Table Of ContentTintinalli’s Emergency Medicine
A Comprehensive Study Guide
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Tintinalli’s Emergency Medicine
A Comprehensive Study Guide
Eighth Edition
Editor-in-Chief
Judith E. Tintinalli, MD, MS
Professor and Chair Emeritus
Department of Emergency Medicine
Adjunct Professor
Department of Health Policy and Administration
University of North Carolina
Chapel Hill, North Carolina
Co-Editors
J. Stephan Stapczynski, MD O. John Ma, MD
Professor, Department of Emergency Medicine Professor and Chair
University of Arizona College of Medicine - Phoenix Department of Emergency Medicine
Phoenix, Arizona Oregon Health & Science University
Portland, Oregon
Donald M. Yealy, MD Garth D. Meckler, MD, MSHS
Chair, Department of Emergency Medicine Associate Professor and Division Head
University of Pittsburgh/University of Pittsburgh Physicians Pediatric Emergency Medicine
Senior Medical Director, Health Services Division, UPMC University of British Columbia/BC Children’s Hospital
Professor of Emergency Medicine, Medicine, and Clinical and Vancouver, British Columbia
Translational Sciences
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
David M. Cline, MD
Professor and Director of Departmental Research
Department of Emergency Medicine
Wake Forest School of Medicine
Winston-Salem, North Carolina
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
Tintinalli_FM_p000i-xliv.indd 3 8/27/15 8:27 PM
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To the clinicians, residents, medical students, NPs, PAs, EMTs, and paramedics
who provide emergency care around the world.
Judith E. Tintinalli, MD, MS
Co-Editors
Dedicated with love and respect to my father and father-in-law, two veterans
from the Greatest Generation, on the 70th anniversary of the end of
World War II.
J. Stephan Stapczynski, MD
For my parents: my mother, Simone, for her continued love and support,
and in loving memory of my father, Mark.
O. John Ma, MD
I thank: My family, who always believe in me and make this all possible;
my partners, who bring excellence to my eyes each day; and those seeking
emergency care, trusting that all will be well.
Donald M. Yealy, MD
To the patients, nurses, students, and mentors who teach me every day, and to
my family and partner for their love and support.
Garth D. Meckler, MD, MSHS
To my family, mentors, residents, and students who continue to give meaning
to this work.
David M. Cline, MD
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Contents
About the Video. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv 18 Cardiac Rhythm Disturbances. . . . . . . . . . . . . . . . . . . . . 112
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii William J. Brady, Thomas S. Laughrey, Chris A. Ghaemmaghami
Pharmacy Reviewer.s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xli 19 Pharmacology of Antiarrhythmics and Antihypertensives . . . . . 135
Sara H. Shields, Rachel M. Holland, R. Dustin Pippin, Benjamin Small
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xliii
20 Pharmacology of Vasopressors and Inotropes. . . . . . . . . . . . 143
SECTION 1 Prehospital Care . . . . . . . . . . . . . . . . . . . 01 Sara H. Shields, Rachel M. Holland
21 Hyperbaric Oxygen Therapy. . . . . . . . . . . . . . . . . . . . . . 146
1 Emergency Medical Service.s . . . . . . . . . . . . . . . . . . . . . 01
David S. Lambert, Stephen R. Thom
C. Crawford Mechem
2 Prehospital Equipmen.t . . . . . . . . . . . . . . . . . . . . . . . . 04
SECTION 4 Resuscitative Procedures. . . . . . . . . . . . . . 151
Andy Boggust
22 Basic Cardiopulmonary Resuscitation. . . . . . . . . . . . . . . . . 151
3 Air Medical Transpor.t . . . . . . . . . . . . . . . . . . . . . . . . . 10
Adam D. Friedlander, Jon Mark Hirshon
C. Keith Stone, Stephen H. Thomas
23 Defibrillation and Cardioversion. . . . . . . . . . . . . . . . . . . . 157
4 Mass Gatherings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Marcus E. H. Ong, Swee Han Lim, Anantharaman Venkataraman
Michael G. Millin
24 Advanced Cardiac Life Support . . . . . . . . . . . . . . . . . . . . 160
SECTION 2 Disaster Management. . . . . . . . . . . . . . . . 23 Anantharaman Venkataraman, Swee Han Lim,
Marcus E. H. Ong, Kenneth B. K. Tan
5 Disaster Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . 23
25 Resuscitation in Pregnancy . . . . . . . . . . . . . . . . . . . . . . 168
Robert G. Hendrickson, B. Zane Horowitz
Boyd Burns
6 Natural Disasters. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
26 Post-Cardiac Arrest Syndrome. . . . . . . . . . . . . . . . . . . . . 174
Lisa D. Mills, Trevor J. Mills
Benjamin S. Abella, Bentley J. Bobrow
7 Bomb, Blast, and Crush Injuries. . . . . . . . . . . . . . . . . . . . 34
27 Ethical Issues of Resuscitation. . . . . . . . . . . . . . . . . . . . . 176
Michael J. Bono, Pinchas Halpern
Catherine A. Marco
8 Chemical Disasters. . . . . . . . . . . . . . . . . . . . . . . . . . . 39
28 Noninvasive Airway Management . . . . . . . . . . . . . . . . . . 178
B. Zane Horowitz, Robert G. Hendrickson
Jestin N. Carlson, Henry E. Wang
9 Bioterrorism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
29 Intubation and Mechanical Ventilation. . . . . . . . . . . . . . . . 183
Anthony G. Macintyre, Joseph A. Barbera
Robert J. Vissers, Daniel F. Danzl
10 Radiation Injurie.s . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
30 Surgical Airways . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Annette M. Lopez, Jennifer A. Stephani
Michael D. Smith, Donald M. Yealy
SECTION 3 Resuscitation. . . . . . . . . . . . . . . . . . . . . 59 31 Vascular Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Chris Wyatt
11 S udden Cardiac Death. . . . . . . . . . . . . . . . . . . . . . . . . 59
Joseph P. Ornato 32 Hemodynamic Monitoring. . . . . . . . . . . . . . . . . . . . . . . 209
H. Bryant Nguyen, David T. Huang, Michael R. Pinsky
12 A pproach to Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Bret A. Nicks, John Gaillard 33 Cardiac Pacing and Implanted Defibrillation. . . . . . . . . . . . . 216
Swee Han Lim, Wee Siong Teo, Anantharaman Venkataraman
13 F luid and Blood Resuscitation in Traumatic Shock. . . . . . . . . . 69
David M. Somand, Kevin R. Ward 34 Pericardiocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Carolyn K. Synovitz, Eric J. Brown
14 A naphylaxis, Allergies, and Angioedema. . . . . . . . . . . . . . . 74
Brian H. Rowe, Theodore J. Gaeta
SECTION 5 Analgesia, Anesthesia, and Procedural Sedation 231
15 Acid-Base Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . 79
35 Acute Pain Managemen.t . . . . . . . . . . . . . . . . . . . . . . . 231
Gabor D. Kelen, David D. Nicolaou, David M. Cline
James Ducharme
16 Blood Gases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
36 Local and Regional Anesthesia . . . . . . . . . . . . . . . . . . . . 238
Casey Glass
Douglas C. Dillon, Michael A. Gibbs
17 F luids and Electrolytes. . . . . . . . . . . . . . . . . . . . . . . . . 92
Roberta Petrino, Roberta Marino
vii
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viii Contents
37 Procedural Sedation. . . . . . . . . . . . . . . . . . . . . . . . . . 249 60 Aneurysmal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 416
Chris Weaver Louise A. Prince, Gary A. Johnson
38 Chronic Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 61 Arterial Occlusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
David M. Cline Anil Chopra, David Carr
SECTION 6 Wound Management . . . . . . . . . . . . . . . . 263 SECTION 8 Pulmonary Disorders . . . . . . . . . . . . . . . . 427
39 Wound Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 62 Respiratory Distress . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Adam J. Singer, Judd E. Hollander John Sarko, J. Stephan Stapczynski
40 Wound Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . 265 63 Hemoptysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
Aleksandr M. Tichter, Wallace A. Carter, Susan C. Stone Troy Sims
41 Wound Closure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 64 Acute Bronchitis and Upper Respiratory Tract Infections. . . . . . 440
Adam J. Singer, Judd E. Hollander Cedric W. Lefebvre
42 Face and Scalp Laceration.s . . . . . . . . . . . . . . . . . . . . . . 281 65 Pneumonia and Pulmonary Infiltrates. . . . . . . . . . . . . . . . 445
Wendy C. Coates Gerald Maloney, Eric Anderson, Donald M. Yealy
43 Arm and Hand Laceration.s . . . . . . . . . . . . . . . . . . . . . . 288 66 Lung Empyema and Abscess. . . . . . . . . . . . . . . . . . . . . . 456
Moira Davenport Eric Anderson, Sharon E. Mace
44 Leg and Foot Laceration.s . . . . . . . . . . . . . . . . . . . . . . . 296 67 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Annabella Salvador-Kelly, Nancy Kwon Vu D. Phan, Janet M. Poponick
45 Soft Tissue Foreign Bodies. . . . . . . . . . . . . . . . . . . . . . . 302 68 Pneumothorax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Richard L. Lammers Bret A. Nicks, David Manthey
46 Puncture Wounds and Bites. . . . . . . . . . . . . . . . . . . . . . 313 69 Acute Asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
James Quinn Rita K. Cydulka
47 Postrepair Wound Care. . . . . . . . . . . . . . . . . . . . . . . . . 320 70 Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . 475
Adam J. Singer, Judd E. Hollander Rita K. Cydulka, Craig G. Bates
SECTION 7 Cardiovascular Disease . . . . . . . . . . . . . . . 325 SECTION 9 Gastrointestinal Disorders . . . . . . . . . . . . . 481
48 Chest Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 71 Acute Abdominal Pain. . . . . . . . . . . . . . . . . . . . . . . . . 481
Simon A. Mahler Mary Claire O’Brien
49 Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . 332 72 Nausea and Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . 489
Judd E. Hollander, Deborah B. Diercks Bophal Sarha Hang, Susan Bork, Jeff Ditkoff
50 Cardiogenic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 73 Disorders Presenting Primarily With Diarrhea. . . . . . . . . . . . 492
Casey Glass, David Manthey Nicholas E. Kman, Howard A. Werman
51 Low-Probability Acute Coronary Syndrome . . . . . . . . . . . . . 353 74 Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Kathleen A. Hosmer, Chadwick D. Miller Vito Rocco, Arash Armin
52 Syncope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 75 Upper Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . 503
James Quinn Christopher M. Ziebell, Andy Kitlowski, Janna M. Welch, Phillip A. Friesen
53 Acute Heart Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . 366 76 Lower Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . 506
Sean P. Collins, Alan B. Storrow Bruce M. Lo
54 Valvular Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . 373 77 Esophageal Emergencie.s . . . . . . . . . . . . . . . . . . . . . . . 508
William D. Alley, Simon A. Mahler Moss Mendelson
55 Cardiomyopathies and Pericardial Disease. . . . . . . . . . . . . . 380 78 Peptic Ulcer Disease and Gastritis. . . . . . . . . . . . . . . . . . . 514
James T. Niemann Matthew C. Gratton, Angela Bogle
56 Venous Thromboembolism . . . . . . . . . . . . . . . . . . . . . . 388 79 Pancreatitis and Cholecystitis. . . . . . . . . . . . . . . . . . . . . 517
Jeffrey A. Kline Bart Besinger, Christine R. Stehman
57 Systemic Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . 399 80 Hepatic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Brigitte M. Baumann Susan R. O’Mara, Kulleni Gebreyes
58 Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . 409 81 Acute Appendicitis. . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Michael E. Winters E. Paul DeKoning
59 Aortic Dissection and Related Aortic Syndrome.s . . . . . . . . . . 412 82 Diverticulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
Gary A. Johnson, Louise A. Prince Autumn Graham
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Contents ix
83 Bowel Obstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . 538 105 Complications of Gynecologic Procedures . . . . . . . . . . . . . . 676
Timothy G. Price, Raymond J. Orthober Nikki Waller
84 Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Donald Byars, Turan Kayagil SECTION 12 Pediatrics . . . . . . . . . . . . . . . . . . . . . . 681
85 Anorectal Disorder.s . . . . . . . . . . . . . . . . . . . . . . . . . . 545 106 Emergency Care of Children. . . . . . . . . . . . . . . . . . . . . . 681
Brian E. Burgess Garth Meckler
86 Gastrointestinal Procedures and Devices. . . . . . . . . . . . . . . 563 107 Neonatal and Pediatric Transport. . . . . . . . . . . . . . . . . . . 684
Michael D. Witting Samuel J. Prater, Manish Shah
87 Complications of General Surgical Procedures. . . . . . . . . . . . 567 108 Resuscitation of Neonates. . . . . . . . . . . . . . . . . . . . . . . 689
Edmond A. Hooker Marc F. Collin
109 Resuscitation of Children . . . . . . . . . . . . . . . . . . . . . . . 695
SECTION 10 Renal and Genitourinary Disorders. . . . . . . 575 William E. Hauda, II
88 Acute Kidney Injury . . . . . . . . . . . . . . . . . . . . . . . . . . 575 110 Pediatric Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . 706
Richard Sinert, Peter R. Peacock, Jr. Camilo E. Gutiérrez
89 Rhabdomyolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581 111 Intubation and Ventilation in Infants and Children. . . . . . . . . 714
Francis L. Counselman, Bruce M. Lo Robert J. Vissers, Nathan W. Mick
90 End-Stage Renal Disease. . . . . . . . . . . . . . . . . . . . . . . . 584 112 Intravenous and Intraosseous Access in Infants and Children. . . . 722
Mathew Foley, Ninfa Mehta, Richard Sinert Matthew Hansen
91 Urinary Tract Infections and Hematuria . . . . . . . . . . . . . . . 589 113 Pain Management and Procedural Sedation
Kim Askew in Infants and Children. . . . . . . . . . . . . . . . . . . . . . . . . 727
92 Acute Urinary Retention. . . . . . . . . . . . . . . . . . . . . . . . 597 Peter S. Auerbach
David Hung-Tsang Yen, Chen-Hsen Lee 114 Neonatal Emergencies and Common Neonatal Problems. . . . . . 734
93 Male Genital Problems. . . . . . . . . . . . . . . . . . . . . . . . . 601 Quynh H. Doan, Niranjan Kissoon
Jonathan E. Davis 115 Sudden Infant Death Syndrome and
94 Urologic Stone Disease. . . . . . . . . . . . . . . . . . . . . . . . . 609 Apparent Life-Threatening Event. . . . . . . . . . . . . . . . . . . 741
David E. Manthey, Bret A. Nicks Ilene Claudius, Joel S. Tieder
95 Complications of Urologic Procedures and Devices . . . . . . . . . 613 116 Fever and Serious Bacterial Illness
Elaine B. Josephson in Infants and Children. . . . . . . . . . . . . . . . . . . . . . . . . 747
Vincent F. Wang
SECTION 11 Obstetrics and Gynecology. . . . . . . . . . . . 619 117 Meningitis in Infants and Children . . . . . . . . . . . . . . . . . . 754
Amy Levine
96 Abnormal Uterine Bleeding. . . . . . . . . . . . . . . . . . . . . . 619
Bophal Sarha Hang 118 Ear and Mastoid Disorders in Infants and Children. . . . . . . . . . 757
Carmen Coombs
97 Abdominal and Pelvic Pain in the Nonpregnant Female . . . . . . 625
Melanie Heniff, Heather R.B. Fleming 119 Eye Emergencies in Infants and Children. . . . . . . . . . . . . . . 764
Janeva Kircher, Andrew Dixon
98 Ectopic Pregnancy and Emergencies in the
First 20 Weeks of Pregnancy. . . . . . . . . . . . . . . . . . . . . . 628 120 Nose and Sinus Disorders in Infants and Children. . . . . . . . . . 775
Heather A. Heaton Joanna S. Cohen, Dewesh Agrawal
99 Comorbid Disorders in Pregnancy. . . . . . . . . . . . . . . . . . . 636 121 Mouth and Throat Disorders in Infants and Children . . . . . . . . 779
Lori J. Whelan Derya Caglar, Richard Kwun, Abigail Schuh
100 Maternal Emergencies After 20 Weeks of 122 Neck Masses in Infants and Children . . . . . . . . . . . . . . . . . 786
Pregnancy and in the Postpartum Period . . . . . . . . . . . . . . 644 Charles E. A. Stringer, Vikram Sabhaney
Janet Simmons Young 123 Stridor and Drooling in Infants and Children. . . . . . . . . . . . . 793
101 Emergency Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 652 Elisa Mapelli, Vikram Sabhaney
Sarah Elisabeth Frasure 124 Wheezing in Infants and Children. . . . . . . . . . . . . . . . . . . 802
102 Vulvovaginiti.s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661 Allan Shefrin, Alia Busuttil, Roger Zemek
Ciara J. Barclay-Buchanan, Melissa A. Barton 125 Pneumonia in Infants and Children. . . . . . . . . . . . . . . . . . 814
103 Pelvic Inflammatory Disease. . . . . . . . . . . . . . . . . . . . . . 668 Joseph E. Copeland
Suzanne M. Shepherd, Brian Weiss, William H. Shoff 126 Congenital and Acquired Pediatric Heart Disease. . . . . . . . . . 822
104 Breast Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672 Esther L. Yue, Garth D. Meckler
Bophal Sarha Hang 127 Syncope, Dysrhythmias, and ECG Interpretation in Children . . . . 835
Andrew C. Dixon
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