Hematologic and Oncologic Emergencies

Hematologic and oncologic emergencies are an uncommon reason for people to present to the emergency department (ED), but when they do, it is important to know how to diagnose and treat these conditions because many of them are life threatening. Whether it is bleeding due to conditions such as hemophilia, von Willebrand’s disease, warfarin use, or dangerous conditions related to cancer such as tumor lysis syndrome or neutropenic fever, knowing the basics will help you manage these patients and also ace the standardized tests. This chapter presents questions related to the diagnosis, clinical effects, best first response in the ED, and most appropriate treatment of a wide range of these hematologic and oncologic emergencies.

Emergency Medical Services, Disaster Medicine, and Legal Issues

There are miscellaneous topics in emergency medicine (EM) that are important to clinical practice and to performance on standardized EM tests, including emergency medical services (EMS), disaster medicine, and legal issues. Most EM physicians work closely with EMS and need to understand the basics of medical control and care in the prehospital setting. Although disasters are, fortunately, rare events, EM physicians need to know the basics of how to respond in such situations because they will often be at the forefront of care. Legal aspects of the practice of medicine are rarely taught in medical school or residency. Unfortunately, many physicians are forced to take a hands-on crash course the first time that they are confronted with a lawsuit, administrative investigation, or other legal inquiry. The legally oriented questions in the chapter will help the learner to become acquainted with some of the basics within the legal realm of medical practice, including the Health Insurance Portability and Accountability Act (HIPAA), informed consent, the Emergency Medical Treatment and Labor Act (EMTALA), malpractice liability, and mandatory reporting.

Procedures and Skills

Emergency medicine providers are expected to have the knowledge to be able to perform a wide range of procedures from simple wound repairs and abscess drainage to life-saving procedures such as transvenous pacing and perimortem cesarean delivery. Important to all of these procedures is an understanding of when they should be performed, potential complications, absolute and relative contraindications, and how to interpret results that are obtained as a result of the performed procedure. This chapter presents questions related to the diagnosis, clinical effects, best first response in the ED, and most appropriate treatment of a wide range of emergencies, focusing on the procedures and skills necessary to achieve the best outcomes for patients.

Thoracic and Respiratory Emergencies

Thoracic and respiratory disorders cover many of the common respiratory and thoracic complaints and pathology that bring both pediatric and adult patients to the emergency department (ED). The etiologies can range from infectious to traumatic to malignancy. It is important to be able to recognize patients who need admission to the hospital and those who can be sent home for outpatient management. Interventions like needle decompression and intubation may need to be done emergently on some patients. This chapter presents questions related to the diagnosis, clinical effects, best response in the ED, and most appropriate treatment of a wide range of these thoracic and respiratory emergencies.

Renal and Genitourinary Emergencies

Renal and genitourinary complaints are common presentations to the emergency department. Urinary tract infections are among the top three sites of infection in patients presenting to the emergency department. Nephrolithiasis is also a common reason for patients to present due to the severe associated pain. Greater than 20 million patients in the United States are diagnosed with a sexually transmitted infection yearly and many of these present to the emergency department due to the associated discomfort and related symptoms. Other conditions related to the renal and genitourinary systems, though less common, are important for emergency providers to be adept at managing.

Psychobehavioral Disorders

Emergency departments (EDs) have seen an increase in patients presenting with psychobehavioral emergencies in the past 20 years. Some of this increase is due to the severe shortage of mental health professionals across the country, and some is due to an increase in the incidence of psychiatric disorders. Patients can present to the ED themselves or can be brought in by emergency medical services or law enforcement under an involuntary hold. The presentations range from intentional ingestions and other suicide attempts to depression, psychosis, and medication interactions. Substance abuse is also common in this population and can exacerbate underlying conditions. Patients who present for other medical complaints and have an underlying history of mental illness are usually taking psychiatric medications that can have drug interactions. It is imperative that a practicing emergency medicine physician be aware of the multitude of drug interactions and side effects.

Cutaneous Disorders

Dermatology can be a challenging subject in emergency medicine. While most dermatologic complaints are benign, the clinician must be able to distinguish them from life-threatening conditions. This chapter reviews some of the most common skin disorders seen in the emergency department (ED), including adult and pediatric pathology. Patients typically present to the ED with a rash. Visual cues and the patient history are helpful in leading to the diagnosis. Knowing the distribution of common rashes and the age groups in which they typically occur can help the clinician reach the correct answer. These conditions range from an inconvenience, such as dermatitis, to the severe in the case of Stevens-Johnson syndrome.

Trauma and Orthopedic Emergencies

Trauma is the leading cause of death for individuals in the United States younger than 45 years, and globally it is anticipated to become the third largest contributor to the burden of disease by 2020. Road traffic accidents account for most deaths worldwide; however, injuries and death due to firearms are a unique concern in the United States. Emergency clinicians play a vital role in the stabilization, diagnosis, and treatment of trauma patients and must be able to manage a full spectrum of patients, from those presenting with isolated, minor trauma to patients with severe multisystem trauma.

Systemic Infectious Diseases

Generalized complaints such as fever, chills, malaise, and body aches are common presentations to the emergency department (ED). Some of these are due to viral infections, and some are due to systemic bacterial infections. Clues to the specific infection can be found in the geographic location of the patient or the patient’s exposure to wildlife (e.g., ticks) and animals. The patient’s history and the timing of the illness play an important part in helping to identify the possible source or cause of the infection. This chapter presents questions related to the diagnosis, clinical effects, and most appropriate treatment of a wide range of these systemic infectious disease emergencies.

Immunologic Emergencies

The immune system is a complex defense mechanism designed to protect human beings from infection and other invasion from outside sources. It usually works perfectly, but at times it can over respond, causing disease and even assault on the tissues of the body that it is designed to protect. Emergency providers will face immunologic emergencies that range from mild allergic reactions to life-threatening anaphylaxis. Immunosuppressive drugs, used in a variety of situations, including in transplant recipients, can place patients at risk for infection and other disease processes. The pediatric population can also present to an emergency department with their first episode of an immunologic disorder, such as Kawasaki disease or juvenile rheumatoid arthritis.