Joseph P. Martinez

Abdominal emergencies in the geriatric patient

Abdominal pain is one of the most frequent reasons that elderly people visit the emergency department (ED). In this article, we review the deadliest causes of abdominal pain in this population, including mesenteric ischemia, abdominal aortic aneurysm, and appendicitis and potentially lethal non-abdominal causes. We also highlight the pitfalls in diagnosing, or rather misdiagnosing, these clinical entities.

Prognosis in cardiac arrest.

Cardiac arrest remains a common problem throughout the world. This article explores several factors that aid in determining prognosis after cardiac arrest. It is broadly divided into prearrest factors, intra-arrest factors, and postarrest factors. Prearrest factors predominantly concern the presence or absence of a shockable rhythm. Intra-arrest factors look at the partial pressure of end-tidal CO2 and the presence of cardiac standstill on ultrasound. Postarrest factors include early outcome measures as well as a more comprehensive algorithmic approach to predicting neurologic outcome.

Drug-Induced Hyperthermic Syndromes: Part I. Hyperthermia in Overdose

Drugs and natural compounds that affect the thermoregulatory system can induce or contribute to hyperthermia when used in excess. Hyperthermia associated with drug overdose is dangerous and potentially lethal. This article reviews the bodys process of maintaining thermodynamic equilibrium, and describes the mechanisms by which it is influenced by sympathomimetic and anticholinergic drugs, salicylates, and thyroid replacement medications. Appropriate treatment strategies such as cooling and the administration of counteractive medications are discussed.

How we started an elective in emergency bedside ultrasound

Abstract The expanding use of bedside ultrasonography in the practice of emergency medicine and other specialties is accompanied by the need to train medical students in its applications and interpretation of its results. In this article, the authors describe their successful design, launch, and management of the ultrasound elective at the University of Maryland School of Medicine. Because the course has been so well received, the authors are now exploring ways of presenting its content and skills-building opportunities in more venues, including the Introduction to Clinical Medicine course.

Electrocardiographic implications of the prolonged QT interval

The QT interval measures the time from the start of the QRS complex to the end of the T wave. Prolongation of the QT interval may lead to malignant ventricular tachydysrhythmias, including torsades de pointes. Causes of QT prolongation include congenital abnormalities of the sodium or potassium channel, electrolyte abnormalities, and medications; idiopathic causes have also been identified. Patients can be asymptomatic or present with syncope, palpitations, seizure-like activity, or sudden cardiac death. Management involves looking for and treating reversible causes. For patients with congenital or idiopathic QT interval prolongation, the use of beta-blockers can be considered. Certain subsets of patients benefit from implantation of a cardioverter-defibrillator. Clinicians must remain vigilant for QT interval prolongation when interpreting electrocardiograms, especially in patients presenting with syncope or ventricular arrhythmias.

Abdominal Pain in the Geriatric Patient

With an aging population, emergency department clinicians can expect an increase in geriatric patients presenting with abdominal pain. Compared with younger patients, this patient population is less likely to present with classic symptoms, physical examination findings, and laboratory values of abdominal disease. However, the morbidity and mortality associated with elderly patients presenting with abdominal pathologic conditions are significant. For this reason, the clinician must be familiar with some subtle and not so subtle differences when caring for the geriatric patient with abdominal pain to ensure timely diagnosis and appropriate treatment.

Abdominal Vascular Catastrophes

Abdominal vascular catastrophes are among the most challenging and time sensitive for emergency practitioners to recognize. Mesenteric ischemia remains a highly lethal entity for which the history and physical examination can be misleading. Laboratory tests are often unhelpful, and appropriate imaging must be quickly obtained. A multidisciplinary approach is required to have a positive impact on mortality rates. Ruptured abdominal aortic aneurysm likewise may present in a cryptic fashion. A specific type of ruptured aneurysm, the aortoenteric fistula, often masquerades as the more common routine gastrointestinal bleed. The astute clinician recognizes that this is a more lethal variant of gastrointestinal hemorrhage.

Adult Hirschsprung's disease.

Hirschsprung’s disease. Named for the Danish pediatrician who described the disease in 1887, Hirschsprung’s disease (congenital aganglionic megacolon) is caused by the failure of neural crest cells to migrate completely during development. This migration failure leads to an aganglionic segment of colon that is unable to relax. Hirschsprung’s disease is the most common cause of neonatal intestinal obstructions and is typically diagnosed early. Patients with short or ultrashort segment disease may not be diagnosed until childhood, and they may occasionally present as adults. The typical presentation in adults is that of a patient with a lifelong history of severe constipation, which he or she has successfully managed with laxatives and enemas. The patient may seek medical attention due to rapidly worsening abdominal distention and the inability to relieve the constipation, despite using the traditional methods. The mortality rate of Hirschsprung’s disease in adults is exceedingly low. However, it occasionally leads to sigmoid volvulus, in which case the mortality rate can be approximately 15%. These patients often present with more acute signs of intestinal obstruction, and they may appear more toxic if the volvulus has progressed to bowel ischemia. The diagnosis

Abdominal and Gastrointestinal Emergencies

Abdominal pain remains one of the most common reasons for an acute visit to a health care professional. While many patients will not receive a specific diagnosis as the cause of their symptoms, a systematic approach to each patient is imperative as life-threatening processes present with gastrointestinal complaints. In this issue of Emergency Medicine Clinics of North America, we have brought together a group of articles that provides such a systematic approach. Many of us approach the abdomen in an anatomic fashion, considering the abdomen as a series of interconnected boxes that house unique disease pathology with localizing symptoms. This issue has articles divided in just such a manner. In addition, we have dedicated articles to common symptom presentations, such as vomiting, diarrhea, or gastrointestinal hemorrhage. As previously mentioned, the abdomen houses a number of life-threatening conditions. One article delves into the vascular catastrophes, those conditions that require action that is measured in minutes rather than hours or days. Special populations are discussed as well, including pediatric patients, geriatric patients, immunocompromised patients, and those patients that have undergone bariatric surgery. Today’s expert clinicians are expected to practice medicine in an evidence-based fashion. With this thought in mind, we have added an article on the evidence-based approach to a patient with abdominal pain. Keeping in mind the age-old adage that “the diaphragm is not a brick wall,” we have also included an article on nonabdominal causes of abdominal pain. It has been our privilege assembling this talented group of authors. We have learned a tremendous amount through their efforts, and it is our hope that you will as well.

'Need-to-Know' emergency medicine articles of 2014

Every year, thousands of articles are published in numerous medical journals that relate to the clinical practice of medicine. However, it is impossible for a single clinician to stay abreast of the literature, let alone to determine which articles should change daily practice. Physicians in our department have searched the emergency medicine and the specialty literature of 2014 to determine which articles are most relevant to the clinical practice of emergency medicine, summarized them, and listed key take-home points from these ‘need-to-know’ articles.