellent sonographic examples of key
anatomy and pathophysiology.
This is not a traditional textbook, nor does it purport to cover any specific
curriculum; instead this is a book that engages the reader, seeks to challenge and
educate the EM physician and will do so whether they are recently qualified or an
established consultant.
The book covers a wide range of conditions and any shift worked in the ED will
include many of the patients and challenges so authoritatively covered by this
text. The result is, in effect, a single volume approach to CPD. Those who read and
note its contents will be better clinicians, better teachers, and better prepared to
challenge concepts in emergency medicine.

Dr Clifford Mann FRCP FCEM

President of the College of Emergency Medicine
ACKNOWLEDGEMENTS

Emergency Medicine is a flourishing specialty, and the chance to coordinate

bringing together a textbook by enthusiastic and inspiring EM colleagues was a
real labour of love. The chapters truly emphasise the challenging grey cases seen
in the ED and the expertise that the specialty has. I hope that the evidence based
medicine described and the pragmatic expert opinions offered, will form a text
that can be applied to both day to day ED scenarios, as well as an aide for exams.
It is essential to thank all the authors and experts that have produced great
chapters and tolerated our relentless emails and phone calls. It is equally if
not more important to thank Fleur as my fellow editor for her tireless energy,
organisational skills and constant positivity to make this book a success despite
being one of the busiest people I know. I shall never forget the colour coded excel
charts!
Finally I must thank my parents for their lifelong support and encouragement,
but most of all my biggest thank you is to my wonderful understanding, patient
and unrelentingly supportive wife Molly and son Reuben – you are my constant
inspirations.

Sam Thenabadu
CONTENTS

Contributors ix Case 15 Headache 147

Abbreviations xiii Case 16 Self-harm 159

Case 1 The sepsis resuscitation bundle 1 Case 17 Febrile seizures 167

Case 2 Cardiopulmonary resuscitation for the Case 18 Right lower quadrant abdominal pain in women:
twenty-first century 11 gynaecology or surgery? 177

Case 3 Traumatic occult pneumothorax 27 Case 19 Dentofacial emergencies 187

Case 4 Facial burns and inhalation injury 39 Case 20 Safeguarding: recognizing the abused child
and acting on the evidence base 197
Case 5 Paediatric head injury 47
Case 21 Femoral nerve block for fractured neck of femur 207
Case 6 Vaginal bleeding in early pregnancy 57
Case 22 Sedation and restraint in the ED 219
Case 7 The limping child 65
Case 23 Hypothermia 229
Case 8 Corneal injury 75
Case 24 ‘Cocaine chest pain’ 239
Case 9 Procedural sedation in the emergency department 85
Case 25 Croup 251
Case 10 Atraumatic testicular pain 99
Case 26 The collapsed marathon runner 259
Case 11 Pretibial laceration 107
Case 27 Haemorrhagic rashes in children 269
Case 12 Complex wrist fractures 117
Case 28 Facial palsy 277
Case 13 Fever in the ED 127
Case 29 Back pain 285
Case 14 Tricyclic antidepressant overdose 137
Index 297
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CONTRIBUTORS

Dr Olumayowa Adenugba Dr Sunil Bhatia

Consultant Emergency Medicine Consultant Maxillofacial Surgeon
Queen Elizabeth Hospital Royal Shrewsbury Hospital
Lewisham and Greenwich NHS Trust Royal Shrewsbury and Telford NHS Trust,
Woolwich, London Shrewsbury, UK

Dr Harith Al-Rawi Dr Lisa Black

Consultant Adult and Paediatric ST6 Emergency Medicine
Emergency Medicine Greater Glasgow and Clyde Health Board,
Guys and St Thomas’ NHS Foundation Trust Royal Alexandra Hospital
St Thomas’ Hospital Paisley, UK
London, UK
Dr Duncan Bootland
Dr Meng Aw-Yong Consultant in Emergency Medicine
Medical Director and Forensic Medical Examiner Royal Sussex County Hospital
Metropolitan Police Service Brighton & Sussex University Hospital Trust
Empress State Building, Brighton, UK
London, UK
Dr Fleur Cantle
Associate Specialist Emergency Medicine
Consultant in Adult & Paediatric
Hillingdon Hospital
Emergency Medicine
Middlesex, UK
King’s College Hospital NHS Foundation Trust
Dr Mike Beckett London, UK
Consultant in Emergency Medicine
Professor Douglas Chamberlain, CBE
West Middlesex University Hospital
Brighton
London, UK
Honorary Professor of Cardiology,
Mr Duncan Bew Brighton and Sussex Medical School.
Consultant Trauma and Emergency Surgeon University of Sussex
Clinical Director for Trauma Surgery
Beth Christian
King’s College Hospital NHS Trust
Consultant in Emergency Medicine
London, UK
St. Thomas’ Hospital
Dr Rhys Beynon Guy’s and St Thomas’ NHS Foundation Trust
Consultant in Adult and Paediatric Emergency London, UK
Medicine
Dr Evan Coughlan
St George’s Healthcare NHS Trust
Consultant in Emergency Medicine
London, UK
Brighton & Sussex University NHS Trust
Dr Neel Bhanderi Royal Sussex County Hospital
Pre-Hospital and Emergency Physician Brighton, UK
Kent, Surrey and Sussex Air Ambulance
Dr Sean Cross
Marden, Kent, UK
Consultant Liaison Psychiatrist
South London and Maudsley NHS Foundation Trust
London, UK
x Contributors

Dr Paul Dargan Dr Ed Glucksman

Consultant Physician and Clinical Toxicologist Consultant in Emergency Medicine
Clinical Director and Reader in Toxicology King’s College Hospital NHS Foundation Trust
Guy’s and St Thomas’ NHS Foundation Trust London, UK
London, UK
Professor Colin A Graham
Dr Rita Das Professor of Emergency Medicine
Consultant in Emergency Medicine Chinese University of Hong Kong
Whittington Health Honorary Consultant in Emergency Medicine
London, UK Prince of Wales Hospital
Shatin New Territories, Hong Kong SAR
Dr Balj Dheansa
Consultant Burns & Plastic Surgeon Dr Sara Hanna
McIndoe Burns Centre Consultant in Paediatric Intensive Care
Queen Victoria Hospital Evelina London Children’s Hospital
East Grinstead, UK Guy’s and St Thomas’ NHS Foundation Trust
London, UK
Dr Chidi Ejimofo
Consultant in Emergency Medicine Professor Tim Harris
Lewisham and Greenwich NHS Trust Professor of Emergency Medicine
University Hospital Lewisham Queen Mary University of London and Brats Health
London, UK London, UK

Dr Sarah Finlay Mr Kambiz Hashemi

Consultant in Emergency Medicine Consultant in Emergency Medicine
Chelsea and Westminster NHS Trust Croydon University Hospital
London, UK Croydon, UK

Dr Anna Forrest-Hay Dr Katherine Henderson

Consultant in Adult and Paediatric Emergency Consultant in Emergency Medicine
Medicine Guy’s and St Thomas’ NHS Foundation Trust
Kingston Hospital NHS Foundation Trust London, UK
Kingston-upon-Thames, UK
Dr Geoff Hinchley
Dr Anne Frampton Consultant in Emergency Medicine
Consultant in Adult and Paediatric Emergency Barnet and Chase Farm Hospital
Medicine London, UK
University Hospitals Bristol NHS Foundation Trust
Dr Andrew Hobart
Bristol, UK
Consultant in Emergency Medicine
Dr Robert Galloway Princess Royal University Hospital
Consultant in Emergency Medicine Kings College Hospital NHS Foundation Trust
Brighton & Sussex NHS Trust London, UK
Brighton, UK
Dr Anthony Hudson
Dr Shweta Gidwani Consultant in Emergency Medicine
Consultant in Emergency Medicine St George’s Hospital, London, UK
Chelsea & Westminster Hospital NHS Trust and
London, UK Kent, Surrey
Sussex Air Ambulance Trust
Marden, UK
 Contributors xi
Dr Anna Johnson Professor Sir Keith Porter
Consultant in Emergency Medicine Professor of Clinical Traumatology
Medway Maritime NHS Foundation Trust Queen Elizabeth Hospital Birmingham
Gillingham, UK University Hospital Birmingham NHS
Foundation Trust
Dr Jeff Keep
Birmingham, UK
Consultant Emergency Medicine
King’s College Hospital NHS Foundation Trust Dr Shwetha Rao
London, UK Consultant in Emergency Medicine,
King’s College Hospital NHS Foundation trust
Dr Adham Khalek
London, UK
Consultant in Emergency Medicine
John Radcliffe Hospital Dr Anna Riddell
Oxford University Hospital NHS Trust Consultant Paediatrician
Oxford, UK Clinical Director for Children’s Health
Barts Health NHS Trust
Dr Lalarukh Khan
London, UK
Consultant in Adult and Paediatric Emergency
Medicine Professor Emmanuel Rivers
King’s College Hospital NHS Foundation Trust Vice Chairman and Research Director
London, UK Department of Emergency Medicine
Attending Staff, Emergency Medicine and
Mr TJ Lasoye
Surgical Critical Care
Consultant and Honorary Senior Lecturer in
Henry Ford Hospital
Emergency Medicine/Director of Medical Education
Clinical Professor, Wayne State University
King’s College Hospital NHS Foundation Trust
Detroit, Michigan, USA
London, UK
Professor John Ryan
Dr Ian Maconochie
Consultant in Emergency Medicine
Consultant in Paediatric Emergency Medicine
St Vincent’s University Hospital
Imperial College Healthcare Trust
Dublin 4
London, UK
Ireland
Dr Katie Mcleod
Dr Samy Sadek
Consultant in Adult & Paediatric Emergency Medicine
Consultant in Emergency Medicine
Princess Royal University Hospital, King’s College
The Royal London Hospital Barts Health NHS Trust
Hospital NHS Foundation Trust
London, UK
London, UK
Tina Sajjanhar
Dr Andrew Neill
Consultant in Paediatric Emergency Medicine
Specialist Registrar in Emergency Medicine
Lewisham and Greenwich NHS Trust
Mater Misericordiae University Hospital
London, UK
Dublin, Ireland
Dr Jessica Spedding
Dr Sophie Parker
Emergency Medicine SpR
Fellow in Intensive Care
The Royal London Hospital
Department of Intensive Care
London, UK
Prince of Wales Hospital
South Eastern Sydney and Illawarra Area Dr Oliver Spencer
Health Service Consultant in Emergency Medicine
Sydney, Australia Croydon University Hospital
Croydon, UK
xii Contributors

Dr Lindsey Stevens Dr Emma Townsend

Consultant in Emergency Medicine Consultant in Emergency Medicine
Epsom and St Helier University NHS Trust Maidstone and Tunbridge Wells NHS Trust
Surrey, UK Kent, UK
Honorary Senior Lecturer
Dr Chetan Trivedy
St George’s Hospital Medical School
National Institute for Health Research
London, UK
Academic Clinical Lecturer in Emergency Medicine
Michael Stone Warwick Medical School
Chief, Division of Emergency Ultrasound Warwick, UK
Department of Emergency Medicine
Dr André Vercueil
Brigham & Women’s Hospital
Consultant in Intensive Care Medicine and
Assistant Professor of Medicine (Emergency
Anaesthesia
Medicine)
King’s College Hospital NHS Foundation Trust
Harvard Medical School
London, UK
Boston, MA, USA
Dr Simon Walsh
Dr Emer Sutherland
Consultant in Adult and Paediatric Emergency
Consultant in Emergency Medicine
Medicine
King’s College Hospital NHS Foundation Trust
The Royal London Hospital
London, UK
Barts Health NHS Trust
Dr Sam Thenabadu London, UK
Consultant in Adult & Paediatric Emergency
Dr Gavin Wilson
Medicine
Consultant in Adult & Paediatric Emergency
Princess Royal University Hospital
Medicine
King’s College Hospital NHS Foundation Trust
Kingston Hospital
Kent, UK
Kingston Hospital NHS Foundation Trust
Kingston upon Thames, UK
ABBREVIATIONS

AANA American Association of Nurse FIC fascia iliaca compartment

Anesthetists FNB Femoral nerve block
ABG arterial blood gas FUO fever of unknown origin
ACEP American College of Emergency GCA Glasgow Coma Scale
Physicians GTN glyceryl trinitrate
ACPs Advanced Care Paramedics HBSS Hanks balanced salt solution
AHA American Heart Association Hib Haemophilus influenza type b
ALS advanced life support HMIC Her Majesty’s Inspector of
ANC absolute neutrophil count Constabulary
ASA American Association of HS hypertonic saline
Anaesthesiology ICP intracranial pressure
ASIS anterior superior iliac spine ICU intensive care unit
ATLS advanced trauma life support IDDM insulin-dependent diabetes mellitus
BDZ benzodiazepine IFP idiopathic facial paralysis
CA cardiac arrest IL-6 Interleukin-6
CBT cognitive behavioural therapy ILE intra lipid emulsion
CDRs clinical decision rules IO intra-osseous
CEM College of Emergency Medicine IOFB intraocular foreign bodies
CES Cauda equine syndrome IPCC Independent Police Complaints
CESi incomplete CES Commission
CI confidence interval ISS injury severity score
CNS central nervous system ITU intensive therapy unit
CPB cardiopulmonary bypass LA local anaesthetic
CPR Cardiopulmonary resuscitation LBP lower back pain
CRP C-reactive protein LOC loss of consciousness
CSE convulsive status epilepticus LP lumbar puncture
CSF cerebrospinal fluid MAP mean arterial blood pressure
CVP central venous pressure MCA Mental Capacity Act (2005)
DV domestic violence MHA Mental Health Act (1983)
DVT deep vein thrombosis NAI non-accidental injury
EAC exercise-associated collapse NDTMS National Drug Treatment Monitoring
ECMO extra-corporeal membrane oxygenation System
ECW extracorporeal warming NMDA N-methyl-D-aspartic acid
ED emergency department NNT number needed to treat
eFAST extendedFAST NOF neck of femur
EGDT early goal-directed therapy NSM neurogenic stunned myocardium
EHS exertional heat stroke OOHCA out-of-hospital cardiac arrest
ENP emergency nurse practitioner OR odds ratio
ENT ear, nose, and throat PCI percutaneous coronary intervention
FACT focused assessment by CT in Trauma PCT procalcitonin
FAST focused abdominal sonography in PDL periodontal ligament
trauma PEA pulseless electrical activity
FIB fascia iliaca block PICU paediatric intensive care unit
xiv Abbreviations

PUO pyrexia of unknown origin SSC Surviving Sepsis campaign

QR quantitative resuscitation STEMI ST elevation myocardial infarction
RBC red blood cell SUFE slipped upper femoral epiphysis
RCT randomized controlled trial SVC superior vena cava
RDT rapid diagnostic testing TCA tricyclic antidepressant
RDTS rapid diagnostic tests TDI traumatic dental injury
RLQ right lower quadrant TMJ temporomandibular joint
ROSC return of spontaneous circulation TPO telephone outpatient score
RROM restricted range of movement TS transient synovitis
SA septic arthritis URTI upper respiratory tract infection
SAH subarachnoid haemorrhage US ultrasound scan
SCD sickle cell disease VA visual acuity
ScvO2 central venous oxygen saturation VAS visual analogue scale
SHEP sonography of the hip joint by the VF ventricular fibrilation
emergency physician VT ventricular tachycardia
SIRS systemic inflammatory response WCC white cell count
syndrome
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