Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Feb 2010
The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll.
The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as "Pump, Tank, and Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.
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Fever is defined as a rectal temperature greater than 38.0 degrees C (>100.4 degrees F). A recently documented fever at home should be considered the same as a fever in the ED and should be managed similarly. All febrile infants younger than 28 days should receive a "full sepsis workup" and be admitted for parenteral antibiotic therapy. ⋯ MRSA infections are now common and should be considered in all patients with pyoderma, severe pneumonia, and catheter-related sepsis. HSV infection of the CNS should be considered whenever a patient has altered mental status and CSF findings are not diagnostic of bacterial meningitis. Fever rarely represents life-threatening pathology; however, a handful of less common serious causes of pediatric fever exist with the potential for morbidity and mortality.
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Risk stratification and management of the patient with low-risk chest pain continues to be challenging despite the considerable effort of numerous investigators. Evidence exists that a specific subset of young patients can be defined as low risk in whom further testing may not be necessary. ⋯ The initial history, electrocardiogram (ECG), and biomarkers are important, but serial ECGs and biomarkers improve sensitivity in detecting ACS. Unless chest pain is clearly explained, objective testing, such as exercise treadmill testing, nuclear scintigraphy, stress echocardiography, or coronary computed tomography angiogram, should be considered before, or soon after, discharge.
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The diagnosis of appendicitis is fraught with potential pitfalls, and despite its prevalence, appendicitis continues to be a condition at high risk for missed and delayed diagnosis. There is no single historical or physical finding or laboratory test that can definitively make the diagnosis. ⋯ Challenges of special populations, such as children, the elderly, and pregnant patients, are also discussed. Although appendicitis continues to be a source of medical legal risk and misdiagnosis, a clear understanding of the strengths and limitations of all tests in suspected appendicitis can improve the emergency physician's diagnostic accuracy in this high-risk disease.
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Emerg. Med. Clin. North Am. · Feb 2010
Pitfalls in the management of headache in the emergency department.
Headache is the fifth most common primary complaint of patients presenting to an emergency department (ED) in the United States. The emergency physician (EP) plays a unique role in the management of these patients, one that differs from that of the primary care physician, the neurologist, and other specialists. ⋯ When certain features are present, empirical therapies and diagnostic testing should be initiated in the ED. The most frequently encountered pitfalls in the management of patients with headache in emergency medicine practice, and those with the greatest likelihood to adversely affect patient outcomes, are discussed.