THE PRACTICE OF EMERGENCY MEDICINE
The emergency department represents a unique environment where physicians in emergency medicine are exposed to a myriad of high risk situations. This paper will focus on those situations and the red flags that suggest their presence and the appropriate response by an emergency room physician.
Indications for CAT Scans of the Head in the Emergency Department:
CAT scans should be obtained if one or more of the following historical or clinical factors are present in a patient with head injury in order to rule out the presence of a significant head injury (epidural, subdural or intracerebral hemmorage or cerebral edema): Headache, loss of consciousness, amnesia and confusion warrant CAT scans. In addition if the mechanism of injury is compatible with severe injury even though the patient looks good now (i.e. hit with a bat or barrel of a gun) the test is indicated. The index of suspicion needs to be raised in the elderly or very young patients.
Other indications for emergency CAT scans in the emergency department would include new types of headaches or the worst headache in a patient's life, suspected stroke, first seizure or an unconscious patient with no clear cause. In a patient with a shunt who is having headache, vomiting or alteration in the level of consciousness it should be considered due to shunt malfunction until proven otherwise. CAT scan and urgent neurosurgical consultation is required since these patients can rapidly deteriorate.
Chest Pain in the Emergency Department:
Major life-threatening causes of chest pain (myocardial infarction, unstable angina, pericarditis, dissecting thoracic aortic aneurysm and pulmonary embolism) must always be considered and must be aggressively ruled-out. Pitfalls in evaluation of chest pain include a history that is inadequate to characterize the symptom, not doing an EKG or not comparing the current with prior EKG, not considering the major life-threatening diagnoses, minimizing the cause of the pain to a benign etiology (chest wall pain) and not getting consultation on suspicious cases of chest pain.
Abdominal Pain in the Emergency Department:
Acute appendicitis must be considered even in cases with an atypical presentation. Common things happen commonly and appendicitis is common. The physician should think appendicitis until proven otherwise in cases of right sided lower abdominal pain or flank pain. Immediate surgical consultation should be obtained in cases where there is a significant suspicion for a surgical abdomen. With an elderly patient it is necessary to maintain a higher level of concern in cases of abdominal pain. Abdominal aortic aneurysm needs to be considered. Enemas for constipation in the Emergency Department should not be given unless intestinal obstruction has been ruled-out by x-ray to minimize the risk of causing a perforation. Pregnancy tests should always be ordered in women of childbearing age who present with abdominal pain to rule-out ectopic pregnancy. If the cause of the pain seems benign or there are inadequate findings to merit a surgical consultation, a follow-up abdominal exam should be scheduled in 8 - 12 hours or sooner, if worse, to exclude a developing surgical problem.
Wound Care in the Emergency Department:
Foreign bodies need to be considered and x-rays obtained when suggested in the history is taken in soft tissue injuries. Wounds need to be irrigated and explored. In cases involving lacerations over the scalp depressed skull fracture needs to be considered. The skull should bepalpated and x-rays obtained to rule out penetrating skull wounds. Arterial injury needs to be ruled out when wounds are in proximity to arteries or if a history of arterial type bleeding or rapid swelling occurs after a skin wound. If evidence of wound infection occurs after an emergency department repair a missed foreign body needs to be considered as the cause of the infection and soft tissue x-rays if not previously obtained should be ordered. Consultation by other specialists should be considered.
Headache in the Emergency Department:
Although most headaches presenting to the emergency department are due to benign causes such as tension or migraine headaches the physician must be on guard for the ominous causes of headache. The following chart lists the possible source of headache and appropriate test to be conducted:
|Glaucoma||Check eye pressure with tonometer|
|Temporal arteritis||Sedimentation rate|
|Subarachnoid bleed||CAT Scan and lumbar puncture|
|Head injury||CAT Scan|
|Tumor||CAT Scan or MRI|
Falls in the Emergency Department:
Patients with an altered mental status for any reason are at risk for falls in the emergency department. Common etiologies for these alterations are simple fainting after procedures in the emergency department, acute alcohol intoxication, post-ictal confusion after seizures, drug overdoses or patients with delirium from any cause. These patients need protection from themselved due to injury from falls and from leaving the emergency department AWOL. Additionally staff needs to be protected from their potentially violent behavior. There patients in this category need to be in restraints or be under constant obserevation. The side railes of the bed should be in the up position.
Emergency department physicians also need to be concerned with older patients who have fallen and complained of hip, thigh or knee pain. Until proven otherwise a broken hip should be suspected. Another area of concern in carefully examining the neurologic, tendon and fascular function of an extremity distal to an injury to rule out occult damage to the deep structures. Examine the area after obtaining a dry field with a tourniquet. If a question exists with regard to deep injury a consultation is indicated. It is important to have a system for picking up miss-reads on x-rays and EKGs and calling back the patients to arrange for follow-up in a timely fashion.