1. OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Emergency
Medicine
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. 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. 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. Dedicated to Dr Robin Mitchell (19642010) Emergency
Physician in Christchurch, Edinburgh and Auckland. Outstanding
clinician and teacher, tremendous colleague and friend.
6. This page intentionally left blank
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
8. This page intentionally left blank
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. 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. 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. 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. 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. 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. 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)
16. This page intentionally left blank
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)