Challenging and Emerging Conditions in Emergency Medicine


  • Michelle M. McLean MD, EMT-P,

  • R. Eric Minnihan MD

Challengingand Emerging Conditionsin Emergency Medicine Edited by Arvind Venkat , MD . Malden, MA : Wiley-Blackwell , 2012 ; 359 pages; $84.95 .

Challenging and Emerging Conditions in Emergency Medicine is an excellent resource for the emergency physician (EP) hoping to better understand patient populations whose ailments are being treated with innovative therapies and patients who present with difficult comorbidities. The book begins with an introduction and then proceeds to cover 15 challenging and emerging conditions in emergency medicine. Each chapter is organized in a similar fashion, even though there are separate authors for each chapter. There is an introduction to the topic, followed by the chapter content. The last section of each chapter is dedicated to what the next 5 years hold for each of these conditions, along with a summarizing conclusion.

The second chapter, “The Post-Cardiac Arrest Patient,” is an excellent introduction to the clinical section of this book. It does an exemplary job of outlining the need for appropriate post–cardiac arrest care including induced therapeutic hypothermia. We are shown the evidence supporting the need for induced therapeutic hypothermia in the emergency department (ED), along with the appropriate specific protocols for doing so. The chapter closes with special situations for post–cardiac arrest care including emergency medical services and ethical concerns.

The third chapter is “Adults with Congenital Heart Disease.” It does a great job explaining the growing population of adults with congenital heart disease that we are seeing in EDs across the nation. The chapter goes into specifics regarding the most common congenital heart diseases that we will see in our adult population. Included are several tables that show the presentation, examination, and x-ray findings of both repaired and unrepaired defects. The chapter closes with a discussion of disposition of adults with congenital heart disease who present to the ED.

The fourth chapter, “The Renal Transplant Patient,” begins with an introduction discussing the fundamentals of renal transplant patients. This includes the associated surgical anatomy and the commonly used immunosuppressive regimens. Next, a discussion about the management of various presentations in the ED ensues. This includes renal injury, urinary tract disorders, surgical complications, and fever. Additionally, we learn some specifics for dealing with renal transplant patients with cardiovascular, respiratory, gastrointestinal (GI), musculoskeletal, hematologic, neurologic, electrolyte, and endocrine disorders. Clearly these patients are challenging to manage, and this chapter does an excellent job with this complex topic.

“The End-Stage Renal Disease Patient on Dialysis” is the fifth chapter. It begins with the principles of hemodialysis and peritoneal dialysis. The topic of fever in end-stage renal disease is presented in conjunction with the organisms that are the most likely root cause. There are some nice tables describing the organisms and the appropriate pharmacologic treatment in these patients. The management of the dialysis patient presenting with blood pressure, respiratory, and cardiac problems is presented. In the next section, the authors discuss emergent GI problems in dialysis patients, worsening anemia, and neurologic problems. Next, the chapter covers acid-base/electrolyte disorders, diabetes, and urinary tract problems. A discussion ensues regarding special considerations while attempting vascular access. This includes intradialytic accidents and calciphylaxis. A detailed table shows the dose adjustment for common medications used in dialysis patients.

The next chapter is titled “Adults with Cystic Fibrosis.” The importance of this chapter is underscored in the first paragraph, where it is mentioned that the number of patients living with cystic fibrosis (CF) has risen by 400% since the 1970s, secondary to increased life expectancy. Included are the typical maintenance medications for those living with CF. The authors then delve into the pulmonary exacerbations of CF. There is extensive discussion about the causative organisms leading to acute pulmonary exacerbations and the appropriate management. In addition, the authors cover multiple associated comorbidities including hemoptysis, pneumothorax, GI disease, pancreatic disease, and hepatobiliary disease. CF-related diabetes mellitus, musculoskeletal and rheumatic disease, cardiovascular disease, and cor pulmonale are additional topics covered. Finally, the authors address psychiatric illness, rhinosinusitis, dermatologic complaints, and ocular disease in adults with CF.

Chapter 7, “Adults with Sickle-Cell Disease: Implications of Increasing Longevity,” begins with a great introduction that covers the epidemiology and pathophysiology of sickle-cell disease (SCD). Next the authors discuss the complications of SCD, which includes vasoocclusive crisis and the management of pain. There is a nice protocol listed for the approach to the sickle-cell patient with pain. In fact, this chapter is full of numbered protocols for different presentations of your SCD patients. These cover the already-listed pain crisis, along with fever, anemia, pulmonary complaints, and chest complaints. The authors also discuss the approach to the pregnant sickle-cell patient, central nervous system (CNS) complications, ocular complications, priapism, and leg ulcers. The authors conclude with the pros and cons of transfusion and which patients are appropriate to consider for transfusion.

Chapter 8, “HIV-Positive Adults on HAART” (highly active antiretroviral therapy), begins by discussing the increasing life expectancy of HIV-positive patients, along with the current epidemiology. Following that, the authors discuss the specific HAART medications, including the side effects and those interactions that most concern EPs. The authors next scrutinize these patients system by system, covering cardiovascular, pulmonary, renal, neurologic, GI and hepatobiliary, hematologic, and oncologic diseases. Endocrine, psychiatric, dermatologic, ocular, and musculoskeletal topics follow. The section on immune reconstitution inflammatory syndrome provides up-to-date information on this emerging condition. This is an information-packed chapter that is very useful in helping the reader to understand their HAART patients.

As the title suggests, Chapter 9, “Adults Receiving Chemotherapeutic Regimens,” covers the ED evaluation and management of patients presenting while on chemotherapy. After covering the epidemiology of cancer, it begins with some general principles that every EP should follow while evaluating one of these patients. There are several helpful tables included that help to organize the myriad of chemotherapeutic options into an easy-to-access form. Included are which therapies are associated with which malignancies, which side effects are associated with these therapies, and which antidotes to use if needed. The authors also go into extensive detail regarding the clinical side effects of chemotherapy. They break up the chapter into a systems-based approach starting with neurologic effects, altered mental status, seizures, sensory changes, CNS toxicity, and cerebrovascular accidents. Next the cardiac, pulmonary, hematologic, GI, renal, electrolyte, and dermatologic effects are covered. Tumor lysis syndrome and the effects on the reproductive system are also covered.

Chapter 10, “The Bariatric Surgery Patient,” begins with documenting the increasing body mass index of our society and the surgical interventions that are currently implemented to treat this growing condition. It then discusses the emergency diagnosis and treatment of post–bariatric surgery complications for laparoscopic adjustable gastric band, Roux-en-Y gastric bypass, longitudinal sleeve gastrectomy, biliopancreatic diversion/duodenal switch, and vertical banded gastroplasty. Each of these procedures has unique complications, and this chapter does a superb job delineating them.

In Chapter 11 we learn about “The Obese Patient.” The authors do an excellent job summarizing the pathophysiology of obesity along with providing practical advice for the evaluation and management of these patients. There is a nice table included that lists some common ED medications and the recommendation for dose adjustment for obese patients. They start by covering how obesity affects the cardiovascular system, including acute coronary syndrome, congestive heart failure, and venous thromboembolism. Next, trauma in the obese population is covered, including the fact that obesity can be protective in some specific situations. The authors next discuss asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, infection, and sepsis in this population. Finally, very practical suggestions are given for airway management, vascular access, lumbar puncture, and needle and tube thoracostomy in the obese patient.

Chapter 12, “The Geriatric Trauma Patient,” begins with a discussion on what defines a geriatric patient, and this chapter is an excellent resource for the EP. There is a summary of the comorbidities that are common in our elderly population, followed by a section describing their ED management after a trauma. This begins with prehospital management and proceeds with airway control. Special note is made of the fact that vital signs do not respond the same in the geriatric population as they do in the younger patients, and several alternatives are presented to compensate for this. As many of these patients are on anticoagulation therapy, there is a section covering specific data regarding this. These discuss the specific injury patterns in which elderly patients often present. These include falls, motor vehicle crashes, burns, subdural hematomas, spinal fractures, rib fractures, blunt abdominal trauma, penetrating trauma, extremity fractures, and lacerations.

Chapter 13 deals with “Children with Intestinal Failure and Complications from Visceral Transplant.” Starting with the epidemiology of intestinal failure, this chapter continues on by describing the various presentations of these patients with a special emphasis on emergent issues encountered in the ED. They discuss the management of electrolyte abnormalities in the pediatric intestinal failure group, along with covering intestinal obstruction, cholecystitis, esophageal variceal bleeding, and encephalopathy. As these patients will often have either central venous catheters or enteral feeding devices, the authors devote several pages to dealing with complications of these two indwelling devices. Finally, there is a discussion concerning the emergent care of the pediatric patient with intestinal transplantation, including graft rejection and infection.

Chapter 14, “Family Violence,” begins with the inherent challenges EPs face while dealing with physical abuse of minors and intimate partner violence. The authors go on to describe the sobering statistics regarding the prevalence of this abuse in our society. There are multiple photos and figures depicting abuse along with several x-rays. We are shown the role of the EP in these cases, followed by the presenting signs and symptoms we will observe. After describing which patients are more likely to be victims of family violence, the authors go on to cover bruises, bites, burns, oropharyngeal injuries, head injuries, and fractures. A significant amount of time is placed on describing several different screening studies for child abuse, including the skeletal survey, neuroimaging, retinal examination, and abdominal CT. There is a helpful table included that informs the provider about the appropriate indications for each test. The authors conclude with a discussion of mandated reporting and the appropriate disposition of these patients.

Chapter 15, “The Intellectually Disabled Patient,” does a commendable job summarizing the history of society’s attitudes and treatment of intellectually disabled patients. The authors discuss the etiology and epidemiology of intellectual disability and then proceed with an organ system–based review of the common pathologies afflicting these patients. They next cover ED management including tips on how to interact with intellectually disabled patients. This includes a discussion of how to best obtain patient history. They discuss the importance of the physical and laboratory exams in this population and then close with the tricky issue of informed consent with intellectually disabled patients.

The final chapter, “Adults with Conditions Causing Chronic Pain,” provides an extensive discussion regarding the unique types and causes of pain, along with note of the extensive number of ED visits each year with pain as a chief complaint. Next, the authors cover the multimodal approach to pain control, including the different routes of intake along with the different classes of analgesics. Then we are shown management for specific conditions leading to chronic pain, including back pain, headaches and migraines, pancreatitis, irritable bowel syndrome, pelvic pain, and chronic postoperative abdominal pain. They close with a discussion regarding chronic pain in the elderly.

Challenging and Emerging Conditions in Emergency Medicine delivers exactly what it promises in the introduction, a comprehensive published reference for EPs that will allow them “to understand patient populations whose ailments either are being treated in new ways or to rectify a lack of common recognition both in diagnosis and the implications of increasing longevity.” The text is written in such a way that it flows well from cover to cover, while allowing for a provider to read only the sections that are pertinent to him or her. This text is a worthy investment.