Emergency medicine practice
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Syncope is a common occurrence in the emergency department, accounting for approximately 1% to 3% of presentations. Syncope is best defined as a brief loss of consciousness and postural tone followed by spontaneous and complete recovery. ⋯ Several risk stratification decision rules are compared for performance in various scenarios, including how age and associated comorbidities may predict short-term and long-term adverse events. An algorithm for structured, evidence-based care of the syncope patient is included to ensure that patients requiring hospitalization are managed appropriately and those with benign causes are discharged safely.
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Shock is a state of acute circulatory failure leading to decreased organ perfusion, with inadequate delivery of oxygenated blood to tissues and resultant end-organ dysfunction. The mechanisms that can result in shock are divided into 4 categories: (1) hypovolemic, (2) distributive, (3) cardiogenic, and (4) obstructive. While much is known regarding treatment of patients in shock, several controversies continue in the literature. ⋯ Determining the intravascular volume status of patients in shock is critical and aids in categorizing and informing treatment decisions. This issue reviews the 4 primary categories of shock as well as special categories, including shock in pregnancy, traumatic shock, septic shock, and cardiogenic shock in myocardial infarction. Adherence to evidence-based care of the specific causes of shock can optimize a patient's chances of surviving this life-threatening condition.
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Review
Emergency department management of calcium-channel blocker, beta blocker, and digoxin toxicity.
While it is relatively uncommon, an overdose of calcium-channel blockers, beta blockers, or digoxin has a significant morbidity and mortality rate, and its management can be complex. Digoxin toxicity can present with an acute overdose or as chronic toxicity while a patient is on therapeutic dosing, which has implications for diagnosis and management. While the patient's specific clinical presentation may depend on factors such as the time of exposure and the type of agent ingested, the differential diagnosis of the bradycardic and hypotensive patient is narrow, and toxicity from these agents must be considered. This review provides an evidence-based overview of the emergency department management of calcium-channel blocker overdose, beta blocker overdose, and digoxin toxicity.
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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.