1. 1. OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Emergency Medicine
2. 2. Published and forthcoming Oxford Handbooks Oxford Handbook for the Foundation Programme 3e Oxford Handbook of Acute Medicine 3e Oxford Handbook of Anaesthesia 3e Oxford Handbook of Applied Dental Sciences Oxford Handbook of Cardiology 2e Oxford Handbook of Clinical and Laboratory Investigation 3e Oxford Handbook of Clinical Dentistry 5e Oxford Handbook of Clinical Diagnosis 2e Oxford Handbook of Clinical Examination and Practical Skills Oxford Handbook of Clinical Haematology 3e Oxford Handbook of Clinical Immunology and Allergy 2e Oxford Handbook of Clinical Medicine - Mini Edition 8e Oxford Handbook of Clinical Medicine 8e Oxford Handbook of Clinical Pharmacy Oxford Handbook of Clinical Rehabilitation 2e Oxford Handbook of Clinical Specialties 8e Oxford Handbook of Clinical Surgery 3e Oxford Handbook of Complementary Medicine Oxford Handbook of Critical Care 3e Oxford Handbook of Dental Patient Care 2e Oxford Handbook of Dialysis 3e Oxford Handbook of Emergency Medicine 4e Oxford Handbook of Endocrinology and Diabetes 2e Oxford Handbook of ENT and Head and Neck Surgery Oxford Handbook of Expedition and Wilderness Medicine Oxford Handbook of Forensic Medicine Oxford Handbook of Gastroenterology & Hepatology 2e Oxford Handbook of General Practice 3e Oxford Handbook of Genetics Oxford Handbook of Genitourinary Medicine, HIV and AIDS 2e Oxford Handbook of Geriatric Medicine Oxford Handbook of Infectious Diseases and Microbiology Oxford Handbook of Key Clinical Evidence Oxford Handbook of Medical Dermatology Oxford Handbook of Medical Sciences Oxford Handbook of Medical Statistics Oxford Handbook of Nephrology and Hypertension Oxford Handbook of Neurology Oxford Handbook of Nutrition and Dietetics Oxford Handbook of Obstetrics and Gynaecology 2e Oxford Handbook of Occupational Health Oxford Handbook of Oncology 3e Oxford Handbook of Ophthalmology 2e Oxford Handbook of Paediatrics Oxford Handbook of Pain Management Oxford Handbook of Palliative Care 2e Oxford Handbook of Practical Drug Therapy 2e Oxford Handbook of Pre-Hospital Care Oxford Handbook of Psychiatry 2e Oxford Handbook of Public Health Practice 2e Oxford Handbook of Reproductive Medicine & Family Planning Oxford Handbook of Respiratory Medicine 2e Oxford Handbook of Rheumatology 3e Oxford Handbook of Sport and Exercise Medicine Oxford Handbook of Tropical Medicine 3e Oxford Handbook of Urology 2e
3. 3. Oxford Handbook of Emergency Medicine Fourth edition Jonathan P. Wyatt Consultant in Emergency Medicine and Forensic Physician Royal Cornwall Hospital, Truro, UK Robin N. Illingworth Consultant in Emergency Medicine St Jamess University Hospital, Leeds, UK Colin A. Graham Professor of Emergency Medicine Chinese University of Hong Kong, Hong Kong SAR, China Kerstin Hogg Clinical Research Fellow, The Ottawa Hospital, Ottawa, Canada with senior international advisors: Michael J. Clancy Consultant in Emergency Medicine Southampton General Hospital, Southampton, UK Colin E. Robertson Professor of Emergency Medicine Royal Inrmary, Edinburgh, UK 1
4. 4. 1Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the Universitys objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With ofces in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York Oxford University Press, 2012 The moral rights of the authors have been asserted Database right Oxford University Press (maker) First edition published 1999 Second edition published 2005 Third edition published 2006 Fourth edition published 2012 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging-in-Publication-Data Data available Typeset by Cenveo, Bangalore, India Printed in Italy on acid-free paper by L.E.G.O. S.p.A.Lavis TN ISBN 9780199589562 10 9 8 7 6 5 4 3 2 1 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding.
5. 5. Dedicated to Dr Robin Mitchell (19642010) Emergency Physician in Christchurch, Edinburgh and Auckland. Outstanding clinician and teacher, tremendous colleague and friend.
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7. 7. vii Abbreviations and symbols ix Normal values xvii Acknowledgements xix 1 General approach 1 2 Life-threatening emergencies 41 3 Medicine 62 4 Toxicology 179 5 Infectious diseases 219 6 Environmental emergencies 253 7 Analgesia and anaesthesia 271 8 Major trauma 319 9 Wounds, fractures, orthopaedics 401 10 Surgery 503 11 Ophthalmology 533 12 Ear, nose and throat 545 13 Obstetrics and gynaecology 563 14 Psychiatry 601 15 Paediatric emergencies 630 Index 737 Contents
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9. 9. ix degrees 8 approximately +ve positive ve negative plus or minus i increase(d) d decrease(d) ABC airway, breathing, circulation ABG arterial blood gas AC acromio-clavicular ACE angiotensin-converting enzyme ACTH adrenocorticotropic hormone ACS acute coronary syndrome AF atrial brillation AIDS acquired immune deciency syndrome AIO Ambulance incident ofcer AIS abbreviated injury scale ALS advanced life support ALT alanine aminotransferase ALTE apparently life-threatening event AP antero-posterior APLS Advanced Paediatric Life Support APTT activated partial thromboplastin time ARDS adult respiratory distress syndrome ARF acute renal failure AST aspartate transaminase ATLS advanced trauma life support AV atrio-ventricular bd twice daily BKPOP below knee Plaster of Paris BKWPOP below knee walking Plaster of Paris BLS basic life support BMG bedside strip measurement of venous/capillary blood glucose BNF British National Formulary BNFC British National Formulary for Children Abbreviations and symbols
10. 10. x ABBREVIATIONS AND SYMBOLS BP blood pressure BTS British Thoracic Society BZP benzylpiperazine CBRN chemical, biological, radiological, nuclear CCU critical care unit CK creatine kinase cm centimetre(s) CMV cytomegalovirus CN chloroacetophenone CNS central nervous system CO carbon monoxide CO2 carbon dioxide COHb carboxyhaemoglobin COPD chronic obstructive pulmonary disease CPAP continuous positive airways pressure CPR cardiopulmonary resuscitation CRF chronic renal failure CRP C-reactive protein CSF cerebrospinal uid CT computed tomography CTPA computed tomography pulmonary angiography CVP central venous pressure CVS cardiovascular system CXR chest X-ray DIC disseminated intravascular coagulation DIPJ distal interphalangeal joint DKA diabetic ketoacidosis dL decilitre DPL diagnostic peritoneal lavage DPT diphtheria, pertussis, and tetanus DSH deliberate self-harm DVT deep venous thrombosis EBV EpsteinBarr virus ECG electrocardiogram ECT electroconvulsive therapy ED emergency department EEG electroencephalogram EMLA eutectic mixture of local anaesthetics ENT ear, nose and throat EPAP expiratory positive airway pressure
11. 11. xiABBREVIATIONS AND SYMBOLS ESR erythrocyte sedimentation rate ET endotracheal ETCO2 end-tidal carbon dioxide FAST focused assessment with sonography for trauma FB foreign body FBC full blood count FFP fresh frozen plasma FG French Gauge FiO2 inspired oxygen concentration FOB faecal occult blood G6-PD glucose 6-phosphate dehydrogenase g gram(s) G gauge GA general anaesthetic GCS Glasgow Coma Score GFR glomerular ltration rate GI gastrointestinal GHB gammahydroxybutyrate GMC General Medical Council GP general practitioner GTN glyceryl trinitrate GU genitourinary 5HT 5-hydroxytryptamine HATI human anti-tetanus immunoglobulin Hb haemoglobin HCG human chorionic gonadotrophin HCM hypertrophic cardiomyopathy Hct haematocrit HDU high dependency unit HHS hyperosmolar hyperglycaemic state HIV human immunodeciency virus HONK hyperosmolar non-ketotic hyperglycaemia hr hour/s HTLV human T-cell lymphotropic virus ICP intracranial pressure ICU intensive care unit IDDM insulin dependent diabetes mellitus IHD ischaemic heart disease IM intramuscular INR international normalized ratio (of prothrombin time)
12. 12. xii ABBREVIATIONS AND SYMBOLS IO intra-osseous IPAP inspiratory positive airway pressure IPg interphalangeal IPPV intermittent positive pressure ventilation ISS injury severity score ITP idiopathic thrombocytopenic purpura IUCD intrauterine contraceptive device IV intravenous IVI intravenous infusion IVRA intravenous regional anaesthesia IVU intravenous urography JVP jugular venous pressure KE kinetic energy kPa kiloPascal(s) pressure KUB X-ray covering the area of kidneys, ureters and bladder L litre(s) LA local anaesthetic LAD left axis deviation LBBB left bundle branch block LDH lactate dehydrogenase LET lidocaine epinephrine tetracaine LFTs liver function tests LMA laryngeal mask airway LMP last menstrual period LMWH low molecular weight heparin LP lumbar puncture LSD lysergic acid diethylamide LV left ventricular LVF left ventricular failure LVH left venticular hypertrophy m metre(s) MAOI monoamine oxidase inhibitor MAST military anti-shock trousers max maximum MC metacarpal MCA Mental Capacity Act MCPJ metacarpophalangeal joint MDU Medical Defence Union MI myocardial infarction min minute/s
13. 13. xiiiABBREVIATIONS AND SYMBOLS MIO medical incident ofcer mL millilitre(s) mmHg millimetres of mercury pressure mmol millimoles MMR mumps, measles, and rubella MRI magnetic resonance imaging MRSA meticillin resistant Staphylococcus aureus MS multiple sclerosis MSU mid-stream specimen of urine MT metatarsal MTPJ metatarsophalangeal joint MUA manipulation under anaesthetic NAC N-acetyl cysteine NAI non-accidental injury ND notiable disease NG nasogastric NHS National Health Service NIV non-invasive ventilation NO nitrous oxide NSAID non-steroidal anti-inammatory drug NSTEMI non-ST segment elevation myocardial infarction NWBPOP non-weight-bearing Plaster of Paris O2 oxygen OA osteoarthritis OCP oral contraceptive pill od once daily OPG orthopantomogram ORIF open reduction and internal xation ORT oral replacement therapy PA postero-anterior PACS picture archiving and communication system PAN polyarteritis nodosa PCI percutaneous coronary intervention pCO2 arterial partial pressure of carbon dioxide PCR polymerase chain reaction PE pulmonary embolus PEA pulseless electrical activity PEEP positive end-expiratory pressure PEFR peak expiratory ow rate PGL persistent generalized lymphadenopathy
14. 14. xiv ABBREVIATIONS AND SYMBOLS PICU paediatric intensive care unit PID pelvic inammatory disease PIPJ proximal interphalangeal joint PO per os (orally/by mouth) pO2 arterial partial pressure of oxygen POP plaster of Paris PPE personal protective equipment PPI proton pump inhibitor PR per rectum PRF patient report form PRN pro re nata (as required) PSP primary spontaneous pneumothorax PV per vaginam qds four times a day RA rheumatoid arthritis RAD right axis deviation RBBB right bundle branch block RBC red blood cells Rh Rhesus ROSC restoration of spontaneous circulation RR respiratory rate RSI rapid sequence induction/intubation RSV respiratory syncytial virus rtPA recombinant tissue plasminogen activator RTS revised trauma score RV right ventricular SA sino-atrial SARS severe acute respiratory syndrome SC subcutaneous SCIWORA spinal cord injury without radiographic abnormality sec second(s) SIDS sudden infant death syndrome SIGN Scottish Intercollegiate Guidelines Network SIRS systemic inammatory response syndrome SL sublingual SLE systemic lupus erythematosus SpO2 arterial oxygen saturation SSP secondary spontaneous pneumothorax SSRI selective serotonin re-uptake inhibitor STD sexually transmitted disease
15. 15. xvABBREVIATIONS AND SYMBOLS STEMI ST segment elevation myocardial infarction SVT supraventricular tachycardia T temperature T3 tri-iodothyronine T4 thyroxine TAC tetracaine, adrenaline and cocaine TB tuberculosis tds three times a day TFTs thyroid function tests TIA transient ischaemic attack TIMI thrombolysis in myocardial infarction tPA tissue plasminogen actvator TSH thyroid stimulating hormone u/U unit(s) U&E urea and electrolytes URTI upper respiratory tract infection USS ultrasound scan UTI urinary tract infection V volts VA visual acuity VF ventricular brillation VHF viral hemorrhagic fever V/Q ventilation/perfusion (scan) VT ventricular tachycardia WB weight-bear(ing) WBC white blood cells WCC white cell count WHO World Health Organization WPW Wolff Parkinson White (syndrome)
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17. 17. xvii Note that normal values in adults may vary slightly between labs. Normal values in pregnancy are shown in b The pregnant patient, p.576. Arterial blood gas analysis Biochemistry Normal values H+ 3545 nanomol/L pH 7.357.45 pO2 (on air) >10.6 kPa, 75100 mmHg pCO2 4.56.0 kPa, 3545 mmHg bicarbonate 2428 mmol/L base excess 2 mmol/L alanine aminotransferase (ALT) 535 iu/L albumin 3550 g/L alkaline phosphatase 30300 iu/L amylase 0180 Somogyi U/dL aspartate transaminase (AST) 535 iu/L bicarbonate 2430 mmol/L bilirubin 317 micromol/L calcium (total) 2.122.65 mmol/L calcium (ionized) 11.25 mmol/L chloride 95105 mmol/L creatine kinase (CK) 25195 iu/L creatinine 70150 micromol/L C-reactive protein (CRP)