Emergency medicine (EM) is the only medical specialty that has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of six organizations: the American Board of Emergency Medicine (ABEM), the administrative organization for the project; the American College of Emergency Physicians (ACEP); the Council of Emergency Medicine Residency Directors (CORD); the Emergency Medicine Residents’ Association (EMRA); the Residency Review Committee for Emergency Medicine (RRC-EM); and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department (ED) visits and several expert panels.1 The resulting product was first published in 20012,3 and has successfully served as the common source document for all EM organizations. One of its strengths is incorporating the reality that EM is a specialty driven by symptoms, not diagnoses, requiring simultaneous therapeutic and diagnostic interventions. The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of EM, to consider alterations to the EM Model suggested by the collaborating organizations, and to recommend changes to the six sponsoring organizations. The initial 2-year review occurred in 2003, with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document. This initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005.4,5 Subsequently, a task force met every 2 years, to review the EM Model and make suggested changes.6–9 This article provides a brief review of the original EM Model, a listing of the conditions and components that include the changes made before and during the 2007 review, a summary of the changes made to it as a result of the 2009 review conducted by the current task force, and an update on current uses of the EM Model by the six collaborating EM organizations. The EM Model is a three-dimensional description of EM clinical practice. The three dimensions are patient acuity, physician tasks, and the listing of conditions and components. All of these dimensions are interrelated and employed concurrently by a physician when providing patient care. The EM physician’s initial approach is determined by the acuity of the patient’s presentation. While assessing the patient, the physician completes a series of tasks collecting information. Through this process, the physician is able to select the most likely etiology of the patient’s problem from the listing of the conditions and components. Through simultaneous application of all three components, the physician is able to arrive at the most probable diagnosis and implement a treatment plan for the patient. Hence, the three dimensions of the EM Model are interrelated and applied concurrently in the practice of EM. The three dimensions, as revised in 2005, are included in Tables 1–4. The Accreditation Council for Graduate Medical Education (ACGME) is implementing the ACGME Outcome Project to assure that physicians are appropriately trained in the knowledge and skills of their specialties. The ACGME has identified six general (core) competencies thought to be essential for any practicing physician: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism, and systems-based practice. The six general competencies are an integral part of the practice of EM and are embedded in the EM Model.10,11 The EM Model is designed for use as the core document for the specialty. It will provide the foundation for developing medical school and residency curricula, certification examination specifications, continuing education objectives, research agendas, residency program review requirements, and other documents necessary for the definition, skills acquisition, assessment, and practice of the specialty. In conjunction with the EM Model, these six general competencies construct a framework for evaluation of physician performance and curriculum design to further refine and improve the education and training of competent emergency physicians. The six competencies and the Model also form the core of ABEM’s maintenance of certification program, Emergency Medicine Continuous Certification (EMCC; for further information on the EMCC program see ABEM’s website, http://www.abem.org. The 2009 EM Model review task force met to consider changes based on feedback received from the six collaborating organizations. Each organization was asked to comment on how it was using the Model and to recommend changes in the document that would address any perceived deficiencies. Table 5 lists the changes recommended by the 2009 EM Model Review Task Force and accepted by the six organizations. The ABEM uses the EM Model to define its test and examination specifications. Each question or structured case used in any ABEM examination is referenced to the EM Model. Every test and examination that ABEM develops is based on a blueprint derived directly from the EM Model. It also uses the conditions and components section to structure the lifelong learning and self-assessment component of its EMCC program. The ACEP uses the EM Model primarily as the basis for its educational activities. In addition, the ACEP Academic Affairs Committee used the EM Model to survey EM residency program directors and recent residency graduates to identify curricula gaps and educational needs. This information has been used to develop a comprehensive list of Web-based educational resources that can be incorporated into residency curricula. The integration of the competencies in the EM Model meets the program requirements of the RRC-EM that the six core competencies are included in residency training. The EM Model is a major tool for CORD and EM program faculty to use when integrating the competencies into the training, residency curricula, and evaluation of residents. In summary, the EM Model is accomplishing the intended purposes for which it was developed. The 2009 review of the EM Model resulted in only minor changes and clarifications (see Table 5). Several EM organizations are using the EM Model to support the ongoing development of the specialty of EM. The complete updated 2009 EM Model can be found on the websites of each of the six collaborating organizations.

[Ann Emerg Med. 2011;57:e1-e15.]OverviewEmergency medicine is the only medical specialty that has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of 6 organizations: the American Board of Emergency Medicine (ABEM), the administrative organization for the project, the American College of Emergency Physicians (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents' Association (EMRA), the Residency Review Committee for Emergency Medicine (RRC-EM), and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department visits and several expert panels.1Hockberger R.S. LaDuca A. Orr N.A. et al.Creating the model of a clinical practice: the case of emergency medicine.Acad Emerg Med. 2003; 10: 161-168Crossref PubMed Google Scholar The resulting product was first published in 20012Core Content Task Force IIThe model of the clinical practice of emergency medicine.Ann Emerg Med. 2001; 37: 745-770Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar, 3Core Content Task Force IIThe model of the clinical practice of emergency medicine.Acad Emerg Med. 2001; 8: 660-681Crossref PubMed Scopus (37) Google Scholar and has successfully served as the common source document for all emergency medicine organizations. One of its strengths is incorporating the reality that emergency medicine is a specialty driven by symptoms, not diagnoses, requiring simultaneous therapeutic and diagnostic interventions.The task force that developed the EM Model recommended that a new task force, composed of representatives from all 6 organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of emergency medicine, to consider alterations to the EM Model suggested by the collaborating organizations, and to recommend changes to the 6 sponsoring organizations.The initial 2-year review occurred in 2003, with representatives from each of the 6 organizations suggesting changes and reporting how their respective organizations had used the document. This initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005.4Hockberger R.S. Binder L.S. Chisholm C.D. et al.The model of the clinical practice of emergency medicine: a 2-year update.Ann Emerg Med. 2005; 45: 659-674Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 5Hockberger R.S. Binder L.S. Chisholm C.D. et al.The model of the clinical practice of emergency medicine: a 2-year update.Acad Emerg Med. 2005; 12: 543-558Crossref Google Scholar Subsequently, a task force met every 2 years to review the EM Model and make suggested changes.6Thomas H.A. Binder L.S. Chapman D.M. et al.The 2003 model of the clinical practice of emergency medicine: the 2005 update.Ann Emerg Med. 2006; 48: e1-e17Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 7Thomas H.A. Binder L.S. Chapman D.M. et al.The 2003 model of the clinical practice of emergency medicine: the 2005 update.Acad Emerg Med. 2006; 13: 1070-1073Crossref PubMed Scopus (22) Google Scholar, 8Thomas H.A. Beeson M.S. Binder L.S. et al.The 2005 model of the clinical practice of emergency medicine: the 2007 update.Acad Emerg Med. 2008; 16: 776-779Crossref Scopus (28) Google Scholar, 9Thomas H.A. Beeson M.S. Binder L.S. et al.The 2005 model of the clinical practice of emergency medicine: the 2007 update.Ann Emerg Med. 2008; 52: e1-e17Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar This article provides a brief review of the original EM Model, a listing of the conditions and components that include the changes made before and during the 2007 review, a summary of the changes made to it as a result of the 2009 review conducted by the current task force, and an update on current uses of the EM Model by the 6 collaborating EM organizations.The EM ModelThe EM Model is a 3-dimensional description of emergency medicine clinical practice. The 3 dimensions are patient acuity, physician tasks, and the listing of conditions and components. All of these dimensions are interrelated and used concurrently by a physician when providing patient care. The emergency physician's initial approach is determined by the acuity of the patient's presentation. While assessing the patient, the physician completes a series of tasks, collecting information. Through this process, the physician is able to select the most likely cause of the patient's problem from the listing of the conditions and components. Through simultaneous application of all 3 components, the physician is able to arrive at the most probable diagnosis and implement a treatment plan for the patient. Hence, the 3 dimensions of the EM Model are interrelated and applied concurrently in the practice of emergency medicine. The 3 dimensions, as revised in 2007, are included in Table 1, Table 2, Table 3, Table 4.Table 1Matrix of physician tasks by patient acuity.Physician TasksPatient AcuityCriticalEmergentLower AcuityPre-hospital careEmergency stabilizationPerformance of focused history and physical examinationModifying factorsProfessional issuesDiagnostic studiesDiagnosisTherapeutic interventionsPharmacotherapyObservation and reassessmentConsultation and dispositionPrevention and educationDocumentationMultitasking and team management Open table in a new tab Table 2Patient acuity definitions.CriticalEmergentLower AcuityPatient presents with symptoms of a life-threatening illness or injury with a high probability of mortality if immediate intervention is not begun to prevent further airway, respiratory, hemodynamic, and/or neurologic instability.Patient presents with symptoms of an illness or injury that may progress in severity or result in complications with a high probability for morbidity if treatment is not begun quickly.Patient presents with symptoms of an illness or injury that have a low probability of progression to more serious disease or development of complications. Open table in a new tab Table 3Physician task definitions.Pre-hospital careParticipate actively in pre-hospital care; provide direct patient care or online or offline medical direction or interact with pre-hospital medical providers; assimilate information from pre-hospital care into the assessment and management of the patient.Emergency stabilizationConduct primary assessment and take appropriate steps to stabilize and treat patients.Performance of focused history and physical examinationCommunicate effectively to interpret and evaluate the patient's symptoms and history; identify pertinent risk factors in the patient's history; provide a focused evaluation; interpret the patient's appearance, vital signs and condition; recognize pertinent physical findings; perform techniques required for conducting the examination.Modifying factorsRecognize age, sex, ethnicity, barriers to communication, socioeconomic status, underlying disease, and other factors that may affect patient management.Professional and legal issuesUnderstand and apply principles of professionalism, ethics, and legal concepts pertinent to patient management.Diagnostic studiesSelect and perform the most appropriate diagnostic studies and interpret the results, eg, ECG, emergency ultrasonography, and laboratory tests.DiagnosisDevelop a differential diagnosis and establish the most likely diagnoses in light of the history, physical, interventions, and test results.Therapeutic interventionsPerform procedures and nonpharmacologic therapies, and counsel.PharmacotherapySelect appropriate pharmacotherapy, recognize pharmacokinetic properties, and anticipate drug interactions and adverse effects.Observation and reassessmentEvaluate and reevaluate the effectiveness of a patient's treatment or therapy, including addressing complications and potential errors; monitor, observe, manage, and maintain the stability of one or more patients who are at different stages in their evaluations.Consultation and dispositionCollaborate with physicians and other professionals to evaluate and treat patients, arrange appropriate placement and transfer if necessary, formulate a follow-up plan, and communicate effectively with patients, family, and involved health care members.Prevention and educationApply epidemiologic information to patients at risk; conduct patient education; select appropriate disease and injury prevention techniques.DocumentationCommunicate patient care information in a concise manner that facilitates quality care and coding.Multitasking and team managementPrioritize multiple patients in the emergency department to provide optimal patient care; interact, coordinate, educate, and supervise all members of the patient management team; utilize appropriate hospital resources; have familiarity with disaster management. Open table in a new tab Table 4Listing of conditions and components.1.0 Signs, Symptoms, and PresentationsCriticalEmergentLower Acuity1.1 General Altered mental statusXX AnxietyX ApneaX AtaxiaXX Back painXXX BleedingXXX ComaX ConfusionX Crying/fussinessXX CyanosisX Decreased level of consciousnessXX DehydrationXX DizzinessXX EdemaXX Failure to thriveXX FatigueXX Feeding problemsX FeverXXX HypotensionXX JaundiceX Joint pain/swellingXX LimpXX LymphadenopathyX MalaiseXX Multiple traumaXX Needle stickXX PainXXX ParalysisXX Paresthesia/dysesthesiaXX PoisoningXXX PruritusXX RashXXX ShockX SIDS (See 3.1)X Sleeping problemsX SyncopeXXX TremorXX WeaknessXX Weight lossXX1.2 Abdominal Abnormal vaginal bleedingXXX AnuriaX AscitesXX ColicXX ConstipationX CrampsXX DiarrheaXX DysmenorrheaX DysuriaX HematemesisXX HematocheziaXXX HematuriaXX Nausea/vomitingXX PainXXX Pelvic painXXX PeritonitisXX Rectal bleedingXXX Rectal painXX Urinary incontinenceX Urinary retentionX1.3 Chest Chest painXXX CoughXX DyspneaXX HemoptysisXX HiccupX PalpitationsXXX Shortness of breathXX TachycardiaXX WheezingXX1.4 Head and Neck CongestionX DiplopiaX DysphagiaXX Eye painXX Headache (See 12.3)XXX Loss of hearingX Loss of visionX RhinorrheaX Sore throatXX StridorXX TinnitusX VertigoXX2.0 Abdominal and Gastrointestinal DisordersCriticalEmergentLower Acuity2.1 Abdominal Wall HerniasXX2.2 Esophagus Infectious disorders Candida (See 4.4, 7.5)XX Inflammatory disorders EsophagitisXX Gastroesophageal reflux (GERD)X Toxic effects of caustic (See 17.1) AcidXX AlkaliXX Motor abnormalities SpasmsX Structural disorders Boerhaave's syndromeXX DiverticulaXX Foreign bodyX HerniasXX Mallory-Weiss syndromeXX Stricture and stenosisXX Tracheoesophageal fistulaXX VaricesXX TumorsXX2.3 Liver CirrhosisXX AlcoholicXX Biliary obstructiveX Drug-inducedXX Hepatorenal failureXX Infectious disordersXX AbscessX Hepatitis AcuteXX ChronicX TumorsXX2.4 Gall Bladder and Biliary Tract CholangitisXX CholecystitisX Cholelithiasis/choledocholithiasisXX TumorsXX2.5 Pancreas PancreatitisXX TumorsXX2.6 Peritoneum Spontaneous bacterial peritonitisXX2.7 Stomach Infectious disordersX Inflammatory disorders GastritisXX Peptic ulcer diseaseXX HemorrhageXX PerforationXX Structural disorders Congenital hypertrophic pyloric stenosisX Foreign bodyXX TumorsXX2.8 Small Bowel Infectious disordersXX Inflammatory disorders Regional enteritis/Crohn's diseaseXX Motor abnormalities ObstructionX Paralytic ileusX Structural disorders Aortoenteric fistulaX Congenital anomaliesXX Intestinal malabsorptionXX Meckel's diverticulumXX TumorsXX Vascular insufficiencyXX2.9 Large Bowel Infectious disorders Antibiotic associatedX BacterialXX ParasiticXX ViralXX Inflammatory disorders Acute appendicitisX Necrotizing enterocolitis (NEC)XX Radiation colitisX Ulcerative colitisXX Motor abnormalities Hirschsprung's diseaseXX Irritable bowelX ObstructionX Structural disorders Congenital anomaliesXX DiverticulaXX IntussusceptionXX VolvulusXX TumorsXX2.10 Rectum and Anus Infectious disorders Perianal/anal abscessXX Perirectal abscessX Pilonidal cyst and abscessXX Inflammatory disorders ProctitisX Structural disorders Anal fissureX Anal fistulaXX Congenital anomaliesX Foreign bodyXX HemorrhoidsX Rectal prolapseX TumorsXX2.11 SpleenXXX3.0 Cardiovascular DisordersCriticalEmergentLower Acuity3.1 Cardiopulmonary ArrestX SIDS (See 1.1)X3.2 Congenital Abnormalities of the Cardiovascular System Disorders due to anatomic anomaliesXXX Genetically transmitted disordersXXX3.3 Disorders of Circulation Arterial AneurysmXXX Aortic dissectionX ThromboembolismXX Venous Thromboembolism (See 16.6)XX3.4 Disturbances of Cardiac Rhythm Cardiac dysrhythmiasXXX VentricularXX SupraventricularXXX Conduction disordersXXX3.5 Diseases of the Myocardium, Acquired Cardiac failureXX Cor pulmonaleXX High outputXX Low outputXX CardiomyopathyXXX HypertrophicXXX Congestive heart failureXX Coronary syndromesXX Ischemic heart diseaseXX Myocardial infarctionXX MyocarditisXXX Ventricular aneurysmXXX3.6 Diseases of the Pericardium Pericardial tamponade (See 18.1)XX PericarditisXX3.7 EndocarditisXX3.8 HypertensionXXX3.9 TumorsXX3.10 Valvular DisordersXXX4.0 Cutaneous DisordersCriticalEmergentLower Acuity4.1 Cancers of the Skin Basal cellX Kaposi's sarcomaX MelanomaX Squamous cellX4.2 Decubitus UlcerXX4.3 Dermatitis AtopicX ContactX EczemaX PsoriasisX Sebaceous cystX SeborrheaX4.4 Infections Bacterial AbscessXX CellulitisXX ErysipelasX ImpetigoX Necrotizing infectionXX Fungal Candida (See 2.2, 7.5)X TineaX Parasitic Pediculosis infestationX ScabiesX Viral Aphthous ulcersX Erythema infectiosumX Herpes simplex (See 10.6, 13.1)X Herpes zoster (See 10.6)XX Human papillomavirus (HPV) (See 13.1)X Molluscum contagiosumX WartsX4.5 Maculopapular Lesions Erythema multiformeXX Erythema nodosumX Henoch-Schönlein purpura (HSP)X Pityriasis roseaX PurpuraXX UrticariaXX4.6 Papular/Nodular Lesions Hemangioma/lymphangiomaX LipomaX4.7 Vesicular/Bullous Lesions PemphigusX Staphylococcal scalded skin syndromeXX Stevens-Johnson syndromeXX Toxic epidermal necrolysisXX5.0 Endocrine, Metabolic, and Nutritional DisordersCriticalEmergentLower Acuity5.1 Acid-Base Disturbances Metabolic or respiratory AcidosisXX AlkalosisXXX Mixed acid-base balance disorderXX5.2 Adrenal Disease Corticoadrenal insufficiencyXX Cushing's syndromeXX5.3 Fluid and Electrolyte Disturbances Calcium metabolismXXX Fluid overload/volume depletionXX Hyperkalemia/hypokalemiaXXX Hypernatremia/hyponatremiaXXX Magnesium metabolismXX Phosphorus metabolismXX5.4 Glucose Metabolism Diabetes mellitus Type IXXX Type IIXX Complications in glucose metabolism Diabetic ketoacidosis (DKA)XX HyperglycemiaXX Hyperosmolar comaXX HypoglycemiaXX SystemicXX5.5 Nutritional Disorders Vitamin deficienciesX Vitamin excessX Wernicke-Korsakoff syndromeX5.6 Parathyroid DiseaseXX5.7 Pituitary DisordersXX PanhypopituitarismX5.8 Thyroid Disorders HyperthyroidismXXX HypothyroidismXXX ThyroiditisXX5.9 Tumors of Endocrine Glands AdrenalXX PituitaryXX ThyroidXX6.0 Environmental DisordersCriticalEmergentLower Acuity6.1 Bites and Envenomation (See 18.1) ArthropodsXX InsectsX SpidersXX MammalsXX Marine organisms (See 17.1)XXX SnakesXXX6.2 Dysbarism Air embolismXX BarotraumaXXX Decompression syndromeXX6.3 Electrical Injury (See 18.1)XXX LightningXX6.4 High-Altitude Illness Acute mountain sicknessXX Barotrauma of ascentXX High-altitude cerebral edemaXX High-altitude pulmonary edemaXX6.5 Submersion Incidents Cold water immersionXX Near drowningXX6.6 Temperature-Related Illness Heat Heat exhaustionXX Heat strokeX Cold FrostbiteXX HypothermiaXX6.7 Radiation EmergenciesXXX7.0 Head, Ear, Eye, Nose, Throat DisordersCriticalEmergentLower Acuity7.1 Ear Foreign bodyXX Impacted cerumenX LabyrinthitisX MastoiditisX Meniere's diseaseX Otitis externaX InfectiveX MalignantX Otitis mediaXX Perforated tympanic membrane (See 18.1)X7.2 Eye External eye BlepharitisX Burn confined to eye and adnexa (See 18.1)X ConjunctivitisX Corneal abrasions (See 18.1)XX DacryocystitisXX Disorders of lacrimal systemX Foreign bodyXX Inflammation of the eyelidsX ChalazionX HordeolumX KeratitisXX Anterior pole GlaucomaXX Hyphema (See 18.1)XX Iritis (See 18.1)XX Posterior pole Choroiditis/chorioretinitisX Optic neuritisX PapilledemaXX Retinal detachments and defects (See 18.1)X Retinal vascular occlusionX Orbit Cellulitis PreseptalX PostseptalX Purulent endophthalmitisX7.3 Cavernous Sinus ThrombosisXX7.4 Nose EpistaxisXXX Foreign bodyXX RhinitisX SinusitisX7.5 Oropharynx/Throat DentalgiaX Diseases of the oral soft tissue Ludwig's anginaXX StomatitisX Diseases of the salivary glands SialolithiasisXX Suppurative parotitisX Foreign bodyXX Gingival and periodontal disorders GingivostomatitisX Larynx/trachea Epiglottitis (See 16.1)XX LaryngitisX TracheitisXX Oral candidiasis (See 2.2, 4.4)X Periapical abscessXX Peritonsillar abscessX Pharyngitis/tonsillitisX Retropharyngeal abscessXX Temporomandibular joint disordersX7.6 TumorsXX8.0 Hematologic DisordersCriticalEmergentLower Acuity8.1 Blood Transfusion ComplicationsXX8.2 Hemostatic Disorders Coagulation defectsXXX AcquiredXXX HemophiliasXXX Disseminated intravascular coagulationX Platelet disordersXXX ThrombocytopeniaXX8.3 LymphomasXX8.4 PancytopeniaXX8.5 Red Blood Cell Disorders Anemias AplasticXX HemoglobinopathiesXX Sickle cell diseaseXX HemolyticX Hypochromic Iron deficiencyXX MegaloblasticXX PolycythemiaXX Methemoglobinemia (See 17.1)XX8.6 White Blood Cell Disorders LeukemiaXX Multiple myelomaXX LeukopeniaXX9.0 Immune System DisordersCriticalEmergentLower Acuity9.1 Collagen Vascular Disease Raynaud's diseaseX Reiter's syndromeXX Rheumatoid arthritis (See 11.3)XX SclerodermaXX Systemic lupus erythematosusXX VasculitisXX9.2 HIV and Manifestations (See 10.6)XXX9.3 Hypersensitivity Allergic reactionXX AnaphylaxisX AngioedemaXX Drug allergiesXXX9.4 Kawasaki SyndromeX9.5 SarcoidosisXX9.6 Transplant-related ProblemsXXX ImmunosuppressionXX RejectionXX9.7 Rheumatic FeverXX10.0 Systemic Infectious DisordersCriticalEmergentLower Acuity10.1 Bacterial Bacterial food poisoningXX BotulismXX ChlamydiaXX Gonococcal infectionsXX MeningococcemiaXX Mycobacterial infections Atypical mycobacteriaXX TuberculosisXX Other bacterial diseasesXX Gas gangrene (See 11.6)XX Sepsis/bacteremiaXX ShockX Systemic inflammatory response syndrome (SIRS)XX Toxic shock syndromeXX Spirochetes SyphilisXX TetanusXX10.2 Biologic WeaponsXX10.3 Fungal InfectionsXX10.4 Protozoan/Parasites MalariaX ToxoplasmosisXX10.5 Tick-borne EhrlichiosisX Lyme diseaseX Rocky Mountain spotted feverX10.6 ViralXX Infectious mononucleosisXX Influenza/parainfluenzaXX HantavirusXX Herpes simplex (See 4.4, 13.1)XX Herpes zoster/varicella (See 4.4)XX HIV (See 9.2)XXX RabiesX RoseolaX RubellaX10.7 Emerging Infections/PandemicsXX11.0 Musculoskeletal Disorders (Nontraumatic)CriticalEmergentLower Acuity11.1 Bony Abnormalities Aseptic necrosis of hipXX OsteomyelitisX TumorsXX11.2 Disorders of the Spine Disc disordersXX Inflammatory spondylopathiesXX Low back pain Cauda equina syndrome (See 18.1)XX SacroiliitisX Sprains/strainsX11.3 Joint Abnormalities Arthritis SepticX GoutXX Rheumatoid (See 9.1)X JuvenileX OsteoarthrosisX Congenital dislocation of the hipXX Slipped capital femoral epiphysisX11.4 Muscle Abnormalities Myalgia/MyositisX RhabdomyolysisXX11.5 Overuse Syndromes BursitisX Muscle strainsX Peripheral nerve syndromeX Carpal tunnel syndromeX TendonitisX11.6 Soft Tissue Infections FasciitisX FelonX Gangrene (See 10.1)XX ParonychiaXX Synovitis/tenosynovitisXX12.0 Nervous System DisordersCriticalEmergentLower Acuity12.1 Cranial Nerve DisordersX Idiopathic facial nerve paralysis (Bell's palsy)X Trigeminal neuralgiaX12.2 Demyelinating DisordersXX Multiple sclerosisXX12.3 Headache (See 1.4)XXX Muscle contractionX VascularXX12.4 HydrocephalusXX Normal pressureXX VP shuntX12.5 Infections/Inflammatory Disorders EncephalitisXX Intracranial and intraspinal abscessXX Meningitis BacterialXX ViralXX MyelitisX Neuralgia/neuritisX12.6 Movement DisordersXX Dystonic reactionXX12.7 Neuromuscular Disorders Guillain-Barré syndromeXX Myasthenia gravisXXX Peripheral neuropathyX12.8 Other Conditions of the Brain Dementia (See 14.5)X Parkinson's diseaseX Pseudotumor cerebriXX12.9 Seizure DisordersXXX FebrileXX NeonatalX Status epilepticusX12.10 Spinal Cord CompressionXX12.11 Stroke Hemorrhagic IntracerebralXX SubarachnoidXX Ischemic EmbolicXX ThromboticXX12.12 Transient Cerebral IschemiaXX12.13 TumorsXX13.0 Obstetrics and GynecologyCriticalEmergentLower Acuity13.1 Female Genital Tract Cervix Cervicitis and endocervicitisXX TumorsX Infectious disorders Pelvic inflammatory diseaseX Fitz-Hugh-Curtis syndromeX Tubo-ovarian abscessX Lesions Herpes simplex (See 4.4, 10.6)X Human papillomavirus (HPV) (See 4.4)X Ovary CystX TorsionX TumorsXX Uterus Dysfunctional bleedingXX EndometriosisX ProlapseX TumorsXX Gestational trophoblastic diseaseX LeiomyomaX Vagina and vulva Bartholin's abscessX Foreign bodyXX Vaginitis/vulvovaginitisX13.2 Normal PregnancyX13.3 Complications of Pregnancy AbortionX Ectopic pregnancyXX Hemolysis, elevated liver enzymes, low platelets (HELLP) syndromeXX Hemorrhage, antepartum Abruptio placentae (See 18.2)XX Placenta previaXX Hyperemesis gravidarumXX Hypertension complicating pregnancyXX EclampsiaXX PreeclampsiaX InfectionsX Rh isoimmunizationX13.4 High-risk PregnancyXX13.5 Normal Labor and DeliveryXX13.6 Complications of Labor Fetal distressX Premature labor (See 18.2)X Premature rupture of membranesX Rupture of uterus (See 18.2)X13.7 Complications of Delivery Malposition of fetusXX Nuchal cordX Prolapse of cordX13.8 Postpartum Complications EndometritisX HemorrhageXX MastitisXX14.0 Psychobehavioral DisordersCriticalEmergentLower Acuity14.1 Addictive Behavior Alcohol dependenceX Drug dependenceX Eating disordersXX Substance abuseX14.2 Mood Disorders and Thought Disorders Acute PsychosisXX Bipolar disorderXX DepressionXX Suicidal riskXX Grief reactionX SchizophreniaXX14.3 Factitious Disorders Drug-seeking behaviorX Munchausen syndrome/Munchausen by proxyXX14.4 Neurotic Disorders Anxiety/panicX Obsessive compulsiveX PhobicX Posttraumatic stressX14.5 Organic Psychoses Chronic organic psychotic conditionsX Alcoholic psychosesXX Drug psychosesXX DeliriumX Dementia (See 12.8)X Intoxication or withdrawal (See 17.1) AlcoholXXX HallucinogensXX OpioidsXXX PhencyclidineX Sedatives/hypnotics/anxiolyticsXXX Sympathomimetics and cocaineXXX14.6 Patterns of Violence/Abuse/Neglect Interpersonal violence Child, intimate partner, elderX Homicidal riskXX Sexual assaultX Staff/patient safetyX14.7 Personality DisordersX14.8 Psychosomatic Disorders HypochondriasisX Hysteria/conversionX15.0 Renal and Urogenital DisordersCriticalEmergentLower Acuity15.1 Acute and Chronic Renal FailureXXX15.2 Complications of Renal DialysisXX15.3 Glomerular Disorders GlomerulonephritisXX Nephrotic syndromeXX15.4 Infection CystitisX PyelonephritisX Urinary tract infection (UTI)X15.5 Male Genital Tract Genital lesionsX HerniasXX Inflammation/infection Balanitis/balanoposthitisXX Epididymitis/orchitisXX Gangrene of the scrotum (Fournier's gangrene)XX ProstatitisXX UrethritisX Structural Paraphimosis/phimosisX PriapismX Prostatic hypertrophy (BPH)X Torsion of testisX Testicular massesX Tumors ProstateX TestisX15.6 NephritisXX Hemolytic uremic syndromeX15.7 Structural Disorders Calculus of urinary tractXX Obstructive uropathyX Polycystic kidney diseaseX15.8 TumorsX16.0 Thoracic-Respiratory DisordersCriticalEmergentLower Acuity16.1 Acute Upper Airway Disorders Infections CroupX Epiglottitis (See 7.5)XX Pertussis/whooping coughXX Upper respiratory infectionX ObstructionX Tracheostomy/complicationsXX16.2 Disorders of Pleura, Mediastinum, and Chest Wall CostochondritisX MediastinitisXX Pleural effusionXX PleuritisX PneumomediastinumX Pneumothorax (See 18.1) SimpleX TensionX16.3 Noncardiogenic Pulmonary EdemaXX16.4 Obstructive/Restrictive Lung Disease Asthma/reactive airway diseaseXX Bronchitis and bronchiolitisXX Bronchopulmonary dysplasiaXX Chronic obstructive pulmonary diseaseXXX Cystic fibrosisXXX Environmental/industrial exposureXXX Foreign bodyXX16.5 Physical and Chemical Irritants/Insults PneumoconiosisXX Toxic effects of gases, fumes, vapors (See 18.1)XXX16.6 Pulmonary Embolism/Infarct Septic emboliXX Venous thromboembolism (See 3.3)XX16.7 Pulmonary Infections Lung abscessX Pneumonia AspirationXX AtypicalX BacterialXX ChlamydiaX FungalXX MycoplasmalXX ViralXXX Pulmonary tuberculosisX16.8 Tumors BreastX Chest wallX PulmonaryXX17.0 Toxicologic DisordersCriticalEmergentLower Acuity17.1 Drug and Chemical Classes Analgesics AcetaminophenX Nonsteroidal anti-inflammatories (NSAIDS)XX Opiates and related narcoticsXX SalicylatesXX Alcohol EthanolXXX GlycolXX IsopropylXXX MethanolXX AnestheticsXX Anticholinergics/cholinergicsXX AnticoagulantsXX AnticonvulsantsXX AntidepressantsXX Antiparkinsonism drugsX Antihistamines and antiemeticsX AntipsychoticsXX BronchodilatorsX Carbon monoxideXX Cardiovascular drugs AntiarrhythmicsXX DigitalisXX AntihypertensivesXX Beta-BlockersXX Calcium-channel blockersXX Caustic agents AcidXX AlkaliXX CocaineXXX Cyanides, hydrogen sulfideXX HallucinogensXX Hazardous materialsXX Heavy metalsXX Herbicides, insecticides, and rodenticidesXX Household/industrial chemicalsXXX Hormones/steroidsXX HydrocarbonsXX Hypoglycemics/insulinXX Inhaled toxinsXX IronXX IsoniazidXX Marine toxins (See 6.1)XXX Methemoglobinemia (See 8.5)XX Mushrooms/poisonous plantsXX NeurolepticsXX Nonprescription drugsXX OrganophosphatesXX Recreational drugsXXX Sedatives/hypnoticsXX Stimulants/sympathomimeticsXX StrychnineXX LithiumXXX18.0 Traumatic DisordersCriticalEmergentLower Acuity18.1 Trauma Abdominal trauma DiaphragmXX Hollow viscusXX PenetratingXX RetroperitoneumXX Solid organXX VascularXX Chest trauma Aortic dissection/disruptionX Contusion CardiacXXX PulmonaryXX Fracture ClavicleXX Ribs/flail chestXXX SternumXX HemothoraxXX Penetrating chest traumaXX Pericardial tamponade (See 3.6)X Pneumothorax (See 16.2) SimpleX TensionX Cutaneous injuries AvulsionsXX Bite wounds (See 6.1)XX Burns Electrical (See 6.3)XXX Chemical (See 16.5)XXX ThermalXXX LacerationsXX Puncture woundsXX Facial fracturesX DentalXX Le FortXXX MandibularXX OrbitalXX Genitourinary trauma BladderX External genitaliaX RenalXX UreteralX Head trauma Intracranial injuryXX Scalp lacerations/avulsionsXX Skull fracturesXX Injuries of the spine Dislocations/subluxationsXX FracturesXXX Sprains/strainsX Lower extremity bony trauma Dislocations/subluxationsX Fractures (open and closed)XX Neck trauma Laryngotracheal injuriesXX Penetrating neck traumaXX Vascular injuries Carotid arteryXX Jugular veinXX Ophthalmologic trauma Corneal abrasions/lacerations (See 7.2)XX Corneal burns AcidX AlkaliX UltravioletXX Eyelid lacerationsX Foreign bodyX Hyphema (See 7.2)X Lacrimal duct injuriesX Penetrating globe injuriesX Retinal detachments (See 7.2)X Traumatic iritis (See 7.2)XX Retrobulbar hematomaX Otologic trauma HematomaXX Perforated tympanic membrane (See 7.1)X Pediatric fractures EpiphysealXX GreenstickX TorusX Pelvic fractureXX Soft-tissue extremity injuries Amputations/replantationX Compartment syndromesX High-pressure injectionX Injuries to jointsXX KneeXX PenetratingX Penetrating soft-tissueXX PeriarticularX Sprains and strainsX Tendon injuries Lacerations/transectionsX RupturesX Achilles tendonX Patellar tendonX Vascular injuriesXX Spinal cord and nervous system trauma Cauda equina syndrome (See 11.2)XX Injury to nerve rootsXX Peripheral nerve injuryXX Spinal cord injuryXX Spinal cord injury without radiologic abnormality (SCIWORA)X Upper extremity bony trauma Dislocations/subluxationsX Fractures (open and closed)XX18.2 Trauma in PregnancyAbruptio placentae (See 13.3)XX Perimortem C-sectionX Premature labor (See 13.6)X Rupture of uterus (See 13.6)X18.3 Multisystem TraumaXX Blast injuryXX Open table in a new tab The Accreditation Council for Graduate Medical Education (ACGME) is implementing the ACGME Outcome Project to ensure that physicians are appropriately trained in the knowledge and skills of their specialties. The ACGME has identified 6 general (core) competencies thought to be essential for any practicing physician: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism, and systems-based practice. The 6 general competencies are an integral part of the practice of emergency medicine and are embedded in the EM Model.10Chapman D.M. Hayden S. Sanders A.B. et al.Integrating the Accreditation Council for Graduate Medical Education core competencies into the model of the clinical practice of emergency medicine.Ann Emerg Med. 2004; 43: 756-759Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 11Chapman D.M. Hayden S. Sanders A.B. et al.Integrating the Accreditation Council for Graduate Medical Education core competencies into the model of the clinical practice of emergency medicine.Acad Emerg Med. 2004; 11: 674-685 PubMed Google ScholarThe EM Model is designed for use as the core document for the specialty. It will provide the foundation for developing medical school and resi

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem. In July 2009, representatives of the leading emergency medicine organizations met in Dallas, TX, for the Future of Emergency Medicine Summit. This consensus document, agreed to and cowritten by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty.

The objective of this study was to determine the efficacy of the rectal administration of dextrose in raising the serum glucose in a hypoglycemic rat model. A randomized, prospective, controlled experimental study was performed using 18-h fasted, acutely anesthetized Harlan Sprague-Dawley rats made hypoglycemic by the intravenous infusion of insulin at 3 U/kg/h for 2 h. At 1 h into the infusion, study rats received 1, 2, or 3 g/kg of 50% dextrose solution infused into the rectum using a balloon tipped catheter. Control animals received an equivolume, equi-osmolar (as compared to the 3 g/kg dose) amount of polyethylene glycol (PEG)-400 by rectum. Blood glucose (BG) measurements were made using blood obtained from the portal vein and a femoral artery. Intravenous insulin administered at 3 U/kg/h consistently produced BG levels 60% of baseline at 60 min and 80% of baseline at 120 min. BG levels in portal and arterial circulation increased after rectal dextrose. In general, portal venous values were greater than arterial after rectal dextrose. The greatest increase was seen 30 min after dextrose by rectum in animals receiving 3 g/kg. A 50% dextrose administered by rectum in hypoglycemic rats is absorbed in quantities sufficient to raise BG in the arterial and portal circulation.

Signs & Symptoms in Emergency Medicine: Literature-Based Guide to Emergent Conditions presents a symptom-based approach to patient care in the emergency department. It is similar in many respects to other texts used as quick references and study guides, but it differs in that the medical literature is used in discussing the signs and symptoms of disease. The net result is a literature-based compendium of common ED presentations. Symptoms, signs, suggested evaluation, and management are addressed. However, many evaluation and treatment recommendations are based on consensus, tradition, or relatively little well-designed research. Some chapters cite primarily review articles or case series. This is not a reflection on the authors but rather the real value of much of the literature used in medicine.

Helium is an inert gas with unique physical properties that allow it to be used for various respiratory emergencies. Because of its low specific gravity and low viscosity, the passage of helium through the respiratory tract is smoother, more laminar, and less turbulent than either air or oxygen. These properties have prompted the use of helium and oxygen in patients with airway obstructions due to tumor, foreign body, edema, or bronchoconstriction. Helium-oxygen has been used to facilitate bronchoscopy through small diameter endotracheal tubes and to increase the effectiveness of high-frequency jet ventilation. Helium has been successful in the treatment of spinal cord decompression sickness seen in divers. Helium-oxygen mixtures are commercially available and may be useful in the emergency department to treat patients with airway obstruction. This article reviews literature concerning the use of helium-oxygen gas mixtures in the emergency department. Additional research conducted in the future may further define the use of this unique gas mixture in the emergency department.

Academic Emergency MedicineVolume 3, Issue 6 p. 634-640 Free Access Clinical Pathological Conference: Pharmacist with Hypotension and Altered Mental Status Tami Van Voorst DO, Tami Van Voorst DO Albert Einstein Medical Center, Philadelphia, PA, Department of Emergency MedicineSearch for more papers by this authorRichard Lanoix MD, Richard Lanoix MD Lincoln Medical and Mental Health Center, New York, NY, Department of Emergency MedicineSearch for more papers by this authorDouglas McGee DO, Corresponding Author Douglas McGee DO Albert Einstein Medical Center, Philadelphia, PA, Department of Emergency Medicine*DO, Department of Emergency Medicine, Albert Einstein Medical Center. 5501 Old York Road, Philadelphia, PA 19141. Fax: 215–456–8502.Search for more papers by this author Tami Van Voorst DO, Tami Van Voorst DO Albert Einstein Medical Center, Philadelphia, PA, Department of Emergency MedicineSearch for more papers by this authorRichard Lanoix MD, Richard Lanoix MD Lincoln Medical and Mental Health Center, New York, NY, Department of Emergency MedicineSearch for more papers by this authorDouglas McGee DO, Corresponding Author Douglas McGee DO Albert Einstein Medical Center, Philadelphia, PA, Department of Emergency Medicine*DO, Department of Emergency Medicine, Albert Einstein Medical Center. 5501 Old York Road, Philadelphia, PA 19141. Fax: 215–456–8502.Search for more papers by this author First published: June 1996 https://doi.org/10.1111/j.1553-2712.1996.tb03474.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat REFERENCES 1 Callaham M, Kassel D. Epidemiology of tricyclic antidepressant ingestion: implications for treatment. Ann Emerg Med. 1985; 14: 1– 9. 2 Litovitz TL, Holm KC, Bailey KM, Schmitz BF., 1991 annual report of the American Association of Poison Control Centers national data collection system Am J Emerg Med. 1992; 10: 452– 505. 3 Marshall JB, Forker AD. Cardiovascular effects of tricyclic antidepressant drugs: therapeutic usage, overdose, and management of complications. Am Heart J. 1982; 103: 401– 14. 4 Callaham M. Tricyclic antidepressant overdose, J Am Coll Emerg Physicians. 1979; 8: 413– 25. 5 Braden NJ, Jackson JE, Walson PD. Tricyclic antidepressant overdose. Pediatr Clin North Am. 1986; 33: 287– 97. 6 Walsh DM. Cyclic antidepressant overdose in children: a proposed treatment protocol. Pediatr Emerg Care. 1986; 2: 28– 35. 7 Teba L, Schiebel F. Dedhia HV, Lazzell VA. Beneficial effect of norepinephrine for treatment of hemodynamic compromise in amitriptyline intoxication. Am J Emerg Med. 1988; 6: 566– 8. 8 Kulig K. Management of poisoning associated with “newer” antidepressant agents. Ann Emerg Med. 1986; 9: 1039– 45. 9 Preskorn SH, Irwin HA. Toxicity of tricyclic antidepressants: kinetics, mechanism, intervention: a review. J Clin Psychiatry. 1982; 43: 151– 6. 10 Swartz CM, Sherman A. The treatment of tricyclic antidepressant overdose with repeated charcoal. J Clin Psychophar-macol. 1984; 4: 336– 40. 11 Emerman CL, Conners AF, Burma GM. Level of consciousness as a predictor of complications following tricyclic overdose. Ann Emerg Med. 1987; 16: 326– 30. 12 Weinstein RS. Recognition and management of poisoning with B-adrenergic blocking agents. Ann Emerg Med. 1984; 13: 1123– 31. 13 Shand DG. Propanolol. N Engl J Med. 1975; 293: 280– 4. 14 Taboutet P, Cariou A, Berdeaux A, Bismuth C. Pathophysiology and management of self-poisoning with B-blockers. Clin Toxicol. 1993; 31: 531– 51. 15 Pearigen PD, Benowitz ML. Poisoning due to calcium antagonist. Experience with verapamil, diltiazem and nifedipine. Drug Safety. 1991; 6: 408– 30. 16 Pentel PR, Salemo DM. Cardiac drug toxicity: digitalis glycosides and calcium-channel and B-blocking agents. Med J Aust. 1990; 152: 88– 94. 17 Frishman W, Jacob H, Eisenberg E, Ribner H. Clinical pharmacology of the new B-adrenergic blocking agents. Part 8. Self-poisoning with B-adrenoceptor blocking agents. Recognition and management. Am Heart J. 1979; 98: 798– 811. 18 Langemeijer JJ, de Wildt DJ, de Groot G, Sangster B. Centrally induced respiratory arrest: a main cause of death in beta-adrenoceptor antagonist intoxication. Hum Toxicol. 1986; 5: 65– 9. 19 Neuvonen PJ, Elonen E, Vuorenmaa T, Laakso M. Prolonged QT interval and severe tachyarrhythmias, common feature of sotalol intoxication. Eur J Clin Pharmacol. 1981; 20: 85– 9. 20 Ramoska EA, Spiller HA, Winter M, Borys D. A one-year evaluation of calcium channel blocker overdoses: toxicity and treatment. Ann Emerg Med. 1993; 22: 196– 200. 21 Bower JO, Mengle HAK. The additive effects of calcium and digitalis: a warning with a report of two deaths. JAMA. 1936; 106: 1151– 3. 22 Braunwald E, Sonnenblick EH, Ross J. Mechanisms of cardiac contraction and relaxation. In: E Braunwald (ed). Cardiovascular Medicine. Philadelphia: W. B. Saunders, 1992, pp 351– 92. 23 Doyon S, Roberts J. The use of glucagon in a case of calcium channel blocker overdose [abstract]. Vet Hum Toxicol. 1992; 34: 328. 24 Zaretsky AL, Horowitz M, Cernou B. Glucagon antagonism of calcium channel blocker-induced myocardial dysfunction. Crit Care Med. 1988; 16: 246– 51. 25 Ellenhom MJ, Barceloux DG. Metals and related compounds: lithium. In: Medical Toxicology: Diagnosis and Treatment in Human Poisoning. New York: Elsevier Science, 1988, pp 1042– 6. 26 Krakower JM. Transient aphasia with lithium toxicity. Psychosomatics. 1978; 19: 25– 6. 27 Zerbi F. EEG changes during lithium treatment. In: FN Johnson, S Hohnson (eds). Lithium in Medical Practice. Lancaster, England: MTP Press, 1978. 28 Simard M, Gumbiner B, Lee A, Lewis H, Norman D. Lithium carbonate intoxication: a case report and review of the literature. Arch Intern Med. 1989; 149: 36– 46. 29 Mateer JR, Clark MR. Lithium toxicity with rarely reported ECG manifestations. Ann Emerg Med. 1982; 11: 208– 11. 30 Janssen PA, van Bever WF. Preclinical psychopharmacology of neuroleptics. In: WG Clark, J Guidice (eds). Principles of Psychopharmacology. Ed 2. Orlando, FL: Academic Press, 1978. 31 Goldfrank L, Flomenbaum N, Weisman R. Management of overdose with psychoactive medications. Emerg Clin North Am. 1984; 2: 63– 76. 32 Greenblatt DJ, Allen MD, Koch-Weser J, Shader RI. Accidental poisoning with psychotropic drugs in children. Am J Dis Child. 1976; 130: 507– 11. 33 Goldberg N, Krasnow N. Sinus of Valsalva aneurysms. Clin Cardiol. 1990; 13: 831– 6. 1 Blaker AM, de Marchena E, Hansen P. Iatrogenic aorto-sinus of Valsalva fistula: angiographic and cine computerized tomography delineation. Cathet Cardiovasc Diagn. 1990; 19: 186– 9. 2 Dev V, Shrivastava S. Echocardiographic diagnosis of unruptured aneurysm of the sinus of Valsalva dissecting into the ventricular septum. Am J Cardiol. 1990; 66: 502– 3. 3 Haraphongse M, Na Ayudhya RK, Jugdutt B, Rossall RE. Isolated unruptured sinus of Valsalva aneurysm producing right ventricular outflow obstruction. Cathet Cardiovasc Diagn. 1990; 19: 98– 102. Volume3, Issue6June 1996Pages 634-640 ReferencesRelatedInformation

A 22-year-old female presented to the Emergency Department after the acute onset of left hemiparesis. Marked prolongation of the partial thromboplastin time, mild thrombocytopenia, a history of syphilis, and recent spontaneous abortion suggested the diagnosis of antiphospholipid antibody syndrome, an unusual cause of ischemic stroke. This case illustrates the clinical and laboratory features of this uncommon disorder.

The objective of our study was to assess the demographics, incidence, types of symptoms, and outcomes of cigarette product ingestions in children. The study was a retrospective database review. Seven hundred children under six years of age ingesting cigarettes or cigarette butts reported to a Poison Control Center between 1988 and 1991. Among 143 patients (20.4%) with symptoms, vomiting was the only symptom in 138 (98.6%) and occurred in less than 20 minutes in 104 (74.3%). The five remaining patients (two with vomiting, three without) developed transient lethargy or irritability that completely resolved. Forty-four of 700 patients ingested potentially toxic amounts and were referred to the emergency department; three were lost to follow-up. Initially asymptomatic patients never developed symptoms. Symptomatic patients improved without sequelae. No patient developed seizures. We concluded that significant toxicity from the ingestion of cigarette products in children is rare. Vomiting within 20 minutes is the most common symptom. Its absence predicts a favorable outcome, even when large amounts are suspected to have been ingested.

Injuries that amputate, crush, or otherwise mangle an extremity are devastating. The possibilities of medical and psychologic disability, multiple operations, and protracted rehabilitation loom before these patients. Fortunately, expert care given by the emergency department physician maximizes the opportunity for success should the limb be replanted or revascularized. The first priority for the emergency department staff is the efficient and aggressive resuscitation of the patient. Only after this has been carried out and other life-threatening injuries addressed can attention be directed toward the injured limb. It is in the patient's best interest if the emergency department staff assumes that a mangled extremity will be replanted or revascularized. Advances in microsurgical technique and equipment have enabled surgeons to achieve salvage rates greater than 90%. Continued improvements in technique, equipment, rehabilitation, and patient selection will enable more patients to benefit from limb salvage procedures.

The role of echocardiography in adult patients with community-acquired pneumonia (CAP) has not been tested in a clinical trial. The aim of the study was to assess the cardiac changes secondary to CAP by echocardiography and to find out the correlation between echocardiographic findings and the severity of CAP.A total of 111 unselected consecutive adult patients hospitalized with CAP were enrolled. The control group consisted of 100 consecutive sex- and age-matched patients. The severity of CAP was evaluated with the pneumonia severity index and the CURB-65 (confusion, urea, respiratory rate, arterial blood pressure and age) score. Blood samples were taken and echocardiography was performed within the first 48 hours.White blood count, N-terminal pro–brain natriuretic peptide, and red blood cell distribution width were significantly higher in the CAP group compared with the control group. The 2 groups did not differ in terms of left and right ventricle ejection fraction, left atrial diameter, pulmonary artery systolic pressure, and left ventricular end-diastolic and end-systolic diameter. However, tricuspid annular plane systolic excursion (21.1 ± 4.3 vs 22.3 ± 4.1 mm; P = .04), aortic distensibility (2.5 ± 0.9 vs 3.5 ± 0.9 cm2:dyne:10, P < .001), and aortic strain (5.8% ± 2% vs 6.5% ± 1.9%, P = .009) were significantly reduced in CAP group than in controls. The plasma concentration of N-terminal pro–brain natriuretic peptide correlated with aortic strain, aortic distensibility, tricuspid annular plane systolic excursion, pneumonia severity index score, and CURB-65 score.Tricuspid annular plane systolic excursion and elastic properties of aorta may play a role in the diagnosis and clinical assessment of CAP severity, which could potentially guide the development of new prognostic models.