Emergency medicine practice
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Review Case Reports
An evidence-based approach to emergency department management of acute urinary retention.
Approximately 10% of men in their 70s and 33% of men in their 80s report at least 1 episode of acute urinary retention, and this urological emergency presents unique assessment and treatment challenges in the emergency department setting. Patients presenting with acute urinary retention are often in severe pain and require urgent diagnosis and prompt treatment. ⋯ This review analyzes the etiology, key historical and physical findings, differential diagnosis, and diagnostic studies for acute urinary retention in both men and women. Treatment algorithms for men and women, current controversies regarding urinary catheter usage, and recommendations on criteria for disposition are also presented.
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Many terminally ill patients seek care in the emergency department. Understanding how to elicit goals of care from dying patients and initiate basic palliative measures is well within the scope of emergency medicine. While a wide variety of factors drive patients at the end of life into the acute-care setting, dyspnea is one of the most distressing symptoms experienced by dying patients, and it is a common reason for such patients to seek care. ⋯ Opioids are the most effective and widely studied agents available for palliation of dyspnea in this population, while adjuvant therapies such as oxygen, noninvasive positive pressure ventilation, and fans may also play a role. Other medications (eg, benzodiazepines and low-dose ketamine) may also be useful in select patients. The early involvement of palliative medicine specialists and/or hospice services for dying patients can facilitate optimal symptom management and transitions of care.
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The management of acute trauma in the pregnant patient relies on a thorough understanding of the underlying physiology of pregnancy. This issue reviews the evidence regarding important considerations in pregnant trauma patients, including the primary and secondary survey as well as the possibility for Rh exposure, placental abruption, uterine rupture, and the need for a prompt perimortem cesarean section in the moribund patient. ⋯ Emergency clinicians are encouraged to advocate for trauma prevention, including proper safety restraints for motor vehicles and screening for domestic violence, as these measures have been shown to be effective in reducing morbidity and mortality in this population. Recommendations for monitoring, admission, discharge, and follow-up are also noted.
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Atrial fibrillation and atrial flutter are the most common dysrhythmias seen in the emergency department. As the aging population continues to grow, atrial fibrillation and atrial flutter are expected to affect 6 million people by 2050. ⋯ This review examines the recent literature on the diagnosis and management of atrial fibrillation. Evidence-based recommendations are provided, including cost-effective strategies to evaluate new-onset arrhythmias and unstable patients with atrial fibrillation, rate control strategies, the use of medical and direct current cardioversion for new-onset atrial fibrillation/atrial flutter, whom and when to anticoagulate, and the use of the novel anticoagulation agents.
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Review Case Reports
The emergency medicine approach to the evaluation and treatment of pulmonary embolism.
Each year in the United States, up to 900,000 individuals will suffer from acute pulmonary embolism, resulting in an estimated 200,000 to 300,000 hospital admissions. Despite decades of research on the topic, the diagnosis remains elusive in many situations and the fatality rate remains significant. ⋯ Key to this approach is the concept of risk stratification: using factors from the history and physical examination, plus ancillary tests, to guide clinical decision making. The pathophysiology of pulmonary embolism and decision-support tools are reviewed, and emergency department management strategies are described.