There are two categories of pulmonary edema: edema caused by increased capillary pressure (hydrostatic or cardiogenic edema) and edema caused by increased capillary permeability (noncardiogenic pulmonary edema, or acute respiratory distress syndrome). This review focuses on cardiogenic pulmonary edema and describes the general approach to patients with suspected cardiogenic pulmonary edema. The pathogenesis, diagnosis, treatment, and outcome of cardiogenic pulmonary edema are reviewed. Figures include chest scans showing pulmonary edema and noncardiogenic pulmonary edema, an illustration of the differences between cardiogenic and noncardiogenic edema, and a chart comparing lung mechanics and other variables in experimental models of cardiogenic pulmonary edema and noncardiogenic edema. Tables show clinical characteristics of patients with cardiogenic pulmonary edema and treatment options.

This review contains 3 figures, 4 tables, and 29 references

Keywords: cardiogenic pulmonary edema, congestive heart failure, pulmonary edema, Starling’s law

There are two categories of pulmonary edema: edema caused by increased capillary pressure (hydrostatic or cardiogenic edema) and edema caused by increased capillary permeability (noncardiogenic pulmonary edema, or acute respiratory distress syndrome [ARDS]). This review focuses on noncardiogenic pulmonary edema and describes the general approach to patients with suspected pulmonary edema. The pathogenesis, diagnosis, treatment, and outcome of noncardiogenic pulmonary edema are reviewed. Miscellaneous causes of pulmonary edema are discussed, including neurologic insults, exposure to high altitude, reexpansion of a collapsed lung, lung transplantation, upper airway obstruction, drugs, and lung resection. Figures include chest scans showing pulmonary edema and noncardiogenic pulmonary edema, an illustration of the differences between cardiogenic and noncardiogenic edema, and a chart comparing lung mechanics and other variables in experimental models of cardiogenic pulmonary edema and noncardiogenic edema. Tables show clinical characteristics of patients with noncardiogenic pulmonary edema, the definition of ARDS, causes of ARDS, and treatments for ARDS that do not involve ventilation.

This review contains 3 figures, 9 tables, and 64 references

Keywords: acute respiratory distress syndrome, diffuse alveolar damage, noncardiogenic pulmonary edema, pulmonary edema

Attention to the quality of care within the United States health care system has grown tremendously over the past decade. We have witnessed a significant change in how quality improvement and clinical performance measurement are approached. The current focus on quality and safety stems in part from the increasingly clear realization that more services and technological advancement are not automatically equivalent to high-quality care. Much of the discussion about cost and quality in health care is shifting towards the concept of value. Value is defined as health outcomes achieved per dollar spent (in other words, an assessment of the quality of care per cost). This chapter reviews the current state of quality improvement in health care and, because improvement cannot be determined without measurement, reviews several aspects of effective clinical performance measurement. Since many measures are already in place, the chapter describes some of the organizations involved in quality measurement and improvement, as well the approaches they utilize. It looks at the multiple strategies in place to improve quality, from process management to collaboration, from financial incentives to transparency, and reviews newer models of care delivery that may materialize in the near future. Tables list types of quality measures, characteristics to consider when developing a quality measure, and organizations involved in quality improvement and performance measurement. A figure shows strategies used by the federal government to spur performance measurement and quality improvement.

This review contains 1 figure, 3 tables, and 56 references

Keywords: Quality of care, performance measure, quality improvement, clinical practice, sigma six, transparency

Prostate cancer is the most commonly diagnosed noncutaneous malignancy in men in the United States. This chapter discusses the epidemiology, pathogenesis, and diagnosis of prostate cancer, as well as risk factors, the use of digital rectal examination and prostate-specific antigen measurement for screening, and staging for the disease. Also reviewed are the natural history of untreated prostate cancer; the treatment of localized and advanced prostate cancer, including prostatectomy, radiation therapy, and androgen deprivation therapy; and the prevention of prostate cancer. Figures illustrate the incidence rates of prostate cancer by race, age-adjusted and/or age-specific cancer of the prostate, the risk of a diagnosis in 20 years (based on being cancer free at certain ages), the 5-year survival rate, and the overall survival in patients with early prostate cancer treated with observation or radical prostatectomy. Tables in this chapter review the clinical staging definitions and the combined-modality staging approach to prostate cancer.

This chapter contains 6 figures, 8 tables and 104 references

Keywords: Prostate cancer, digital rectal exam, PSA, prostatectomy, men's health, prostate cancer screening

The three main elements in the pathophysiology of thrombosis are endothelial injury, a decrease in blood flow, and an imbalance between procoagulant and anticoagulant factors. The latter element can be either hereditary (e.g., antithrombin deficiency) or acquired (e.g., antiphospholipid syndrome). This review details the assessment of patients with thrombotic disorders, hereditary and acquired hypercoagulable states, and the management of venous thromboembolism. Figures show how the degradation of thrombin-activated factor V Leiden by activated protein C (APC) is significantly slower than that of normal activated factor V (factor Va), leading to enhanced thrombin generation; how normal factor V serves as a cofactor of APC in the inhibition of factor VIIIa, whereas factor V Leiden has a poor cofactor function; and how IgG antibodies recognize platelet factor 4–heparin complexes in heparin-induced thrombocytopenia. Tables list inherited and acquired hypercoagulable states, questions for assessing thrombosis, screening tests for patients with suspected hypercoagulable states, clinical features that suggest thrombophilia, frequency and relative risk of venous thrombosis in selected hypercoagulable states, proposed clinical and laboratory criteria for antiphospholipid syndrome, the classification of antiphospholipid antibodies, the 4Ts scoring system for heparin-induced thrombocytopenia, and general guidelines for the management of patients with venous thromboembolism.

This review contains 2 figures, 27 tables, and 174 references

Keywords: Venous thromboembolism, deep vein thrombosis, pulmonary embolism, protein S, protein C, factor V Leiden, heparin-induced thrombosis, antiphospholipid syndrome

With the advent of HPV DNA testing and the availability of HPV vaccinations, the recommendations and rationale for screening and prevention of cervical cancer and its precursors have undergone revision, reflecting this new knowledge and understanding of cervical intra-epithelial neoplasia and the role of HPV. This review incorporates the new guidelines and rationale for current screening guidelines for cervical cancer and in the management of patients with atypical or unsatisfactory cervical cytology.

This review contains 4 figures, 4 tables, and 71 references

Keywords: Cervical cancer, Gynecological cancer, HPV, HPV testing, HPV vaccine, Pap smear, HPV DNA, Human papillomavirus

The medical management of pulmonary arterial hypertension (PAH) has advanced considerably over the years. Once the diagnosis of PAH is made, the medical management includes both conventional and PAH-pathway specific therapies. Five different classes of drugs are now available targeting the endothelin, prostacyclin, and nitric oxide pathways (i.e. endothelin receptor antagonists, phosphodiesterase-5 inhibitors, soluble guanylate cyclase stimulators, prostacyclin analogues, and prostacyclin receptor agonists). These targeted therapies are approved for treatment of patients with PAH and chronic thromboembolic pulmonary hypertension (CTEPH) only. Long-term and event-driven studies of novel drugs have led to further improvement in the medical management of PAH and CTEPH. In this review, we will focus on the medical management of patients with PAH and CTEPH.

This review contains 4 figures, 7 Tables and 50 references

Keywords: Pulmonary arterial hypertension, Chronic thromboembolic pulmonary hypertension, Medical management, Pulmonary vasodilators, Phosphodiesterase inhibitor, Soluble guanylate cyclase stimulator, Endothelin receptor antagonist, Prostacyclin receptor agonist

Hemostasis, the process of blood clot formation, is a coordinated series of responses to vessel injury. It requires complex interactions between platelets, the clotting cascade, blood flow and shear, endothelial cells, and fibrinolysis. This review covers platelet plug formation, clotting cascade, initiation and propagation of blood clot formation, control mechanisms, overview of blood coagulation, blood coagulation as part of the host defense system, heterogeneity of endothelial cells and vascular bed–specific hemostasis, platelet production and thrombopoietin, and coagulation tests and their use. Figures show activated platelets, platelet aggregation, the classic and revised view of the clotting cascade, the inhibition of thrombin by antithrombin, the protein C/protein S pathway, the synergism between nitric oxide (NO) and prostacyclin (PGI₂), tissue-type plasminogen activator, the transformation of fibrinogen to fibrin, activated protein C (APC) and carboxypeptidase B-2 (CPB-2) at the site of vascular injury, and an algorithm detailing the exposure of tissue factor at a vascular wound that initiates the clotting cascade. The table lists natural antithrombotic mechanisms of endothelial cells.

This review contains 10 figures, 4 tables, and 45 references

Keywords: hemostasis, coagulation, fibrinolysis, bleeding disorder, platelets

Nonalcoholic fatty liver disease (NAFLD) is defined by the pathologic accumulation of fat in more than 5% of hepatocytes in the absence of significant alcohol consumption (daily intake < 20 g in women and < 30 g in men) and by excluding secondary causes of hepatic steatosis. NAFLD can be categorized into two principal phenotypes: nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). NAFL is defined by the presence of macrovesicular steatosis without inflammation, whereas NASH sees inflammation and hepatocyte ballooning injury, is associated with varying degrees of fibrosis, and can progress to cirrhosis and end-stage liver disease. This review addresses the epidemiology, etiology, pathophysiology, diagnosis, treatment, and prognosis of NAFLD. Figures show the spectrum of fatty liver disease, hepatic consequences of insulin resistance, role of liver biopsy in evaluation of NAFLD, histologic features of NASH, and principles of NAFLD. Tables list risk factors and clinical manifestations for NAFLD, physical examination findings in NAFLD, comparison of imaging modalities, and noninvasive fibrosis markers.

This review contains 6 figures, 9 tables and 167 references

Keywords: Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, non-invasive assessment, vibration controlled transient elastography, magnetic resonance elastography, diet and lifestyle treatment

Acute abdominal pain and abdominal mass are intimately connected; therefore, the diagnostic process for evaluating abdominal pain and abdominal masses is largely the same and has been preserved since ancient times. The primary goals in the management of patients with abdominal pain and/or abdominal mass are to establish a differential diagnosis by obtaining a clinical history, to refine the differential diagnosis with a physical examination and appropriate studies, and to determine the role of operative intervention in the treatment or refinement of the working diagnosis. This review describes the process of diagnosing abdominal pain, including taking a clinical history and performing a physical examination. Investigative studies, including laboratory tests, imaging, and pathology are reviewed. Management, including surgical treatment, is discussed. Tables describe intraperitoneal and extraperitoneal causes of acute abdominal pain, frequency of specific diagnoses in patients with acute abdominal pain, and common abdominal signs and findings noted on physical examination. Figures show abdominal pain in specific locations, a data sheet, the differential diagnosis of an abdominal mass by quadrant or region, characteristic patterns of abdominal pain, acute appendicitis with associated appendicolith, bilateral adrenal masses, adrenocortical carcinoma, retroperitoneal leiomyosarcoma, pancreatic mass, a sagittal ultrasonogram of the pancreas, ultrasonograms of the liver, a dark and well circumscribed abdominal mass, gastroesophageal junction adenocarcinoma, and percutaneous biopsy of a large abdominal mass. An algorithm outlines the assessment of acute abdominal pain and abdominal mass.

This review contains 16 figures, 22 tables, and 171 references

Keywords:  anatomy, swellings, inflammatory, opioid, palpatation, PET, COVID 19

Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care.

This review contains 12 figures, 8 tables and 63 references

Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey

The technology and innovations in endovascular surgery are advancing at a dramatically rapid pace. In this review, the fundamentals of endovascular procedures that are necessary to take advantage of this advancing technology are outlined and explained. Preoperative patient assessment, appropriate access site selection, and vascular access technique are explained. The selection and use of appropriate guide wires, catheters, and sheaths are also reviewed and outlined. The basic techniques for angioplasty and stenting are described as well. Finally, appropriate closure techniques and postprocedure care are described. As with any operation or procedure, mastering the fundamentals is necessary to proceed to advanced intervention.

This review contains 10 figures, 1 table, 1 video, and 13 references

Key words: access troubleshooting, arterial access, endovascular instruments, endovascular preparation, endovascular techniques

Almost as critical as an operation itself is the preparation of the patient. Although this often includes psychosocial concerns such as expectations of recovery, inpatient stay, and other patient-centered issues, the discussion prior to surgery should not be limited to these factors. A medical assessment of the patient’s fitness and physiologic preparedness for the planned procedure must be performed by the surgeon and the resultant findings and plan reviewed with the patient. Although vascular disease affects multiple organ systems requiring a thorough general preoperative patient assessment, the focus of preoperative risk reduction strategies center on cardiac outcomes. Therefore, this review focuses on cardiac-related interventions with added coverage of preoperative strategies regarding diabetes, pulmonary and renal risk assessment, and infection reduction. Lastly, the perioperative management of anticoagulation/antiplatelet medications and cerebrovascular disease are discussed Techniques and treatments to optimize patients for surgery are integrated into the respective sections, allowing for a primer to guide this critical phase in a patient’s journey through surgery. Tables outline the Revised Cardiac Risk Index, assessment of functional capacity from patient self-reported activities, optimal delay in elective surgery after percutaneous coronary revascularization according to the 2014 American College of Cardiology/American Heart Association clinical practice guidelines, Respiratory Failure Risk Index, Szilagyi classification of vascular surgical site infection, and recommendations regarding perioperative management of anticoagulants and antiplatelet agents. A suggested algorithm for preoperative cardiac workup and the Cockcroff-Gault equation are provided.

This review contains 2 figures, 10 tables, and 117 references

Keywords: Preoperative period, risk factors, heart disease, diabetes mellitus, hyperkalemia, coagulopathy, thrombosis

Obesity and obesity-related comorbid conditions have been steadily increasing in the United States over the past few decades. Despite the availability of several anti-obesity measures such as diet, exercise, pharmacotherapy and behavioral modifications, bariatric surgery is the only effective modality that can provide a sustainable long-term weight loss and improve obesity-associated comorbidities. In this chapter, we discuss perioperative assessment and work-up of morbidly obese patients, minimally invasive approaches to various bariatric surgery procedures including laparoscopic adjustable gastric band, sleeve gastrectomy, gastric bypass and biliopancreatic diversion with duodenal switch, and their short and long term outcomes. We also address revisional bariatric surgery and use of robotic platform and other new procedures and their role in metabolic and bariatric surgery.

This review contains 7 figures, 2 videos, 2 tables, and 110 references.

Keywords: Obesity, comorbidities, metabolic surgery, bariatric surgery, gastric bypass, adjustable gastric band, sleeve gastrectomy, Biliopancreatic Diversion with Duodenal Switch, revisional surgery

Breast cancer is the most common malignancy in women in the Western world. Its prevalence and public health impact are increasing in developing countries, and breast cancer leads to the death of hundreds of thousands of women worldwide annually. In the United States, surgeons are involved in the treatment of most women with breast cancer and surgical care must be coordinated with other components of comprehensive breast cancer treatment. This review covers breast evaluation and management of findings suspicious for cancer, management of clinical or screening-detected findings, management of breast cancer, noninvasive cancer (carcinoma in situ), invasive breast cancer, special circumstances, and follow-up after breast cancer treatment. 

This review contains 9 figures, 41 tables, and 106 references.

Key words: Breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, chemotherapy, hormone receptor-positive, HER2/neu, breast-conserving therapy, reconstruction, mastectomy, adjuvant therapy, radiation therapy

With an estimated 232,670 new cases in the United States in 2014, breast cancer is among the most common malignancies treated by US surgeons. Meanwhile, the incidence of melanoma is rising faster than for all other solid malignancies, with an estimated 76,100 new cases of invasive melanoma in the United States in 2014. Over the past 20 years, significant strides have been made in the management of these two diseases from the standpoint of both surgical and adjuvant therapy. For both diseases, the presence or absence of lymph node metastases is highly predictive of patient outcome and is the most important prognostic factor for disease recurrence and cancer-related mortality. This review covers lymphatic mapping and sentinel node biopsy for melanoma, special circumstances associated with sentinel node biopsy in melanoma, lymphatic mapping and sentinel node biopsy in breast cancer, and radiation exposure guidelines and policies. The figures show lymphatic mapping and sentinel lymph node biopsy for melanoma, lymphatic mapping and sentinel node biopsy for breast cancer, and touch-imprint cytology from lymphatic mapping and sentinel node biopsy for breast cancer.

This review contains 3 figures, 4 tables and 91 references

Keywords: sentinel node, dissection, biopsy, breast cancer, melanoma, cancer, lymphatic mapping

Effective surgical treatments are available for a wide variety of diseases in the modern era; at the same time, surgical interventions have become increasingly complex and specialized. The contemporary surgeon must coordinate evaluation and management of patients with multiple medical diagnoses and shepherd these patients through an increasingly elaborate process of medical and surgical care. To provide effective care, the organ systems–oriented approach is key. This approach, demonstrated in the following review, guides the practitioner through each organ system in order and can be used to generate a differential diagnosis for each system and a comprehensive problem list for each patient. 

This review contains 20 tables, and 59 references.

Keywords: Postoperative period, perioperative period, cardiac complications, surgical site infection, incentive spirometry, postoperative delirium, postoperative renal failure

The aim of this review is to provide practical clinical information on modern pain management options to guide the clinician on evidence-based practices, optimizing the treatment of pain and avoiding practices that may lead to potential abuse. Postoperative pain management is an essential component of any surgeon’s practice and has clear implications for surgical outcomes, patient satisfaction, and population health. Understanding options within a multimodal approach to pain management in the acute setting is a key determinant to improving outcomes for our patients. This review discusses multimodal analgesic options, including a variety of pain medications (opiates, antiinflammatory medications, and patient-controlled analgesia) and techniques (epidural catheter placement, regional nerve blocks) to be used in tandem. Lastly, best possible practices to avoid opiate abuse are discussed.

This review contains 4 figures, 5 tables, 1 video and 96 references.

Key words: antiinflammatories, epidural, narcotics, patient-controlled analgesia, postoperative pain, regional nerve block

Gastroesophageal reflux disease (GERD) is common, affecting approximately 18 to 27% of adult Americans, and can have a considerable impact on quality of life. Hiatal hernias are present in 80% of patients with symptomatic GERD. This review covers the basic pathophysiology, evaluation, and treatment algorithms for patients with GERD and hiatal hernia. Figures show normal gastroesophageal junction anatomy, treatment algorithm for patients with symptomatic GERD, schematic and endoscopic images of long segment Barrett's esophagus, a normal barium esophagogram, esophageal intraluminal pressures assessed by esophageal manometry, test results from a 48-hour wireless pH study, laparoscopic Nissen fundoplication, laparoscopic gastroesophageal junction reinforcement, classification of paraesophageal hernia, and endoscopic view of Cameron ulcers at the level of the diaphragm in the setting of a type III paraesophageal hernia. Tables list risk factors for GERD and a standardized approach to Nissen fundoplication.

This review contains 10 figures, 3 tables, and 68 references.

Keywords: Gastroesophageal reflux disease, GERD, hiatal hernia, paraesophageal hernia, anti-reflux surgery, Nissen fundoplication, Barrett's esophagus, manometry, pH study

Gallbladder disease is one of the most common problems that the general surgeon will encounter. This comprehensive review discusses the management of uncomplicated gallstone disease, functional gallbladder disease, and gallbladder polyps. It provides indications for cholecystectomy in the asymptomatic patient. There is a thorough review of the diagnosis and management of symptomatic cholelithiasis, including special situations such as pregnancy and cirrhosis, and the latest evidence regarding routine versus selective cholangiography during cholecystectomy. This review also discusses the latest updates to the criteria for diagnosing functional gallbladder disease and sphincter of Oddi dysfunction. 

This review contains 6 figures, 6 tables, and 99 references.

Key words: asymptomatic gallstones, biliary dyskinesia, cholangiography, gallbladder polyps, laparoscopic cholecystectomy, sphincter of Oddi dysfunction, symptomatic cholelithiasis

Acute wounds are the result of local trauma and may be associated with severe life-threatening injuries. All patients with acute wounds should be assessed for comorbidities such as malnutrition, diabetes, peripheral vascular disease, neuropathy, obesity, immune deficiency, autoimmune disorders, connective tissue diseases, coagulopathy, hepatic dysfunction, malignancy, smoking practices, medication use that could interfere with healing, and allergies. The authors address the key considerations in management of the acute wound, including anesthesia, location of wound repair (e.g., operating room or emergency department), hemostasis, irrigation, débridement, closure materials, timing and methods of closure, adjunctive treatment (e.g., tetanus and rabies prophylaxis, antibiotics, and nutritional supplementation), appropriate closure methods for specific wound types, dressings, postoperative wound care, and potential disturbances of wound healing. 

This review contains 11 figures, 31 tables, and 92 references.

Keywords: Wound, wound infection, burns, suture, staple, wound closure, wound healing, dehiscence, skin grafting

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients.

This review contains 5 figures, 9 tables, and 58 references

Keywords: Advance directives, power of attorney in health care, do not resuscitate order, decision-making, end-of-life, critical care

Diabetes mellitus is the seventh leading cause of death in the United States; diabetic patients have a 50% chance of undergoing a surgical procedure during their lifetime, and operations in this patient population have been associated with a reported mortality of 4% to 13%. Careful planning of operative management and perioperative care must be taken into account when scheduling surgery for diabetic patients, especially patients taking insulin or oral hypoglycemic agents. Debate continues and inconsistencies remain regarding the management of both diabetes and hyperglycemia in the surgical setting. The review covers the evaluation of the diabetic patient, preoperative management, intraoperative management, postoperative management, total parenteral nutrition and blood glucose, cardiovascular and renal assessment, infection, and special populations. 

This review contains 2 figures, 5 tables, and 21 references

Keywords: Glucose, Hyperglycemia, perioperative period, surgery, diabetes mellitus, surgical site infection, preoperative management, postoperative management, wound healing

In most instances, laparoscopy has replaced open procedures as the standard of care. Nevertheless, equipoise remains in the literature regarding the benefits of surgery compared with alternative treatment strategies such as medications in the case of gastroesophageal reflux disease (GERD) or endoscopic procedures in the case of achalasia. According to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines published in 2010, indications for surgery include (1) failure of medical management, (2) patient preference, (3) complications of GERD (Barrett esophagus, peptic stricture), and (4) extraesophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration). This chapter is organized by surgical procedure, all of which are derivatives of the laparoscopic Nissen fundoplication. In this chapter, the authors focus on minimally invasive surgical approaches to the treatment of the following benign esophageal disorders: GERD, achalasia, and paraesophageal hernias. New in this chapter is the in-depth coverage of laparoscopic paraesophageal hernia repair. The majority of patients with paraesophageal hernias are asymptomatic, and their hernias are found incidentally with a retrocardiac gastric bubble on an upright chest x-ray or herniated gastroesophageal junction seen on a chest or abdominal computed tomographic scan. For patients who are symptomatic, surgical repair is indicated as there is no medical treatment for this mechanical problem. For asymptomatic patients, clinical judgment needs to be used. All surgical procedures are covered by preoperative evaluation, operative planning, and operative technique, with a troubleshooting note for every step. Procedure complications, postoperative care, and outcome evaluation follow each procedure, listing the most current reports and data.

This review contains 10 figures, 9 tables and 49 references

Keywords: Minimally invasive surgery, esophagectomy, myotomy, gastroesophageal reflux disease, Barrett esophagus, Nissen fundoplication, fundoplication, paraesophageal hernia

Acute limb ischemia (ALI) is one of the most challenging conditions in vascular surgery and carries a high risk of amputation and mortality when treatment is delayed. Limb ischemia occurs when there is abrupt interruption of blood supply to an extremity because of either embolic or in situ thrombotic arterial or bypass graft occlusion. The goals of management include limb salvage, minimization of morbidity, and prevention of death. However, given that no objective markers of limb viability are currently available, the initial determination of whether a limb is likely to be viable must be made on clinical grounds. An early clinical evaluation is crucial for the diagnosis and identification of the underlying etiology of the ALI. As ALI is a clinical diagnosis, this review describes all aspects of the clinical evaluation as essential: patient history, staging of limb ischemia, and investigative studies. Atheromatous embolization is also discussed in depth. The characteristic signs of ALI may be summarized as the “six p’s”: pulselessness, pain, pallor, poikilothermia, paresthesia, and paralysis. Pain is the most common symptom in an ischemic limb and progresses along with the ischemia. As ischemia continues to progress, severe pain can be replaced by anesthesia of the limb, which can confound the examiner. Thus, pain should be documented with regard to severity, localization, and progression. ALI therapies covered are heparin therapy, thrombolytic therapy, thrombectomy, and surgical embolectomy and revascularization. The pathophysiology of limb ischemia is related to the progression of tissue infarction and irreversible cell death. Compared with other organs and tissues (e.g., the brain and the heart), the extremities are relatively resistant to ischemia. However, the various tissue types of which an extremity is composed have different metabolic rates.

This review contains 2 figures, 16 tables, and 167 references 

Keywords: Acute limb ischemia, peripheral artery disease, thrombolysis, embolectomy, atheromatous embolization, anticoagulation, revascularization

An understanding of anal anatomy is essential for optimal management. Patients with anal lesions that appear suspicious or fail to respond to conventional therapy within a month should undergo a biopsy. Premalignant perianal lesions are managed with local excision. Epidermoid carcinoma of the anus is usually managed with chemoradiation. Presacral tumors are managed with excision.

This review contains 11 figures, 13 tables, and 57 references.

Keywords: anal cancer, anterior sacral meningocele, basal cell carcinoma, chordoma, epidermoid carcinoma, high-grade squamous intraepithelial lesions, retrorectal tumor 

The most vulnerable time for a fetus is during embryogenesis in the first 8 to 10 weeks of pregnancy, when women may be unaware of their pregnancy. Once pregnancy is established, a standard approach to the pregnant patient is the optimal way to ensure medical and surgical decisions are made within the context of maintaining the safety of both mother and fetus. This review describes the approach to the pregnant patient for surgical conditions within the context of physiologic changes of the patient and fetus at each trimester, anesthesia and critical care in pregnancy, imaging and drugs safe for use in pregnancy, and nongynecologic surgery in the pregnant patient and specific surgical conditions. Tables outline the classification of abortion, the assessment of pregnancy viability, physiologic changes in pregnancy, laboratory changes in pregnancy, imaging modality and radiation dose, and antibiotics and safety in pregnancy. Figures include a diagram of types of hysterectomy, respiratory changes in pregnancy, and enlargement of the uterus. Algorithms outline the approach to abdominal pain in the pregnant patient and diagnosis and management of ectopic pregnancy.

This review contains 5 figures, 21 tables, and 87 references

Keywords: Pregnancy, appendicitis, tocolysis, fetal monitoring, biliary tract disease, nonobstetric surgery in the pregnant patient, ectopic pregnancy

Pancreatic injury continues to present challenges to the trauma surgeon. The relatively rare occurrence of these injuries (0.2–12% of abdominal trauma), the difficulty in making a timely diagnosis, and high morbidity and mortality rates following complications justify the anxiety these unforgiving injuries invoke ^1-3. Mortality rates for pancreatic trauma range from 9 to 34%, with a mean rate of 19%. Complications following pancreatic injuries are alarmingly frequent, occurring in 30 to 60% of patients ⁴. Nonetheless, if recognized early, the treatment of most pancreatic injuries is straightforward, with low morbidity and mortality.

This review contains 10 figures, 5 tables, and 66 references

Keywords : Pancreatic trauma, injury, pediatric trauma, ERCP, MRCP, spleen-preserving pancreatectomy

The majority of cases of inherited colorectal cancer (CRC) are accounted for by two syndromes: Lynch syndrome and familial adenomatous polyposis (FAP). In the management of FAP, the role of prophylactic surgery is clearly defined, although the optimal procedure for an individual patient depends on a number of factors. In the management of Lynch syndrome, the indications for prophylactic procedures are emerging. The authors address the clinical evaluation, investigation findings, medical and surgical therapy, and extracolonic diseases of FAP, attenuated form of FAP (AFAP), MYH-associated polyposis, Lynch syndrome, familial colorectal cancer type X (FCCTX), hyperplastic polyposis syndrome, Peutz-Jeghers syndrome, and juvenile polyposis syndrome. AFAP has been described that is associated with fewer adenomas and later development of CRC compared with classic FAP. The AFAP phenotype occurs in less than 10% of FAP patients. The clinical criteria for AFAP are no family members with more than 100 adenomas before the age of 30 years and (1) at least two patients with 10 to 99 adenomas at age over 30 years or (2) one patient with 10 to 99 adenomas at age over 30 years and a first-degree relative with CRC with few adenomas. Given that polyposis has a later onset and the risk of CRC is less well established in AFAP, some authors question whether prophylactic colectomy is necessary in all AFAP patients.

This review contains 26 tables and 173 references

Keywords: Colorectal cancer, Lynch syndrome, hyperplastic polyp, Peutz-Jeghers syndrome, juvenile polyposis syndrome, familial adenomatous polyposis

Pancreatic neuroendocrine tumors (PNETs) comprise a diverse, heterogeneous group of tumours that range in presentation and biologic behavior, including small, asymptomatic, incidentally discovered, nonfunctional neoplasms, functional tumors (both localizable and unlocalizable) with associated clinical syndromes, and diffuse metastatic disease. Based on its functional status, the malignancy of a PNET can vary, from the benign (insulinoma) to that which is commonly malignant more than 50% of the time (gastrinoma, somatostatinoma). According to a recent study, PNETs appear to be increasing in incidence or at least in clinical detection; currently the disorder accounts for 1 to 2% of pancreatic tumors and with a reported clinical incidence of one to five cases per million persons annually in the United States. Nonfunctional PNETs make up the majority of cases, and comprise 2% of all pancreatic malignancies. Treatment has been primarily done through surgical management, particularly via resection. However, medical management has played a more increased role for patients where the disease is advanced, encompassing biotherapy, chemotherapy, and targeted therapies such as peptide receptor radionuclide therapy (PRRT). For nonfunctional PNETs—insulinomas, gastrinomas, glucagonomas, somatostatinomas, and VIPomas—the epidemiology, biology of disease, clinical presentation and diagnosis, localization of tumor, operative management considerations, surgical management of primary tumor, and prognosis and outcomes of each are discussed.

This review contains 6 figures, 18 tables, and 58 references

Keywords: Pancreas, neuroendocrine tumor, gastrinoma, somatostatinoma, VIPoma, insulinoma, incidentaloma, glucagonoma, enucleation

Clinical evaluation and surgical decision making in patients with acute pancreatitis (AP) and chronic pancreatitis (CP) are two of the most complex conditions that a general surgeon faces. Each entity has unique laboratory and radiographic investigations, operations, and postoperative care. The clinical evaluation, history, and physical examination of AP is described. The clinical features necessary for diagnosis are listed, and contrast-enhanced computed tomography is described as the gold standard for diagnosis. This review uses definitions and terminology developed at the Atlanta symposium in 1992. The severity of an episode of AP is described in terms of established scoring systems (APACHE II [Acute Physiology and Chronic Health Evaluation II], Glasgow Coma Scale score, Ranson criteria). AP can range from mild to severe necrotizing, with each described. The clinical course is described in detail. For CP, the history, physical examination, and diagnosis via investigative and imaging studies are described. The anatomic and morphologic subtypes of chronic pancreatitis are listed and the operations directed at patients with CP are detailed, and can involve drainage or combined resection and drainage. 

This review contains 12 figures, 15 tables, and 55 references

Keywords: Acute pancreatitis, chronic pancreatitis, gallbladder disease, alcoholism, amylase, Whipple procedure

Aneurysms are localized arterial dilations with a propensity toward expansion and rupture. The abdominal aorta is the most common site of aneurysmal disease and shares risk factors with atherosclerosis, including advanced age, male sex, and tobacco use. Rupture is unpredictable, typically unheralded, and most often fatal. The risk of rupture is related to aneurysm size and continued tobacco use. There is no established medical treatment; therefore, prevention of aneurysm-related death relies on aneurysm detection through screening followed by intervention on appropriately selected and prepared individuals. Intervention is typically warranted when the aneurysm has reached a size of 5.5 cm. Treatment is possible through open surgical repair or through endovascular exclusion of the aneurysm. Optimal outcomes rely on careful consideration of the patient’s comorbid disease and life expectancy and the anatomic features of the aneurysm to determine the most appropriate timing and approach to repair. Continued surveillance after intervention is critical to optimizing long-term benefits of repair, especially for those treated through endovascular means.

This review contains 33 figures, 1 table, and 37 references

Key words: abdominal aortic aneurysm, aneurysm, endovascular, endovascular aneurysm repair, repair, rupture, screening

To be a good surgeon, one must be technically good and scientifically sound, but also ethical to the degree that has traditionally been demanded by our profession. In this chapter, the authors discuss what ethical problems in surgery are and how they might be approached. Respect for autonomy, nonmaleficence, beneficence, and justice define Principlism that forms the backbone of most discourse in clinical medical ethics. Consequentialism/utilitarianism, deontology, virtue ethics, “ethics of care”, and casuistry are all covered. The authors then scrutinize several contemporary problems in surgical ethics. Described and discussed in depth are issues associated with the ‘end of life’; surrogate decision making, futility, “do not resuscitate” orders in the operating room, conflicts of interest, industry payments, and surgical innovation, informed consent, and refusal of care. This review is not meant to be an exhaustive treatment of surgical ethics but a survey highlighting the most common ethical problems.

This review contains 2 figures, 11 tables, and 61 references

Keywords: Autonomy, nonmaleficence, beneficence, justice, principlism, medical ethics, surgery, informed consent, do not resuscitate, living will, advanced directives

Contributions from the armed conflicts of the 20th century have defined the standards for vessel ligation or repair of arterial and venous injuries. Since the Vietnam War, there has been considerable modernization in the battlefield medical environment, and forward surgical capability, expeditious evacuation and new and effective resuscitation strategies have provided the foundation for innovation and progress. Lessons learned during current US military operations continue to advance the practice of vascular trauma surgery, and these techniques are directly translated to surgical practices in trauma centers around the world. This review covers mechanisms and sites of extremity vascular injury,  initial assessment,  management, and special considerations. Figures show an avulsion injury, in which an artery is stretched, an algorithm for the workup of a patient with a potential extremity vascular injury, an algorithm for the management of complex extremity trauma, exposure of the axillary artery, exposure of the brachial artery, exposure of the femoral artery, medial exposure of the proximal and distal popliteal arteries, the two-incision technique for lower leg decompression in compartment syndrome, and incisions for forearm decompression in compartment syndrome.

This review contains 11 figures, 6 tables, and 84 references

In patients who have injuries to the great vessels of the abdomen, the findings on physical examination generally depend on whether a contained hematoma or active hemorrhage is present. This review covers resuscitation in profoundly hypotensive patients, damage control resuscitation, injuries in zones 1, 2, and 3, injuries in the porta hepatis or retrohepatic area, damage control laparatomy, endovascular therapies, and complications. Figures show algorithms illustrating management of intra-abdominal hematoma found at operation after penetrating trauma and blunt trauma; left medial visceral rotation performed by sharp and blunt dissection with elevation of the left colon, the left kidney, the spleen, the tail of the pancreas, and the gastric fundus; an autopsy view of the supraceliac aorta and the celiac axis, the proximal superior mesenteric artery, and the medially rotated left renal artery after removal of lymphatic and nerve tissue; injuries to the prepyloric area of the stomach and to the supraceliac abdominal aorta from a gunshot wound; a temporary intraluminal shunt inserted into the proximal superior mesenteric artery in a patient who had an adjacent injury to the neck of the pancreas after sustaining a gunshot wound; polytetrafluoroethylene patch repair of an injury to the infrarenal inferior vena cava; right perirenal hematoma and left external iliac artery and vein injury repaired with segmental resection and insertion of an 8 mm polytetrafluoroethylene graft and segmental resection and an end-to-end anastomosis, respectively. Tables list American Association for the Surgery of Trauma abdominal vascular organ injury scale, and survival rates after injuries to arteries and veins in the abdomen.

This review contains 9 figures, 7 tables, and 90 references

Keywords: Hemorrhage, great vessel injury, aorta, laparotomy, porta hepatis, endovascular techniques, hematoma, inferior vena cava

Arterial thoracic outlet syndrome (TOS) is the least common form of TOS in adults. It is an entity that is associated with bony anomalies resulting in chronic subclavian artery compression. Most patients with arterial TOS are young adults presenting either with limb-threatening upper extremity ischemia or chronic symptoms suggestive of arterial insufficiency involving the extremity. Initial diagnostic evaluation involves chest radiography, which may reveal cervical or anomalous first rib. Catheter-based arteriography has a diagnostic as well as therapeutic role. Magnetic resonance angiography and computed tomographic angiography, which are readily available, can be used in surgical planning. Treatment involves revascularization of the extremity, subsequent first rib resection, and possible reconstruction of the subclavian artery.

This review contains 4 figures, 1 table and 45 references

Keywords: arterial complication, brachial thromboembolectomy, cervical rib, costoclavicular space, first rib resection, pectoralis minor space, scalene triangle, subclavian artery stenosis, thoracic outlet syndrome

Stroke used to be the third leading cause of death in the United States, behind coronary artery disease and cancer. However, a 2011 report states that stroke has now dropped to the fourth leading cause of death. Nearly 80% of strokes are ischemic, but only 15% of stroke patients have warning transient ischemic attacks. The management of patients with asymptomatic carotid stenosis is controversial; in this review, a stepwise approach to the management of asymptomatic carotid bruit/extracranial carotid artery stenosis is provided. Specifically, this review covers clinical evaluation, carotid bruits, vascular risk evaluation, imaging modalities, natural history of asymptomatic carotid artery disease, carotid plaque progression, natural history of asymptomatic carotid stenosis with evidence of clinically silent cerebral emboli, recommendations for carotid intervention/medical therapy, level 1 evidence supporting carotid endarterectomy in asymptomatic patients, and decision making for medical therapy alone versus intervention. Figures show color Doppler image with Doppler sampling from the right common carotid artery (CCA) and internal carotid artery (ICA), color duplex image with Doppler sampling of the distal left CCA and proximal ICA, color duplex ultrasound image of a plaque at the carotid bifurcation, magnetic resonance angiography showing severe stenosis of the right ICA and occluded left ICA, computed tomographic angiography showing severe stenosis of the left ICA with calcification, diagram for management of patients with both carotid stenosis and coronary artery disease, and protocol of management of asymptomatic bruit/carotid artery stenosis. Tables list the annual risk of stroke, prevalence of carotid stenosis in patients with bruits and in healthy volunteers, duplex velocity criteria for carotid stenosis, consensus criteria, validation of consensus criteria: duplex ultrasonography versus angiographic stenosis, risk factors for stroke, ranking of modifiable stroke risk factors, asymptomatic randomized trials comparing medical with medical and surgical treatment (stenosis > 60%), and a summary of specialty/societal guidelines.

This review contains 7 figures, 13 tables, and 92 references

Keywords: Carotid bruit, carotid artery stenosis, duplex ultrasonography, atherosclerosis, stroke, transient ischemic attack

The thyroid plays a key role in normal metabolic and homeostatic processes, including thermomodulation, protein synthesis, carbohydrate and lipid metabolism, and modulation of adrenergic regulation. Surgical consultations are most often requested for control of hyperthyroidism or for treatment of euthyroid nodular disease. This review describes the approach to the patient with hyperthyroidism and with euthyroid nodular disease, including papillary, follicular, anaplastic, medullary, and primary thyroid cancer, and oncocytic (Hürthle cell) carcinoma. Operative techniques of thyroidectomy are described and include positioning, incisions-making, and troubleshooting. Postoperative care, including thyroid hormone management, is described. Complications and outcome evaluation are discussed. Tables list the etiologies of hyperthyroidism, benign and malignant etiologies of euthyroid nodular disease, familial syndromes of thyroid disease, the Bethesda classification of fine needle aspiration cytology and associated malignancy risk, the elements of common prognostic schemes for well-differentiated thyroid cancer, and the staging of differentiated, medullary, and anaplastic thyroid cancer. Figures show the six levels of cervical lymph nodes, the initial incision in a thyroidectomy, a midline incision, the superior pole vessels, the upper and lower parathyroid glands, the recurrent laryngeal nerve, and Delphian lymph nodes. An algorithm shows the approach to the patient with thyroid disease

This review contains 7 figures, 25 tables, and 70 references

Keywords: Hyperthyroidism, Graves disease, goiter, toxic nodular, solitary toxic nodule, thyroid cancer, radioactive iodine, Bethesda classification

Palliative care is a multidisciplinary approach to care that includes relief of suffering and attention to the social, spiritual, physical, and psychological needs of patients and families. The intent of palliative care is to help patients live as well as possible for as long as possible, and relevant domains of palliative care include symptom relief, prognostication, communication with patients, families and clinicians, transitions of care, and end-of-life care. Palliative care is distinct from hospice in many respects including that it can be provided simultaneously with recovery-directed treatments rather than reserved for individuals at end of life. Patients with surgical disease are particularly in need of palliative care due to the common occurrence of severe symptoms such as pain and nausea, complex decision-making, and the often sudden onset of the disease or injury which precludes preparation for the new health state.

This review contains 3 figures, 14 tables, and 63 references

Keywords: communication, end-of- life, goals of care, high-risk surgery, palliative, palliative care, palliative surgery, patient comfort, surgical decision-making, surgical prognostication

Raynaud phenomenon is an episodic, exaggerated vascular response to cold or emotional stimuli, typically involving the fingers. Raynaud phenomenon is classified as either primary or secondary which is often associated with autoimmune disease as described in this review. Clinical evaluation and diagnostic studies are discussed, including evaluation of digital pressure response to cooling, evaluation that differentiates Raynaud phenomenon from other ailments affecting perfusion to the digits, and nailfold capillaroscopy if secondary Raynaud phenomenon is suspected. Management of Raynaud phenomenon is discussed, including lifestyle modification and many different medical therapies that have been studied in this disease process. Interventional procedures are also discussed. Guidelines to assist in the treatment of both primary and secondary Raynaud phenomenon are provided.

This review contains 2 figures, 5 tables, and 53 references

Keywords: calcium channel blockers, capillaroscopy, cold intolerance, digits, discoloration, Raynaud phenomenon, vasospastic

Many diseases cause inflammatory large vessel vasculitis. However, giant cell arteritis (GCA) and Takayasu arteritis (TA) are the most common large vessel vasculitides. Vascular surgeons should be aware of the workup and management of these two large vessel vasculitides as they are often involved in the care of these patients. Medical management is the primary therapy for both GCA and TA. However, surgical or endovascular therapy may be necessary in certain circumstances. This review explores all of the above aspects of both GCA and TA. Tables highlight inflammatory large vessel vasculitides, major differences between GCA and TA, criteria for the classification of GCA and TA, the distribution of arterial lesions in GCA and TA, and clinical presentation in TA patients by symptom. Figures show occlusive or aneurysmal disease of the aorta and its branches; pallid and sectoral edema; external carotid artery, superficial temporal artery, and facial nerve anatomy; frequency of arterial involvement in GCA and TA; the placement of incision for superficial temporal artery biopsy; right subclavian and axillary arteries in TA; and histology of the superficial temporal artery and a superficial temporal artery in GCA.

This review contains 12 figures, 10 tables, and 91 references

Keywords: Giant cell arteritis, Takayasu arteritis, vasculitis, endovascular surgery, temporal artery, autoimmune

For the past decade, cardiovascular disease (CVD) has been the leading cause of death and disability worldwide, and in most cases, atherosclerosis is the dominant underlying pathologic process. Atherosclerosis is characterized by subendothelial accumulation of lymphocytes, lipid-filled macrophages, and inflammation-induced migration of vascular smooth muscle cells slowly forming a fibroinflammatory lipid plaque. Over time, the plaque progressively weakens and occludes the vessel; however, with continued inflammation and hemodynamic changes, atheromas can dangerously manifest as ischemia (acute or chronic) or aneurysmal disease. This review discusses the economic impact, historical background, and pathogenesis of atherosclerosis, as well as normal arterial biology, risk factors, and screening. Tables outline physiologic properties of nitric oxide in native vessels, selected cellular and chemical mediators and their role in atherogenesis, current risk factors for peripheral arterial disease (PAD) development, and diagnosis criteria for diseases that confer increased PAD risk. Graphs demonstrate mortality due to PAD, PAD prevalence, and the economic impact of CVD. Illustrations depict normal vessel anatomy, blood flow with plaque at carotid bifurcation, the superficial femoral artery (SFA) with plaque, and the progression of atherosclerotic changes. A flow chart for atherogenesis, photograph of a human carotid endarterectomy specimen, and angiogram showing the classic occluding lesion of the SFA are also provided.

This review contains 9 figures, 9 tables, and 93 references

Keywords: Atherosclerosis, cardiovascular disease, dyslipidemia, hypercholesterolemia, peripheral artery disease

Duodenal trauma is rare enough to prevent most surgeons from having extensive experience with its management, but not so unusual as to be ignored. The challenges are not simply in the operative decision-making, but also in the timely diagnosis.  The duodenum accounts for only 5% of intra-abdominal traumatic injuries, likely owing to its deep, mostly retroperitoneal location.  Fully three-quarters of duodenal injuries reported in the world’s literature are from penetrating wounds, and nearly all (90%) will have associated intra-abdominal injuries.  Hemorrhage control, halting contamination, and definitive repair of the duodenal injury are the hallmarks of good management.  The grade or severity of the duodenal injury will direct the appropriate surgical repair technique. Timely diagnosis is imperative, for a delay will increase mortality four-fold. 

This review contains 7 figures, 5 tables, and 25 references

Keywords: Duodenum, pylorus, injury, trauma, pyloric exclusion, amylase, lipase, tube-duodenostomy, whipple procedure, retroperitoneum

This review is a summary of the acid-base physiology that is essential to understanding acid-base pathophysiology. An acid is defined as a proton donor; a base is defined as a proton acceptor. The body fluids are composed of acids and bases, which are tightly regulated by our organ systems, specifically the respiratory system and kidneys. Derangements in the body’s acid-base homeostatic mechanisms or overloading the capacity of the body’s ability to respond can lead to acid-base disorders. These include acidosis and alkalosis, which can be further classified into respiratory, metabolic, or mixed disorders. The approach to these disorders is to stabilize the patient, focusing on respiratory and circulatory status and treating the underlying cause of the acid-base derangement.

This review contains 4 figures, 6 tables, and 30 references

Keywords: acid-base disorders, acid-base homeostasis, acid-base physiology, acidemia, alkalemia, metabolic acidosis, metabolic alkalosis, mixed acid-base disorders, respiratory acidosis, respiratory alkalosis 

This review describes the approaches taken for patient with massive hemorrhage, a derangement of hemostasis, and anemia. For hemorrhage, control of the source of bleeding, restoration of the blood volume, and management of the coagulopathy is presented. Exclusion of technical causes of bleeding, an initial assessment of potential coagulopathy, and an interpretation of coagulation parameters is described for derangements of hemostasis. For anemia, acute coronary artery ischemic syndromes and neurologic conditions are described. Additionally, bleeding disorders are presented. Figures depict various algorithms related to decision-making and treatment. Tables show the management of the patient with an increased International Normalized Ratio, coagulopathy scores, classification and management of Von Willebrand disease, and tests of platelet function.

This review contains 5 figures, 16 tables and 83 references

Keywords: Bleeding, intraoperative hemorrhage, coagulopathy, packed red blood cells, hemostasis, fresh frozen plasma, hemophilia, bleeding disorders

Nosocomial infections are a threat to all hospitalized patients. They can increase morbidity, mortality, length of stay, and costs and occur in almost every body site. This review features an algorithmic approach to the risk, detection, and treatment of nosocomial infections. Respiratory infections include pneumonia, tracheitis or tracheobronchitis, paranasal sinusitis, and otitis media. Operative site or injury-related infections include those occurring in wounds, the intra-abdominal space, methicillin-resistant Staphylococcus aureus (MRSA), empyema, posttraumatic meningitis, osteomyelitis, and sternal and mediastinal infection. A review of intravascular device--associated infection focuses on catheter-related bacteremia and its management. Catheter-associated urinary tract infections (UTIs) and enteric infections are also considered. Enteric infections and transfusion-associated infections are covered in depth, reviewing the most important recent advances and studies. A discussion of postoperative fever addresses the magnitude and incidence of hospital infections, UTIs, and catheter duration and pathogens typically involved and considers the associated costs and the risks of acquiring a nosocomial infection.

This review contains 5 figures, 13 tables and 292 references

Keywords: Nosocomial infection, hospital-acquired infection, MRSA, empyema, meningitis, osteomyelitis, urinary tract infection, peritonitis, postoperative fever, surgical site infection

Nosocomial infections are a threat to all hospitalized patients. They can increase morbidity, mortality, length of stay, and costs and occur in almost every body site. This review features an algorithmic approach to the risk, detection, and treatment of nosocomial infections. Respiratory infections include pneumonia, tracheitis or tracheobronchitis, paranasal sinusitis, and otitis media. Operative site or injury-related infections include those occurring in wounds, the intra-abdominal space, methicillin-resistant Staphylococcus aureus (MRSA), empyema, posttraumatic meningitis, osteomyelitis, and sternal and mediastinal infection. A review of intravascular device--associated infection focuses on catheter-related bacteremia and its management. Catheter-associated urinary tract infections (UTIs) and enteric infections are also considered. Enteric infections and transfusion-associated infections are covered in depth, reviewing the most important recent advances and studies. A discussion of postoperative fever addresses the magnitude and incidence of hospital infections, UTIs, and catheter duration and pathogens typically involved and considers the associated costs and the risks of acquiring a nosocomial infection.

This review contains 5 figures, 13 tables and 292 references

Keywords: Nosocomial infection, hospital-acquired infection, MRSA, empyema, meningitis, osteomyelitis, urinary tract infection, peritonitis, postoperative fever, surgical site infection

The solitary pulmonary nodule is a common finding that is observed in more than 150,000 persons each year in the United States. Factors influencing probability of malignancy are discussed, including age and environmental factors. Investigative studies are described. Imaging includes chest radiography, computed tomography, and positron emission tomography. Biopsy can be excisional or performed via transthoracic needle or bronchoscopy. The differential diagnosis is broad and can include malignant or benign lesions. Malignant lesions include nonsmallcell lung cancer, small cell lung cancer, pulmonary neuroendocrine tumors, and metastatic malignancies. Benign lesions can include pulmonary hamartoma or inflammatory or infectious nodules. Few, if any, randomized controlled trials exist to direct management. Most clinicians rely on a combination of single-institution studies, a few prospective trials, and clinical acumen to assess a given patient's risk profile to inform decisions on invasive and noninvasive testing. In this review, the tables describe the differential diagnosis of a solitary pulmonary nodule, factors affecting malignant probability of a solitary pulmonary nodule, and the initial assessment of probability of cancer in a solitary pulmonary nodule.

This review contains 8 figures, 10 tables, and 76 references

Keywords: bronchoscopy, compute tomography, lung cancer, nodule, positron emission tomography, solitary

Thoracic outlet syndrome (TOS) is a condition caused by compression of the neurovascular structures leading to the arm passing through the thoracic outlet. The incidence of TOS is reported as 0.3 to 2% in the general population. There are three distinct types of TOS: neurogenic (95%), venous (4%), and arterial (1%). Treatment algorithms depend on the type of TOS. Arterial and venous TOS often present urgently with arterial or venous thrombosis, which is fairly easily identified by thorough history taking and a physical examination. Diagnosis is also aided by duplex ultrasonography. Restoration of arterial or venous flow can often be readily accomplished by thrombolysis. More important, however, is the diagnosis of the underlying structural component involved in the development of symptoms. Although statistically the most common, neurogenic TOS is often the most difficult to diagnose and treat. There are good data indicating that appropriately selected patients benefit from surgical therapy for neurogenic TOS as well. To prevent recurrence of symptoms, patients must undergo first rib resection and anterior scalenectomy, as well as resection of any rudimentary or cervical ribs. Regardless of the type of TOS encountered, proper therapy requires a thorough diagnostic evaluation and multimodal treatment.

This review contains 5 figures, 3 tables and 30 references

Keywords: thoracic outlet syndrome, arterial thoracic outlet syndrome, neurogenic thoracic outlet syndrome, venous thoracic outlet syndrome, TOS, effort thrombosis, thoracic outlet decompression

The history and general principles of OR design are discussed, including physical layout and design standards, which encompass the layout and storage of devices and equipment. As both patient and staff safety are paramount, all of the risks that can be mitigated by good design are discussed: biologic, ergonomic, chemical, and physical. Environmental issues in the OR are listed and include temperature, humidity, and lighting. The proper use, storage, and risks of electronic and mechanical devices are discussed. Infection control is addressed and includes hand hygiene, gloves and protective barriers, antimicrobial prophylaxis and nonpharmacologic preventive measures. A housekeeping section discusses the benefits of segregating clean, clean-contaminated, and dirty cases. OR scheduling is noted. Tables outline International Commission on Radiological Protection–recommended radiation dose limits; key principles of the Joint Commission Universal Protocol; devices used in the operating room; standard equipment for endovascular operating rooms; benefits of voice activation technology in the laparoscopic operating room; criteria for defining a surgical site infection; factors that contribute to the development of surgical site infection (SSI); Centers for Disease Control and Prevention hand hygiene guidelines; distribution of pathogens isolated from surgical site infections: operating room cleaning schedules; classification of operations in relation to the epidemiology of SSIs; and basic principles of OR efficiency. Figures depict patient positioning and basic components of an ultrasound transducer,

This review contains 3 figures, 27 tables, and 216 references

Keywords: Operating room, patient positioning, safety, surgical site infection, equipment, protective barriers, antimicrobial prophylaxis

Compartment syndrome is a process that can develop anywhere skeletal muscle or abdominal organs are encased by a rigid fascial layer. This review describes the different aspects of these conditions, including the epidemiology, pathophysiology, diagnosis, and management of compartment syndrome in the extremities and abdomen. Diagnosis is expanded on further to describe clinical signs in the alert patient and the different methods of compartment measurement in the obtunded patient or when a physical examination is inconclusive. The anatomy of the leg, thigh, buttocks, forearm, and arm is described, along with surgical techniques for fasciotomy. Postoperative care, the different methods of wound management and skin closure, and diagnostic criteria for the diagnosis and management of abdominal compartment syndrome are discussed. Treatment of abdominal compartment syndrome with decompressive laparotomy and temporary abdominal closure is also described. Figures depict various fasciotomies and an algorithmic approach to management. Tables show the contents and function of the compartments of the leg and forearm.

This review contains 16 figures, 14 tables and 74 references

Keywords: abdominal compartment syndrome, compartment syndrome, decompressive laparotomy, extremity, fasciotomy, intra-abdominal hypertension, intra-abdominal pressure, temporary abdominal closure, tibia fracture

The primary goal of treatment in dealing with an infected aortic graft is to save life and limb. This goal is best accomplished by eradicating all infected graft material and maintaining adequate circulation with appropriate vascular reconstruction. This review describes the choice of procedures, including an extra-anatomic bypass, an aortic allograft, an antibiotic-treated prosthetic graft, and an in situ autogenous reconstruction. Once a procedure has been decided on, preoperative evaluation and operative planning must take place. The review describes operative technique from the thigh incision and exposure of the femoral vessels to closure. Postoperative care is described. Outcomes and complications are discussed. Special consideration is given to aortoenteric fistulas.

This review contains 8 figures, 6 tables, and 84 references

Keywords: antibiotic-impregnated Dacron, aortic graft infection, aortoenteric erosion, aortoenteric fistula, axillobifemoral bypass, cryopreserved allograft,  neoaortoiliac surgery 

Nearly 9% of men and 30% of women in the United States experience symptoms or complications of gallstone disease. As such, nearly every general surgeon in the country encounters patients with this pathology numerous times during his or her career. Cholelithiasis can cause complications such as acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and the rare entities of Mirizzi syndrome and gallstone ileus. Patients with gallstones have a 1 to 3% risk per year of a complication, and that risk increases significantly to 30% in those with biliary colic. Surgical management of the complications of gallstones is especially intriguing because the cases are often perceived as low complexity; however, it is an operation that can challenge even the most seasoned attending and result in significant complications. Studies demonstrate complication rates up to 10% following cholecystectomy, with bile duct injury rates hovering at 4 in 1,000. This chapter aims to provide the reader with knowledge of the presentation, imaging, work-up, and framework for the management of complicate gallbladder disease. Furthermore, we hope to provide you with a foundation of how to perform a safe cholecystectomy in a variety of circumstances and impart a few tips and tricks for some challenging intraoperative situations.

This review contains 2 figures, 19 tables and 58 references

Keywords: cholecystitis, choledocholithiasis, cholescintigraphy, common bile duct exploration, critical view of safety, ERCP, gallstone pancreatitis, subtotal cholecystectomy

Locally advanced rectal cancer is a complex disease that requires a multidisciplinary treatment team to carefully evaluate each patient before prescribing a treatment plan. The current standard of care in the United States is multimodal therapy, consisting of chemotherapy, radiation, and surgery. Commonly, this involves neoadjuvant long-course chemoradiation, followed by total mesorectal excision and then adjuvant systemic chemotherapy. However, alternative regimens using chemotherapy first, followed by chemoradiation and then surgery (total neoadjuvant therapy), may allow for better tolerance of therapy. Short-course radiation is also acceptable but is rarely used in the United States. Minimally invasive surgical techniques such as laparoscopy, robotic surgery, and transanal total mesorectal excision offer several potential advantages over conventional open surgery, but their oncologic equivalence has not been determined. The role of nonoperative management for locally advanced rectal cancer is still evolving, and additional studies are needed to improve patient selection and evaluate long-term outcomes of a watch-and-wait approach. 

This review contains 1 figure, 3 tables and 60 references

Keywords: colorectal cancer, locally advanced rectal cancer, minimally invasive surgery, nonoperative management, radical proctectomy, robotic surgery, total mesorectal excision, total neoadjuvant therapy, transanal total mesorectal excision, watch and wait

Operative exposure and management of significant blunt or penetrating injuries to the abdomen is a critical skill required of all surgeons caring for victims of trauma. Application of damage control resuscitation and damage control surgical principles improves survival. Advances in diagnostics, increasing experience with selective nonoperative management, and use of endovascular and angiographic techniques have all significantly decreased the frequency of laparotomies performed for trauma. This decreasing clinical experience mandates that surgeons dealing with victims of trauma remain facile with the operative approaches and techniques detailed in this chapter to achieve optimal outcomes. Detailed management of specific injuries is covered in other chapters of this text.

This review contains 7 figures, 9 tables, and 41 references 

Keywords: abdominal trauma, damage control resuscitation, damage control surgery, endovascular control of hemorrhage, open abdomen, REBOA, supraceliac control of aorta, trauma systems, visceral medial rotation

Soft tissue sarcoma (STS) refers to a rare group of cancers that develop from mesenchymal cells and their progenitors. Histologic subtype, in conjunction with tumor location and size, largely defines the biologic behavior of a given lesion and the associated clinical prognosis in these cancers. The diverse characteristics of these tumors means that their treatment is similarly complex. The etiology, tumor staging and prognosis, evaluation, and treatment of STS are discussed in this review, with an aim to present an algorithm for patient evaluation and treatment while highlighting common indications for diverging from this strategy as dictated by disease subtype and location. Figures show the histologic distribution of primary STS diagnosed in the extremity and retroperitoneum and intra-abdominal compartments; disease-specific survival for primary extremity and retroperitoneal and intra-abdominal tumors stratified by histologic subtype; local recurrence in primary extremity STS stratified by histologic subtype; disease-specific survival according to American Joint Committee on Cancer (AJCC) TNGM stage; a postoperative nomogram for prediction of sarcoma-specific death at 12 years postresection for patients with STS; representative cross-sectional images of an atypical lipomatous tumor, a myxofibrosarcoma, and a desmoid tumor; a treatment algorithm for STS of the extremity; a magnetic resonance image and intraoperative photographs showing a mixoid liposarcoma of the posterior thigh; and computed tomography showing a retroperitoneal dedifferentiated liposarcoma and a photograph of the surgical bed following resection. 

This review contains 10 figures, 12 tables, and 49 references

Keywords: Sarcoma, soft tissue, cancer, myxofibrosarcoma, leiomyosarcoma, liposarcoma, gastrointestinal stromal tumor, rhabdomyosarcoma

Inflammatory bowel disease is a chronic inflammatory disease of the intestine that can be divided into two main categories: Crohn disease and chronic ulcerative colitis (CUC). Although the role of medical therapy in CUC is directed at symptom control or the underlying inflammatory process, fortunately, the intestinal manifestations of CUC can be effectively cured by surgery. The operation of choice is an ileal pouch-anal anastomosis (IPAA), which can be performed open or laparoscopically, with a hand-sewn or stapled anastomosis, or in a one-, two-, or three-stage fashion. Although pouch function and quality of life remain good following IPAA, common complications include pouchitis, anal stricture, pouch fistulas, and small bowel obstructions. The most dreaded complication is an anastomotic leak resulting in pelvic sepsis and, often, eventual pouch excision. Less common complications include pouch dysplasia or cancer and de novo Crohn disease of the pouch. Overall, regardless of age, patient satisfaction following IPAA remains high, and more than 90% of patients retain their pouches for more than 20 years. 

This review contains 11 figures, 4 tables and 85 references

Keywords: Inflammatory bowel disease, ulcerative colitis, laparoscopy, ileal pouch-anal anastomosis, pouchitis

Few patient complaints offer such a large range of acuity and differential diagnoses as the complaint of leg pain. This is in part due to the multiple organ systems at play, including cardiac, pulmonary, musculoskeletal, neurologic, vascular, and dermatologic. The surgeon is frequently presented with the challenge of identifying and managing these complaints in a variety of settings. Management involves a spectrum from conservative care to surgical intervention where appropriate. The wide array of symptoms, signs, and often contradictory test results can be confusing and frustrating to patients and physicians alike, leading to delays and errors in diagnosis and ineffective management. This review offers a sequential and ordered approach to the evaluation of leg pain. Tables highlight atherosclerotic risk factors, vascular causes of lower extremity pain, the classification of acute limb ischemia, the ankle-brachial index and corresponding peripheral arterial disease, and the revised cardiac risk score for preoperative risk. Figures show bilateral lower extremity ischemia, chronic ischemic changes to the foot, classic dry gangrene, wet gangrene, acute limb ischemia, Charcot foot, segmental waveform and pulse volume recording analysis of the bilateral lower extremities, and angiographic evaluation of patients with aortoiliac and tibial disease.

This review contains 10 figures, 7 tables, and 55 references

Disorders of water and sodium balance are common in clinical practice. To better assess them, we must have a clear understanding of water-electrolyte homeostasis and renal function. The following review goes over practical equations necessary for electrolyte balance analysis as well as the foundations of renal physiology. Emphasis is placed on the understanding of sodium transport and its physiologic and pharmacologic regulation. In addition, we explore the most common electrolyte imbalance affecting up to 28% of hospitalized patients: hyponatremia (ie, low sodium concentration). Hyponatremia has been found in several acute and chronic clinical scenarios including postoperative, drug-induced, and exercise-associated hyponatremia. However, it is not uncommon to find this disorder coexisting with other diseases such as syndrome of inappropriate secretion of antidiuretic hormone (SIADH), acquired immunodeficiency syndrome (AIDS), cancer, and in rare cases, hypothyroidism. To better understand this disorder, the etiology, diagnosis with clinical manifestations and laboratory values, and treatment options are explored.

This review contains 9 figures, 9 tables, and 53 references

Keywords: aldosterone, antidiuretic hormone, body fluids, electrolyte balance, hyponatremia, hypovolemia, osmolality, sodium transport, vasopressin

Hypernatremia is an electrolyte disorder most prevalent in the elderly and the critically ill, with over 60% of cases developing over the course of an inpatient stay. Characterized by elevated serum sodium concentrations, this disorder is manifested either by pure-water loss without replacement, or excessive sodium intake without appropriate water balance. Left untreated it may lead to seizures and coma. General treatment in the case of severe hypernatremia is infusion of isotonic saline followed by pure-water after the patient is stabilized. Further treatment of the underlying cause may involve diuretics, thiazides, and a variety of other medications in conjunction with dietary and lifestyle modifications. This review offers an overview of various disorders of water balance: diabetes insipidus, nephrotic syndrome, cirrhosis, idiopathic edema, and volume depletion, as well as their clinical presentations, lab tests, and management.

This review contains 1 figure, 5 tables, and 26 references

Keywords: Hypernatremia, Edematous States , Diabetes insipidus, Volume Depletion, Cirrhosis, Diuretics

Major amputations (proximal to the ankle) of the lower extremity are the manifestations of end-stage, nonreconstructable chronic arterial occlusive disease. A well-performed amputation provides the patient with the best prognosis for return to functional mobility. However, an amputation that fails to heal primarily may cause substantial physical and psychological harm to an already chronically ill patient. Minor amputations (at the toe or forefoot level) are not technically complex, but poor patient selection or technical imperfection can result in major amputation and loss of independent ambulation. In this chapter, selection of the level of amputation is reviewed; the methods to perform digital, forefoot, transtibial, and transfemoral amputations are presented; and postoperative management and potential complications are discussed.

This review contains 10 figures, 7 tables and 23 references

Keywords: above-the-knee amputation, below-the-knee amputation, Guillotine amputation, ray amputation, transmetatarsal amputation, transphalangeal amputation

Venous outflow pathology of the lower extremity may be categorized into thrombotic or nonthrombotic etiology. This chapter focuses on the nonthrombotic etiology that results from the compression of the left iliac vein or May-Thurner syndrome (MTS). MTS is an anatomic variant condition associated with venous outflow stenosis due to extrinsic compression of the iliocaval venous segment. The most common cause of the partial obstruction is left iliac vein compression by the overlying right common iliac artery, although other anatomic varieties of MTS do exist. Partial or complete impedance to the venous outflow in the iliocaval venous segment may lead to extensive deep vein thrombosis of the ipsilateral extremity. Clinical presentations may include, but are not limited to, pain, extensive lower-extremity swelling, venous stasis ulcers, and skin discolorations. Treatment is based entirely on the clinical presentation; normally for nonthrombotic MTS, angioplasty and stenting of the diseased iliac vein segment are usually sufficient after defining the location and extent of stenosis. In this review, we (1) describe and define MTS, (2) highlight variable presentations of MTS, and (3) outline the possible management strategies within the current Society for Vascular Surgery updated consensus guidelines.

This review contains 3 figures, 2 tables and 48 references

Keywords: angioplasty, artery compression, deep venous thrombosis, iliac vein, iliofemoral stenosis, May-Thurner syndrome, spur, stent, venogram, venous hypertension

The prevalence of malignant skin cancers has increased significantly over the past several years. Approximately 1.2 million cases of non-melanoma skin cancer are diagnosed per year. More alarming, up to 80,000 cases of melanoma are diagnosed per year, an incidence that has been steadily increasing, with a lifetime risk of 1 in 50 for the development of melanoma. The disturbing increase in the incidence of both non-melanoma skin cancer and melanoma can largely be attributed to the social attitude toward sun exposure. The clinical assessment and management of skin lesions can be challenging. This review describes the assessment process, including thorough history and examination; the need for possible biopsy; and excision criteria. Specific types of skin cancer are distinguished and include basal cell carcinoma; squamous cell carcinoma; and melanoma; and for each type the incidence; epidemiology; histologic subtypes; diagnosis; and both surgical and non-surgical treatments are provided. Stages I-IV of melanoma are detailed, with prognostic factors described. Surgical treatment for stages I and II include description of the margins of excision and sentinel lymph node biopsy. The surgical treatment of Stage III melanoma further includes therapeutic lymph node dissection and isolated limb perfusion. Adjuvant therapies are also presented and include radiotherapy and chemotherapy. The additional treatment of metastasectomy for Stage IV melanoma is described. For both Stage III and IV melanoma, the study of vaccines to host immune cells is reported. For Stage IV melanoma, the text also describes immunotherapy treatment. Operative procedures specific to superficial and deep groin dissections are outlined.

This review contains 9 figures, 19 tables, and 99 references

Deep vein thrombosis (DVT) and pulmonary embolism (PE) comprise venous thromboembolism (VTE). Together, they comprise a serious health problem as there are over 275,000 new VTE cases per year in the United States, resulting in a prevalence of one to two per 1,000 individuals, with some studies suggesting that the incidence may even be double that. This review covers assessment of a VTE event, initial evaluation of a patient suspected of having VTE, medical history, clinical presentation of VTE, physical examination, laboratory evaluation, imaging, prophylaxis against perioperative VTE, indications for immediate intervention (threat to life or limb), indications for urgent intervention, and management of nonemergent VTE. Figures show a modified Caprini score questionnaire used at the University of Michigan to determine individual risk of VTE and the indicated prophylaxis regimen; Wells criteria for DVT and PE; phlegmasia cerulea dolens secondary to acute left iliofemoral DVT after thigh trauma; compression duplex ultrasonography of lower extremity veins; computed tomographic angiogram of the chest demonstrating a thrombus in the pulmonary artery, with extension into the right main pulmonary; management of PE according to Wells criteria findings; management of PE with right heart strain in cases of massive or submassive PE; treatment of DVT according to clinical scenario; a lower extremity venogram of a patient with May-Thurner syndrome and its subsequent endovascular treatment; and various examples of retrievable vena cava filters (not drawn to scale). Tables list initial clinical assessment for VTE, clinical scenarios possibly benefiting from prolonged anticoagulation after VTE, indications for laboratory investigation of secondary thrombophilia, venous thromboembolic risk accorded to hypercoagulable states, and Pulmonary Embolism Rule-out Criteria Score to avoid the need for D-dimer in patients suspected of having PE.

This review contains 11 figures, 15 tables, and 171 references

Keywords: anticoagulation; deep vein thrombosis; postthrombotic syndrome; pulmonary embolism; recurrent venous thromboembolism; thrombophilia; venous thromboembolism; PE; VTE; DVT 

The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients.

This review contains 10 figures, 7 tables, 8 videos and 58 references

Keywords: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

The term “drugs of abuse” lacks a formal medical definition. Historically, discussions of drugs of abuse focused on “street drugs”; however, the adverse effects of the nonmedical use of prescription medications, such as opiates, benzodiazepines, and therapeutic amphetamines, are increasingly seen. The purpose of this review is to aid the clinician in identifying and treating a broad representation of drugs of abuse, which may include those illicitly produced in laboratories (e.g., methamphetamine), diverted pharmaceuticals (oxycodone), and herbal products (marijuana). This review covers stimulants, hallucinogens, cannabinoids, and sedative-hypnotics. Figures show substances ranked according to weighted harm score on a normalized scale from 0 being no harm to 100 being extreme harm to self and others, a treatment algorithm for sympathomimetic toxicity, a treatment algorithm for sedative-hypnotic overdose, and a treatment algorithm for opioid overdose. Tables list commonly abused sympathomimetic agents, modern novel drugs of abuse, commonly abused sedative-hypnotic agents, commonly abused opiates, and pitfalls of the drug screen.

This review contains 4 highly rendered figures, 5 tables, and 89 references

Abdominal trauma accounts for approximately 12% of all trauma. The evaluation of abdominal trauma is difficult as the patient may have concomitant distracting injuries or alteration of mental status. As a result, a systematic approach to abdominal trauma is needed to ensure that life threatening injuries are not missed. The evaluation and management of abdominal trauma is directed by the Western and Eastern Trauma Association guidelines.Trauma to the abdomen is divided into two main categories, penetrating and blunt. The initial steps in management of both types are determined by the hemodynamic stability of the patient. Unstable patients with either pattern of injury are emergently taken to the operating room (OR) for exploration. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is being used at select trauma centers in unstable patients with abdominal trauma that are unresponsive to standard trauma resuscitation. For hemodynamically stable patient with penetrating trauma, recent data on selective non-operative management has shown promising outcomes. Patients with tenuous hemodynamics and blunt abdominal trauma are resuscitated with blood transfusions while being worked up by a Focused Assessment with Sonography for Trauma (FAST) exam or deep peritoneal lavage (DPL). If the patient stabilizes further work up with labs and imaging is performed. Patients that remain tenuous should be taken to the OR. Hemodynamically stable patients with blunt trauma and evidence of peritonitis on exam can be evaluated with labs and imaging to assess for organ injury. Non- tender patients can be evaluated with labs and serial abdominal exams. The American Association for the Surgery of Trauma (AAST) organ injury scales are used to guide the definitive management of patients with intraabdominal injury. The Young-Burgess Classification System can be used to characterize pelvic fractures and to guide stabilization and definitive management. Tables demonstrate the AAST Injury Scales for the different abdominal organs. Images demonstrate the FAST exam and CT findings for different abdominal organs.

This review contains 14 figures, 6 tables and 48 references

Key Words: Abdominal Trauma, Penetrating Trauma, Blunt Trauma, FAST exam, Liver Trauma, Splenic Trauma, Intestinal Trauma, Pancreatic Trauma, Diaphragmatic Trauma, Aortic Trauma, Pelvic Fracture, Deep peritoneal lavage, DPL, Focused Assessment with Sonography for Trauma, REBOA, Resuscitative Endovascular Balloon Occlusion of the Aorta

Orthopedic extremity injuries may require emergent orthopedic consultation, but are typically managed by the acute care provider. Initial management for all fractures should focus on providing immediate analgesia and ensuring adequate blood flow distal to the fracture. This review summarizes the assessment and stabilization, diagnosis, treatment and disposition, and outcomes for fractures, dislocations, and sprains. Figures include illustrations of fracture types, carpal bones and their articlulation in the wrist, bones of the hand, the anatomy of the hip demonstrating the areas where hip fractures occur, the Weber classification, the Bohler angle, and fractures of the proximal fifth metatarsal; a bedside sonogram of a fracture of the distal radius; and 10 radiographs showing various fractures and dislocations. Tables list the Gustilo classification of open fractures; common terms used to accurately describe fractures; components of the Ottawa Knee Rules and the Ottawa Ankle/Foot Rules; Schatzker classification system of tibial plateau fractures; common fractures of the hand and foot, respectively, with their associated treatment, splint, and recommended follow-up; normal anatomic alignments that should be assessed on radiographic evaluation of a possible Lisfranc injury; common splints and the associated fractures they are used to treat; AC joint injuries graded according to the severity of injury to the joint structures; and the four stages of worsening lunate instablity.

This review contains 18 highly rendered figures, 11 tables, and 98 references.

Approximately 8000 persons are bitten by venomous snakes in the US each year.  Mortality is low (4 to 6/yr), but morbidity can be significant, treatment costly. Overuse of surgery and antivenom is common. Simply cutting the wound with attempted aspiration is not indicated. Fasciotomy should only be used for patients with elevated compartment pressures. CroFab is a highly effective (but expensive) treatment useful for serious envenomation. Antivenom should be used in patients with life-threatening symptoms (hypotension, clinical coagulopathy) or rapid advancement of local signs, and to reduce compartment pressures to avoid fasciotomy. The most significant morbidity from insect envenomation is secondary to anaphylaxis. A bite from the black widow spider can induce abdominal cramping and pain that can mimics an acute abdomen. Brown recluse envenomation can produce tissue necrosis and long-term complications. Most events are seen rarely by the average physician; this review can be a useful guide in management. 

Key words: antivenom, copperhead bite, CroFab, insect bite, rattlesnake bite, snakebite, water moccasin bite

Small bowel obstruction can be a surgical emergency, and may be the ultimate diagnosis in 2 to 15% of patients presenting to the emergency department with abdominal pain. Bowel obstruction can be either mechanical (caused by extrinsic compression, twisting of the bowel, or intrinsic obstruction) or functional (caused by an impaired ability of the bowel to propel contents distally). The most common cause of small bowel obstruction in the developed world is postoperative adhesions.This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and outcomes for patients with bowel obstruction.

This review contains 4 figures, 9 tables, 5 videos and 21 references.

Keywords: Bowel obstruction; Small bowel obstruction; Bowel peristalsis; Small intestinal peristalsis; Obstipation; Postoperative adhesions; Pendulous peristalsis; Decreased peristalsis

Upper airway disorders are frequently encountered in the primary care setting and present in both adults and children.  This review covers earache, sinusitis, sore throat, peritonsillar abscess, sialolithiasis and sialadenitis, parotitis, epiglottitis, epistaxis, foreign body in the ear, nose, or throat, and Ludwig angina. Figures show right-sided peritonsillar abscess demonstrating swelling and distortion of the anterior and posterior tonsillar pillars and uvular deviation, peritonsillar abscess demonstrated by an ultrasound image of a hypoechoic fluid collection, ultrasound imaging of sagittal view of the tonsillar pillars, lateral radiograph of the neck demonstrating a swollen epiglottis and widened vallecula, photographs of brawny swelling of the submandibular region of the neck in Ludwig angina, and a patient with peritonsillar abscess with extension to the base of the tongue. Tables list criteria for diagnosing acute sinusitis, and clinical presentations that best identify patients with acute bacterial versus viral rhinosinusitis.

This review contains 7 figures, 17 tables, and 66 references

Keywords: Epiglottitis, epistaxis, parotitis, peritonsillar abscess, pharyngitis, sialolithiasis, sinusitis

Aortic diseases are relatively rare but are associated with high morbidity and mortality. Emergency physicians (EPs) should consider aortic disease in all patients with pain in the torso, particularly those with other diverse or seemingly unconnected complaints. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with abdominal aortic aneurysms (AAAs), thoracic aortic aneurysms (TAAs), and aortic dissection. Figures show a transverse image of an AAAs with a transmural hematoma, a three-dimensional computed tomographic angiogram (CTA) rendering of a thoracic aneurysm associated with a bicuspid aortic valve in the typical ascending aortic location, a chest x-ray film demonstrating prominent and blurred aortic knob due to TAA, acute aortic dissection subtypes, an electrocardiogram and transesophageal echocardiography of a patient with acute ascending aortic dissection, magnetic resonance images of a patient with dissection of the proximal descending aorta, CT representations of a type A dissection involving a dilated ascending aorta and a type B dissection involving the descending thoracic aorta, and a decision algorithm for evaluation and treatment of a suspected aortic dissection. Tables list normal aortic dimensions by CTA and echocardiography, average annual rate of expansion and rupture of AAA based on current diameter, and the etiology of TAA.

Key words: AAA, aorta, aortic dissection, ascending aortic dissection, descending aortic dissection, intimal tear, intramural hematoma, thoracic aortic aneurysm

Diarrhea, qualitatively defined as an increase in stool frequency and liquid content, is a frequent complaint in patients presenting to emergency departments. Although most cases are uncomplicated viral infections, the most frequent causes of dangerous underlying entities are often not viral. In uncomplicated cases, laboratory testing for metabolic derangements is not required unless there are signs of moderate to severe dehydration or the patient has particular risks, such as chronic kidney disease. Secondary infections associated with antibiotic use (C difficile–associated diarrhea), other significant nosocomial exposures, recent international travel history, the presence of a nonintact immune system (HIV/AIDS, cancer/chemotherapy), and exposure to high-risk environments (including zoonotic exposures, outbreak-prone environments such as day care facilities) increase the likelihood of a bacterial or other infectious cause requiring either microbiologic testing or empirical antimicrobial treatments. Diarrhea is often present as a feature of clinically significant noninfectious conditions, including complications of inflammatory bowel diseases (Crohn disease and ulcerative colitis), overdoses, and withdrawal syndromes. In such cases, after hemodynamic stability has been ensured, advanced workup and treatment are guided by the underlying condition and antecedent risks, not the presence of diarrhea per se. Oral rehydration is the first step in management for mild dehydration caused by uncomplicated diarrhea. Intravenous fluids may be necessary in moderate to severe dehydration and in cases of electrolyte derangement requiring resuscitation where fluid choice and rate are paramount, as well as in patients who cannot tolerate oral intake. In cases of suspected bacteria-caused diarrhea, antibiotics, most often fluoroquinolones, reduce both the severity and duration of illness. In patients safe for home management, antidiarrheal agents such as loperamide may be used in uncomplicated and resolving cases. Probiotics appear safe in most cases and impart a small but clinically detectable decrease in the duration and severity of illness. Although there have been fears of bacterial outbreaks following natural disasters, improvements in local and global health efforts have led to decreases in cholera outbreaks, and typical viral causes of diarrhea are generally the most common causes.

This review contains 4 figures, 12 tables and 37 references

Keywords: Clostridium difficile, diarrhea, infectious diseases, inflammatory bowel diseases, medication side effects, overdose syndromes, sepsis, traveler’s diarrhea, zoonotic infections 

The ultimate goal of cardiac resuscitation is full neurologic recovery; however, the probability of achieving this goal deteriorates rapidly with each minute of cardiac arrest. The most essential steps are rapid recognition of cardiac arrest, early high-quality chest compressions with minimal interruptions, and early defibrillation. Additional key components include effective leadership and followership, appropriate airway management, and effectual investigation for possible reversible causes of the arrest. This review discusses the role of and evidence for using pharmacologic agents. Additional discussion evaluates the use of ultrasonography and end-tidal CO₂ in cardiac arrest resuscitation. Lastly, this review discusses cardiac arrest in special circumstances, such as patients who are pregnant, have left ventricular assist devices, or are subjects of trauma.

This review contains 6 figures, 3 tables and 101 references

Key words: advanced cardiovascular life support, antidysrhythmics, asystole, cardiac arrest, basic life support, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, pulseless electrical activity, resuscitation, ventricular fibrillation, ventricular tachycardia

Injury to the urogenital tract from blunt or penetrating trauma comprises 10% of injuries sustained from trauma with renal injuries comprising the majority of those cases at 1-5 % of all trauma, followed by bladder injuries. Worldwide variations in trauma mechanisms exist, with blunt trauma causing the majority of renal trauma in the United States. Careful attention to the mechanism, anatomic location, and specific physical and radiologic findings can aid in the diagnosis and appropriate management to optimize patient outcomes. Unless trauma is overtly obvious on a physical examination, imaging is required for diagnosis and staging purposes. Owing to the complexity of the urogenital tract, there is a great deal of variation in management, ranging from a conservative approach in most renal injuries to the need for operative intervention with intraperitoneal bladder rupture. This review discusses common practice and provides more recent up-to-date guidelines pertaining to the clinical history, examination findings, and imaging modalities, along with the diagnosis and management of injuries to the genitourinary system.

Keywords: Genitourinary Trauma, Renal Trauma, Ureter Trauma, Bladder Trauma, Urethral Trauma, External Genitalia Trauma

Delirium, an acute confusional state characterized by disturbances in attention, cognition, and arousal, is present in 7 to 10% of older emergency department (ED) patients, underdiagnosed in the ED setting, and associated with increased short-term mortality. Delirium is typically precipitated by a physiologic stressor, such as an acute medical illness, a new medication, or a change in environment. The keys to the care and management of delirious patients are timely diagnosis of delirium and identification and treatment of the precipitating cause. The medical evaluation should include a formal delirium assessment that includes tests of attention and targeted diagnostic tests to identify the underlying etiology, such as infection, metabolic derangement, neurologic emergencies, new medications, and/or toxidromes. Pharmacologic treatment of delirium should be limited to patients who are severely agitated and at risk for substantial harm to self and/or others and patients with delirium secondary to alcohol withdrawal. Typical and atypical psychotics at low doses are first line for use in severely agitated patients. Benzodiazepines may worsen delirium and should be reserved for treatment of patients with delirium secondary to alcohol withdrawal or if sedation is required for critical imaging and/or procedures. ED physicians should also be conscious of and strive to minimize iatrogenic precipitants of delirium.

This review contains 2 figures, 10 tables and 53 references

Key words: aged, agitation, arousal attention, confusion, delirium, delirium/diagnosis, delirium/etiology, delirium/therapy, dementia complications, geriatrics, risk factors

Patients with acute respiratory failure present to the emergency department (ED) on a regular basis, and emergency physicians (EPs) are expected to be skilled in endotracheal intubation. Historically, although a significant portion of emergency medicine residency training focuses on airway management, extended management of the ventilated patient has received relatively short shrift. Recent data indicate that not only is endotracheal intubation one of the most commonly performed ED procedures, but also that in the initial hours of care, it is also often the EP rather than the intensivist who provides the bulk of critical care to the patient. It is therefore critical that EPs are skilled in ongoing management of the ventilated patient in the early hours as inappropriate management of the ventilator or sedation/analgesia can have a significant impact on complications such as ventilator-induced lung injury, ventilator-associated pneumonia (VAP), ventilator weaning, and delirium. This review outlines basic strategies for the physiologic management of respiratory failure patients to reduce periintubation complications and discuss ventilation strategies, appropriate use of analgesia/sedation, and prevention of secondary complications such as VAP and delirium. Basic troubleshooting of common ventilator problems is also reviewed. Although it is not expected that the EP will replace the intensivist, the goal of this review is to optimize patient management early in the ED stay, to facilitate the transition between the ED and the intensive care unit, and to reduce preventable complications by optimizing the care of ventilated patients in the ED.

This review contains 9 figures, 4 tables and 46 references

Key words: acute respiratory distress syndrome, analgesia, chronic obstructive pulmonary disease, delirium, hypercapnia, hyperventilation, hypoxia, patient-ventilator dyssynchrony, pulmonary edema, respiratory failure, sedation, ventilator-associated pneumonia

Urinary tract infections (UTIs) affect people of all ages. Although the incidence of invasive bacterial diseases continues to decline, the prevalence of UTIs in febrile pediatric patients continues to remain a focus for serious bacterial infection in this population. In older age groups, symptoms become more obvious and present more classically. Clinical practice guidelines have been developed because morbidity can be dependent upon the rapid identification of a UTI with prompt initiation of appropriate antimicrobials. This review provides a summary for the evaluation of UTIs with discussion of diagnosis and management. 

This review contains 6 figures, 5 tables and 47 references

Key words: antibiotics, cystitis, pyelonephritis, urinary tract infection, uropathogens

The number of permanent pacemakers implanted per year increased by 55.6% between 1993 and 2009, and is continuing to rise. Accordingly, the number of patients treated in the emergency department who have permanent pacemakers is increasing, and it is important for physicians in the emergency department to be familiar with the operation and potential complications of these devices. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with pacemakers presenting to the emergency department. 

This review contains 6 figures, 10 tables, and 25 references.

Keywords: Pacemaker, sinus node, atrioventricular block, supraventricular tachycardia, bifascicular block, carotid sinus dysfunction, cardiac sarcoidosis, ventricular pacing, cardiac resynchronization therapy

Coronaviruses (CoVs) are a group of viral pathogens that infect mammals and birds. The presentation in humans is typically that of a mild upper respiratory tract infection, similar to the common cold. However, in recent years, dramatic attention has arisen for more lethal members of this viral family (e.g., severe acute respiratory syndrome [SARS-CoV], Middle East respiratory syndrome [MERS-CoV], and coronavirus disease 2019 [COVID-19]). The epidemiology, clinical presentation, diagnosis, and management of these viruses are discussed in this review. Importantly, new guideline tables from the Centers for Disease Control and Prevention, as well as the World Health Organization are provided at the conclusion of the review.

This review contains 12 tables, 3 figure and 48 references.

Keywords: Coronavirus, severe acute respiratory distress syndrome (SARS), Middle East respiratory syndrome (MERS), COVID-19, respiratory infection, antiviral, real-time polymerase chain reaction

The upper respiratory tract includes the sinuses, nasal passages, pharynx, and larynx, and is susceptible to a variety of pathogens including many viruses.  Although other pathogens can also cause infections of the upper respiratory tract, we are focusing on viral illnesses for the purposes of this review.  Upper respiratory tract infections (URIs) include sinusitis, nasopharyngitis (common cold), pharyngitis, epiglottitis, and tracheitis.  URI’s are one of the most frequent causes for visits to see a physician in the United States. Despite the fact that many URIs are caused by viral pathogens, more than half of patients in both the clinic and the emergency department setting with a diagnosis of URI received antibiotics. URIs are generally mild, and self-limited illnesses; however, it is important to recognize clinical entities that may be severe and warrant more extensive diagnostic workup and treatment such as epiglottitis and tracheitis. This review covers the pathophysiology, diagnosis, treatment, disposition and outcome for multiple viral URIs seen commonly in the emergency department setting.

This review contains 3 figures, 8 tables, and 87 references.

Key words: Common cold, epiglottitis, nasopharyngitis, pharyngitis, sinusitis, tracheitis, upper respiratory tract infection

Pulmonary infections span a wide spectrum, ranging from self-limited to life threatening.  Pneumonia refers to infection of lung parenchyma, specifically the alveolar or gas-exchanging portions of the lung. Taken together, pneumonia and influenza rank as the sixth leading cause of death in the United States and the leading infectious cause of death in the United States and the world. Tuberculosis (TB) is a bacterial disease caused by Mycobacterium tuberculosis. TB, historically a leading cause of death worldwide, remains an enormous global public health epidemic in much of the developing world. Rates of coinfection with HIV are high, and HIV increases the morbidity and mortality associated with TB. This review details the pathophysiology, epidemiology, clinical presentation, and treatment of pulmonary infection, including pneumonia, empyema, pulmonary abscess, and tuberculosis (TB). Figures show chest radiographs of reactivation pulmonary tuberculosis, HIV-infected patients with proven culture-confirmed tuberculosis, prominent hilar adenopathy with clear lung fields, and bilateral interstitial changes; and treatment of drug-susceptible pulmonary tuberculosis. Tables list major causes of pulmonary infection, host defence mechanisms against pulmonary infection, initial empirical antibiotic therapy in patients with suspected community-acquired pneumonia, initial antibiotic therapy for community-acquired pneumonia in outpatients, initial antibiotic therapy for community-acquired pneumonia in patients who require hospitalization, antibiotic choices for aspiration pneumonia, pneumonia severity index scoring, and mortality by pneumonia severity index point score.

This review contains 2 figures, 9 tables, and 87 references 

Key words: Pulmonary infections; Pneumonia; Tuberculosis; Lung infection; Mycobacteria; Community-acquired pneumonia; Health care-associated pneumonia; Aspiration pneumonia; Empyema; Legionnaires disease

The resuscitation of a neonate in the emergency department is an infrequent occurrence. As such, it is imperative that emergency physicians are aware of the resources available at their institution in the event that resuscitation arises. The two mainstays of neonatal resuscitation are respiration and temperature. When resuscitation is required, it is due to a respiratory cause in the majority of neonates. Therefore, if the airway and breathing are managed properly, the heart rate and overall neonatal status will follow suit. Should the neonate’s heart rate continue to be below 60 beats per minute, then he or she will need chest compressions in addition to respiratory support. During the transition from intrauterine life to extrauterine life, neonates stand to lose substantial amounts of heat. Therefore, the temperature of the neonate also needs to be actively managed to prevent the loss of heat. The resuscitation will eventually end in one of two pathways: the termination of efforts or the successful resuscitation of the neonate. If the resuscitation is successful, the proper admission or transfer will need to be arranged for definitive care for the neonate. Figures include the review of fetal and neonatal circulation, proper use of equipment, and proper chest compression technique. Tables include equipment needed, Apgar scores, normal neonatal vital signs, disposition, and neonatal intensive care unit levels.

This review contains 6 figures, 6 tables and 27 references

Keywords: Apgar scores, fetal circulation, neonatal chest compressions, neonatal circulation, neonatal resuscitation, neonatal intensive care unit levels

Subarachnoid hemorrhage (SAH) represents a small portion of cerebrovascular disease but a disproportionally large percentage of the morbidity and mortality. The overall prognosis depends on the volume of the initial bleeding, rebleeding, and the degree of delayed cerebral ischemia. The presence of cardiac manifestations and neurogenic pulmonary edema at the initial presentation indicates a higher degree of severity and systemic complications. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of SAH. Figures show common saccular aneurysm locations, a noncontrast head computed tomographic scan of an SAH, an angiogram and surgical clipping of a broad-based anterior communicating aneurysm, and a three-dimensional reconstruction angiogram of a complex anterior communicating aneurysm with additional imaging of endoscopic stent-assisted coiling of the same aneurysm. Tables list the natural history of unruptured aneurysms and the annual risk of rupture, common clinical features and syndromes related to aneurysm location, the World Federation of Neurologic Surgeons grading system, the Hunt and Hess grading systems, and the Fisher scale.

This review contains 4 figures, 7 tables, and 145 references

Keywords: aneurysm rupture, cerebral aneurysm, cerebral vasospasm, Fisher scale, Glasgow Coma Scale assessment, Hunt and Hess grading criteria, subarachnoid hemorrhage, World Federation of Neurologic Surgeons grading scale 

Acute heart failure (AHF) is a heterogeneous syndrome characterized by patients who present with signs and symptoms of heart failure (HF) in need of urgent or emergent therapy. Although dyspnea is the most common presentation, AHF is accompanied by a variety of signs and symptoms. AHF primarily afflicts the elderly; these patients typically have numerous comorbid conditions, both cardiovascular and noncardiovascular. Although signs and symptoms are similar in nearly all patients with AHF, the precipitant of acute decompensation, cardiac structure and function, and etiology of HF, as well as other comorbid conditions, vary considerably. This review covers the epidemiology, pathophysiology, diagnosis, treatment, and disposition of patients who present to the emergency department with nonacute coronary syndrome AHF.

This review contains 6 figures, 2 videos, 8 tables, and 84 references

Keywords: heart failure, decompensated heart failure, ejection fraction, cardiac function, cardiac structure

Hematologic and oncologic emergencies that afflict children and adolescents are important for emergency medicine physicians to recognize. Pediatric patients can present with a previous formal diagnosis and have a complication related to their disease or with new symptoms that suggest a hematologic or oncologic process. Oncologic treatments can also lead to life-threatening complications. Recognizing these emergencies is very important for emergency physicians to prevent further morbidity. This review covers common patient presentations, diagnosis, and treatments for hematologic and oncologic emergencies.

 This review contains 6 figures, 9 tables and 66 references

Keywords: hematology, oncology, tumor lysis syndrome, hemophilia, pediatrics, von Willebrand Disease, sickle cell disease

Most individuals will wish to avoid pregnancy for some part of their reproductive years. A variety of hormonal and nonhormonal contraceptive methods are available, which have different characteristics related to systemic effects, bleeding patterns, and effort required on the user’s part. The goal of contraceptive counseling is to identify a method that is safe and compatible with the individual’s preferences. Clinicians may often be able to help patients initiate contraception on the day of the initial office visit. They should remain available and supportive to patients who wish to switch methods and provide comprehensive counseling for all available contraceptive methods as well as emergency contraception options.

This review contains 8 figures, 7 tables and 51 references

Keywords: birth control, contraception, emergency contraception, Essure, hysteroscopy, interval, laparoscopy, microinserts, postpartum, salpingectomy, sterilization

The puerperium starts after the birth of a baby and continues until 6 to 8 weeks postpartum. Several recent interventions in management have been shown to improve outcomes. Delayed cord clamping, the practice of waiting for a period of time after a baby is born before clamping and cutting the umbilical cord, can increase hemoglobin levels, improve iron stores, and increase birth weight in newborns. Rooming in, the practice of mothers and newborns staying together, improves infant sleep and breast-feeding without affecting maternal sleep. Immediately after birth, significant physiologic and anatomic changes occur. Thromboembolic events are more common in the postpartum state than during pregnancy, but the majority of women do not require specific thromboprophylaxis but should be encouraged to walk after birth. Women who have not been previously immunized for influenza; tetanus, diphtheria, pertussis (Tdap); and rubella should be offered these immunizations. Women with uncomplicated pregnancies may engage in exercise within days after delivery. Pelvic floor physical therapy performed during pregnancy and postpartum may assist in maintaining or regaining muscle tone of the pelvic floor and may prevent or treat urinary incontinence. Perinatal depression affects one in seven women. Baby blues, which include mood swings, anxiety, tearfulness, and insomnia, should resolve by 2 weeks after delivery. Patients should be screened for depression using a standardized, validated tool and appropriate treatment initiated. All women should undergo a comprehensive postpartum visit within 6 weeks of delivery.

This review contains 2 figures, 1 table and 32 references

Key words: delayed cord clamping, hemodynamic changes, perinatal depression, postpartum, puerperium, rooming in, skin-to-skin contact

Abnormal uterine bleeding (AUB) is a common presentation that can occur in all age groups. AUB is an umbrella term for any uterine bleeding that occurs outside a woman’s normal pattern in volume, regularity, and/or timing. AUB is described by using frequency, regularity, duration, and volume or by using PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy and premalignant conditions; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified). Workup for AUB comprises a history (with a detailed menstrual history), physical examination (including a pelvic and bimanual examination), lab tests, and imaging (primarily transvaginal ultrasonography). For treatment, medical therapies should be considered before surgical therapies, especially when fertility is desired. The decisions for treatment are based on etiology, fertility concerns, contraindications, or patient preference. Of the medical therapies, there are hormonal and nonhormonal therapies. The most common treatments for AUB are levonorgestrel intrauterine device, tranexamic acid, oral contraceptives, and nonsteroidal anti-inflammatory drugs. The most common surgical treatments are myomectomy, endometrial ablation, uterine artery embolization, and hysterectomy.

This review contains 7 figures, 10 tables and 45 references

Key words: abnormal uterine bleeding, adenomyosis, contraceptives, endometrial, fibroids, hysterectomy, menorrhagia

The female reproductive system matures in a continuous, natural process from menarche to menopause as the finite numbers of oocytes produced during fetal development are gradually lost to ovulation and senescence. Menopause is defined as the permanent cessation of menses; by convention, the diagnosis of menopause is not made until the individual has had 12 months of amenorrhea. Menopause is thus characterized by the menstrual changes that reflect oocyte depletion and subsequent changes in ovarian hormone production. However, hormonal changes, rather than the cessation of menstruation itself, cause the manifestations that occur around the time of menopause. Therefore, a woman who has undergone a hysterectomy but who retains her ovaries can experience normal menopausal symptoms as oocyte depletion leads to changes in estrogen levels, even though cessation of menstruation occurred with surgery. This review covers definitions, natural menopause, menopausal transition and postmenopausal symptom management, and premature ovarian insufficiency. Figures show stages of reproductive aging, serum concentrations of hormones during menopausal transition and postmenopause, hormonal changes associated with reproductive aging, symptoms of menopausal transition and menopause, treatment algorithm(s), and Women’s Health Initiative findings: risks and benefits of estrogen alone and estrogen plus progestin by age group: 50 to 59, 60 to 69, and 70 to 79 years. Tables list target tissues, physical manifestations, and menopausal symptoms; selective estrogen receptor modulators used in postmenopausal women; differential diagnosis and evaluation of common menopausal symptoms; estrogen doses; progestogen dosing for endometrial protection; nonhormonal pharmaceutical hot flash therapies; and pharmacologic therapy for genitourinary atrophy.

This review contains 6 figures, 8 tables, and 122 references.

Prenatal genetic testing offers patients and providers the opportunity to screen for aneuploidy, genetic syndromes, and congenital malformations during pregnancy. Screening options include taking a clinical history, evaluation of maternal serum markers or noninvasive cell-free DNA, and ultrasound evaluation during the first and second trimesters. Invasive diagnostic testing such as amniocentesis or chorionic villus sampling allows for further investigation of positive screening results and a directed test to identify aneuploidy as well as specific gene mutations and gain, loss, or rearrangement of genetic information. Laboratory methods for testing fetal samples differ by types of genetic abnormalities that can be detected and turnaround time for results; these methods include karyotype, fluorescence in situ hybridization, and microarray.

This review contains 5 figures, 5 tables and 43 references

Key words: amniocentesis, aneuploidy, cell-free DNA, chorionic villus sampling, karyotype, microarray, prenatal genetic screening, ultrasonography

In pregnancy, the majority of women experience at least some nausea and vomiting. For many women, these symptoms are mild and self-limiting and resolve by the second trimester. A minority of women experience severe symptoms of hyperemesis gravidarum with persistent vomiting, weight loss, and electrolyte derangements. The diagnosis of hyperemesis gravidarum is based on clinical history and exclusion of other etiologies of nausea and vomiting. First-line pharmacologic treatment is with pyridoxine and doxylamine. Other medical treatments include metoclopramide, phenothiazines, antacids, and ondansetron. In refractory cases, corticosteroids and enteral or parenteral nutrition may be considered.

This review contains 3 figures, 2 tables and 83 references

Key words: enteral feeding, hyperemesis gravidarum, maternal outcomes, nausea and vomiting of pregnancy, neonatal outcomes, nonpharmacologic antiemetics, pharmacologic antiemetics

Vulvovaginal complaints are a common indication for women to seek gynecologic care. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis, which account for 22 to 50%, 17 to 39%, and 4 to 35% of vaginitis, respectively. This review describes the presentation, diagnosis, and prevention strategies for the most important causes of vulvovaginitis, including characteristic findings on office microscopy and newer available diagnostic testing. It outlines treatment modalities for uncomplicated infections in healthy women, as well as nuances of treatment for recurrent and persistent infections, pregnant women, and HIV-positive women. It also explores the diagnosis and management of non-infectious vaginitis as well special consideration for vaginitis in children and adolescents.

This review contains 4 figures, 8 tables, and 55 references.

Key words: vaginitis, vulvovaginitis, bacterial vaginosis, candidiasis, trichomoniasis, vaginitis treatment

Chronic pelvic pain (CPP) in women is responsible for greater than 10% of referrals to gynecologists. A majority of them will remain undiagnosed or inadequately treated. Over time, CPP may lead to a syndrome that results in disability, loss of employment, and discord within relationships. This review discusses how to achieve a comprehensive assessment of CPP from a variety of causes.

This review contains 12 figures, 2 tables and 57 references

Key Words: dysmenorrhea, dyspareunia, endometriosis, interstitial cystitis, irritable bowel syndrome, pelvic floor dysfunction, pelvic pain, pudendal neuralgia, somatic pain, visceral pain

Since the Papanicolaou (Pap) smear became implemented as a screening tool for cervical cancer, the mortality from cervical cancer has sharply declined in the United States. The discovery of the human papillomavirus (HPV) as the causative agent in the progression from dysplasia of the cervix to cervical cancer has changed the types of screening offered to women and the management of abnormal Pap smears. The management of abnormal Pap smears has changed depending on the age of the woman, with women under the age of 24 years being managed more conservatively given the low rates of cervical cancer in this age group and the high rates of regression of HPV and cytologic abnormalities. Colposcopy remains the first line in evaluation of an abnormal Pap smear, with excisional treatment reserved for high-grade dysplasias with a high risk of progression to cervical cancer. Treatment for cervical dysplasia is highly effective, but even after treatment, there is an increased risk of recurrence or progression to cervical cancer for up to 20 years, and these women should be followed closely.

This review contains 18 figures, 3 tables and 53 references

Key words: cervical cancer screening, high-grade cervical dysplasia, human papillomavirus, low-grade cervical dysplasia, management of abnormal Pap smears, Pap smear, recurrence of cervical dysplasia, treatment of dysplasia

A normal menstrual cycle is the end result of a sequence of purposeful and coordinated events that occur from intact hypothalamic-pituitary-ovarian and uterine axes. The menstrual cycle is under hormonal control in the reproductively active female and is functionally divided into two phases: the proliferative or follicular phase and the secretory or luteal phase. This tight hormonal control is orchestrated by a series of negative and positive endocrine feedback loops that alter the frequency of the pulsatile secretion of gonadotropin-releasing hormone (GnRH), the pituitary response to GnRH, and the relative secretion of luteinizing hormone and follicle-stimulating hormone from the pituitary gonadotrope with subsequent direct effects on the ovary to produce a series of sex steroids and peptides that aid in the generation of a single mature oocyte and the preparation of a receptive endometrium for implantation to ensue. Any derailment along this programmed pathway can lead to an abnormal menstrual cycle with subsequent impact on the ability to conceive and maintain a pregnancy.

This review contains 7 figures and 26 references

Key words: follicle-stimulating hormone, follicular phase, gonadotropin-releasing hormone, luteal phase, luteinizing hormone, menstrual cycle, ovulation, progesterone, proliferative phase, secretory phase

The goal of preconception care is to optimize the health and knowledge of every woman prior to pregnancy. Inquiring about plans for pregnancy can occur at any patient encounter, not just at a scheduled preconception care visit, because many women do not present for care until they are already pregnant. Identifying medical, social, environmental, and psychological risks prior to pregnancy can lead to interventions that may enhance the health of both mother and baby. Relevant preconception issues discussed in this review include medications; medical, surgical, mental health, and social history, including substance use and intimate partner violence; immunization recommendations; nutrition; genetic screening; and infectious disease.

This review contains 2 figures, 5 tables and 52 references

Keywords: depression, diabetes, exercise, hypertension, immunizations, intimate partner violence, nutrition, preconception care, reproductive life plan, thyroid disease

Labor pain is a complex entity composed of physical, emotional, and psychological factors. The physical treatment of pain is most effectively managed with pharmacologic therapies. Pharmacologic treatments are distinguished by being administered in the neuraxis (spinal or epidural) or systemically. All pharmacologic therapies have side effects associated with the medications being used. Nonpharmacologic methods have undergone refinement in the last century. These methods focus on the emotional and psychological factors surrounding labor. Both psychological methods, exemplified by the practice of Lamaze, and physical methods, such as continuous labor support, can be effective in producing a satisfying labor experience.

This review contains 2 figures, 7 tables and 43 references

Keywords: combined spinal epidural, doula, epidural analgesia, labor pain, neuraxial analgesia, nitrous oxide, opioid therapy, parturient, psychoprophylaxis

Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine disorder in women of reproductive age. In this review, the pathophysiology and current diagnostic criteria for PCOS are reviewed. Treatment options for symptoms commonly associated with PCOS such as hirsutism, acne, and menstrual irregularity are reviewed. Combined hormonal contraceptives are the first line of therapy in women not attempting pregnancy. The metabolic complications commonly associated with PCOS are impaired glucose tolerance and dyslipidemia. A summary of the current guidelines on screening and prevention of these complications is presented. In addition, PCOS is associated with an increased risk of depressive symptoms and anxiety disorders for which patients should be monitored.

This review contains 7 tables and 59 references. 

Keywords: Polycystic ovary syndrome, PCOS 

Infertility affects 12 to 18% of couples in the United States and may be due to female factors, male factors, or both. A systematic evaluation of the common causes of infertility can identify conditions that may be treated by the obstetrician-gynecologist to help the couple achieve their family-building goals or those that require referral to a subspecialist. This review discusses current recommendations regarding the workup and treatment of the common causes of infertility, including tubal and pelvic factors, ovulatory disorders, and male factors. Advances in assisted reproductive technology are also discussed, including the use of genetic screening in in vitro fertilization and fertility preservation options for individuals facing gonadotoxic therapy.

This review contains 6 figures, 8 tables, and 53 references

Key words: anovulation, assisted reproductive technology, clomiphene citrate, infertility, letrozole, oocyte cryopreservation, ovulation induction, semen analysis, tubal factor, uterine factor

Fecal incontinence is the uncontrolled passage of feces or flatus. It is a debilitating and often unrecognized condition whose prevalence is increasing with our aging population and often carries significant stigmata associated with decreased quality of life. It is also one of the leading causes of nursing home admissions in the United States. The etiology of fecal incontinence is multifactorial, with many risk factors contributing to this disease process. Treatment may be challenging and needs to be individualized. In this review, we discuss the initial evaluation of the patient presenting with fecal incontinence, adjunctive testing modalities, and nonoperative management.

This review contains 6 figures, 2 tables and 50 references

Key words: accidental bowel leakage, biofeedback, bowel incontinence, fecal incontinence, pelvic floor physical therapy, pelvic floor retraining

The healthcare community and lay public have become more aware of transgender (TG) people in the past decade as celebrities have publicly transitioned and activists have pushed back against restrictive laws. Movies, television, nonfiction books, and novels increasingly represent the experience of people who are TG. News organizations and entertainment outlets have given attention to the lives, needs, and challenges of TG and gender-nonconforming individuals. Nonetheless, TG individuals are often fearful when seeking healthcare. Experiences of shame, judgment, and rejection with providers lead to anxiety in future encounters. The number of clinical providers who feel prepared to offer care for TG individuals is limited. Many TG individuals have been denied basic primary and preventive healthcare as a result of their TG status. Understanding the concepts of TG and gender nonconformance expands the skill set of the healthcare professional for providing culturally competent care to all patients and their family members.

This review contains 26 figures, and 59 references.

Key Words: cis-sexual, gender binary, gender confirmation surgery, gender dysphoria, gender nonconforming, intersex, LGBTQ, queer, transgender, WPATH

During pregnancy many chronic gastrointestinal disorders can undergo exacerbations. In addition, pregnant women are often susceptible to new gastrointestinal symptoms. The goal of care is to control symptoms, minimize exposure to excessive tests and medications and rule out any urgent need for surgery.  Efforts should be made to minimize risk to mother and fetus when performing diagnostic endoscopic and radiologic tests. In this chapter, we will review the current management of common gastrointestinal disorders during pregnancy, including gastro-esophageal reflux disease, constipation, appendicitis, inflammatory bowel disease and gall stone disease. The safety of medications used to treat gastrointestinal disease will be reviewed and new treatment guidelines and concepts will be discussed.

This review contains 5 tables, 4 figures and 55 references.

Key words: appendicitis, cholelithiasis, constipation, Crohn’s disease, gall stones, gastrointestinal disease, gastro-esophageal reflux disease, jaundice, pregnancy, ulcerative colitis 

The exacerbation of pre-existing psychiatric conditions and the development of a new-onset psychiatric disorder during pregnancy directly affects the care of pregnant women. Depression and anxiety are highly prevalent in reproductive age women and may be exacerbated in the perinatal and postpartum periods. Post-traumatic stress disorder is another common condition seen in this population and may worsen under the stress of pregnancy, delivery, and childrearing. Substance abuse is also pervasive in this population, requiring obstetricians to have a thorough understanding of how to manage and treat pregnant women with dependence disorders. Psychiatric conditions and substance abuse often co-exist. These and other disorders present significant risk to the mother and fetus. It is essential therefore for obstetric care providers to understand how to screen for, diagnose, and treat psychiatric disorders during pregnancy and in the postpartum period.

This review contains 4 tables, and 58 references.

Keywords: perinatal depression, postpartum depression, postpartum psychosis, anxiety in pregnancy, substance abuse in pregnancy, post-traumatic stress disorder in pregnancy, eating disorders in pregnancy, pregnancy screening

While certainly a life-saving procedure for some, an excess of cesarean delivery in recent years has contributed to morbidity and mortality among women of childbearing age. The prevention of cesarean delivery focuses on changing the habits of providers: promoting patience with labor, standardizing the terminology and interventions for fetal heart rate tracings, proper selection of candidates for trial of labor after cesarean, and decreasing production pressure stress on the Labor and Delivery unit. Progress can be assessed through audit and feedback. Even as providers aim to lower the cesarean delivery rate, they must also monitor maternal, fetal, and newborn morbidity as balancing measures.

 This review contains 3 figures, 6 tables and 56 references

Keywords: cesarean, maternal morbidity, neonatal morbidity, labor, VBAC, TOLAC, induction, quality improvement, delays in transport to OR

Pediatric rashes are a common chief complaint in the emergency department (ED) and a source of anxiety for both parents and providers. Many of these rashes will not require intervention aside from symptomatic relief and parental reassurance. However, there is a subset of rashes that are the result of underlying life-threatening conditions that will warrant immediate intervention and treatment to prevent further deterioration and possible death. This review focuses on outlining the pathology of seven potentially deadly pediatric rashes that ED physicians are likely to encounter, how they present, and how to treat and manage them according to the most recent available guidelines. Figures show primary lesions, pattern of lesions, and distribution of rash associated with bacterial meningitis, toxic shock syndrome (TSS), Rocky Mountain spotted fever, Stevens-Johnson syndrome/toxic epidermal necrolysis, erythema multiforme minor and major, necrotizing fasciitis, and Henoch-Schönlein purpura. Tables list bacterial meningitis antibiotic treatment, Centers for Disease Control and Prevention clinical and laboratory criteria for TSS, TSS antibiotic treatment regimens, scoring systems for toxic epidermal necrolysis and necrotizing fasciitis, and the latest guidelines as of June 2017.

This review contains 9 figures, 17 tables, and 58 references

Keywords: Pediatric rash, toxic shock syndrome, skin rash, rash distribution, Rocky Mountain spotted fever, Stevens-Johnson syndrome, toxic epidermal necrolysis,  necrotizing fasciitis, Henoch-Schönlein purpura

Fever is one of the most common chief complaints among pediatric emergency departments. The evaluation and approach to a pediatric fever can be challenging. Although most cases of fever are viral in origin, the potential for a deadly bacterial infection would make even the most seasoned practitioner attentive. This review discusses the initial assessment of the pediatric patient and both necessary and recommended workups for pediatric fevers among various age groups. Common infections of bacterial and viral causes for fever are discussed and treatment recommendations offered. 

This review contains 3 figures, 9 tables and 57 references

Keywords: Pediatric fever, otitis media, pneumonia, urinary tract infection, neonatal sepsis, bacteremia, meningitis, serious bacterial infection, viral illness

Head injury is one of the most common reasons children present to the emergency department (ED) and the leading cause of pediatric death and disability. Head injuries can range from having no neurologic deficits to death. Management in the ED centers on determining if there is a serious brain injury and preventing secondary brain injury. In most cases of mild traumatic brain injury, serious injuries can be ruled out based on the history of the injury, associated symptoms, and clinical assessment. Concussion is a common presentation of head injury and encompasses a wide range of symptoms. Computed tomography should be used judiciously, and extensive research has led to algorithms to aid in this decision. Prior to discharge from the ED, parents will often have questions about when their child may resume normal activity. This is a decision that most often will involve the patient’s primary care provider or a concussion specialist as the ED provider is unable to follow progression or resolution of symptoms. However, the ED provider should be able to provide anticipatory guidance.

This review contains 5 figures, 7 tables, and 48 references.

Keywords: computed tomography, concussion, head injury, mild traumatic brain injury, traumatic brain injury

Pediatric endotracheal intubation is a procedure that can be stress provoking to the emergency physician. Although the need for this core skill is rare, when confronted with this situation, the emergency physician must have knowledge of the anatomic, physiologic, and pathologic components unique to the pediatric airway to optimize success. Furthermore, the emergency physician should be well versed in the various equipment and adjuncts as well as techniques developed to effectively manage the pediatric airway. This review covers the pathophysiology and practice of endotracheal intubation. Figures show a gum elastic bougie; the Mallampati classification; appropriate oropharyngeal, laryngeal, and tracheal axes; advancing the laryngoscope to lift the epiglottis; endotracheal tube position in neonates; and synchronized intermittent mandatory ventilation pressure-regulated volume control mechanical ventilation. Tables list endotracheal tube sizes, neonatal endotracheal tube sizes, pediatric laryngeal mask airway sizes, commonly used induction agents, and endotracheal tube insertion depth guidelines.

This review contains 6 figures, 8 tables, and 77 references.

Key words: emergent tracheal intubation; endotracheal tube; laryngoscopy; pediatric airway; pediatric airway management; pediatric endotracheal intubation; pediatric laryngeal mask; video laryngoscopy

Upper airway obstruction is a common reason that children present for emergency care, and causes range from simple and benign etiologies to life-threatening conditions requiring emergent intervention. Both congenital and acquired conditions can result in airway obstruction at various levels, and due to the high risk of acute decompensation associated with some of these conditions, rapid diagnosis and treatment are essential. This review covers assessment and stabilization, diagnosis, and treatment of foreign-body aspiration, croup, bacterial tracheitis, epiglottitis, peritonsillar abscess, and retropharyngeal abscess. Figures show a diagram of the pediatric airway, an anteroposterior radiograph of the neck demonstrating the characteristic “steeple sign” in croup, an algorithm for the treatment of croup, lateral radiographs demonstrating a thickened epiglottis, consistent with a diagnosis of epiglottitis,  and a widening of the prevertebral soft tissues of the neck, consistent with a diagnosis of retropharyngeal abscess. Tables list causes of upper airway obstruction by anatomic location, symptoms of upper airway obstruction by anatomic location, severity of croup, and microbiology of deep neck abscesses.

This review contains 5 figures, 13 tables, and 32 references

Key words: Upper airway obstruction; Pediatric upper airway obstruction, Foreign-body aspiration, Croup, Bacterial tracheitis, Epiglottitis, Peritonsillar abscess, Retropharyngeal abscess, Stridor

Child abuse accounts for over 1% of visits to pediatric emergency departments (EDs), and injuries related to abuse have higher morbidity and mortality than accidental injuries. Recognizing child abuse and neglect in the ED is challenging but critical to prevent recurrent episodes of abuse and long-term physical and emotional sequelae. This review defines child abuse and neglect and explores historical and physical examination findings, assessment and diagnosis, treatment, disposition, and outcomes for victims of child abuse. Figures show x-rays demonstrating common fracture patterns associated with abusive injury and an algorithm for evaluation of nonaccidental trauma in the ED. Tables list key historical elements in the evaluation for abuse or neglect, bruising characteristics suggestive of abuse, fractures that are specific for abuse, and recommended laboratory evaluation for suspected abuse. 

This review contains 4 figures, 4 tables, and 37 references.

Key words: child abuse, child neglect, nonaccidental trauma, sexual abuse

Diarrhea is a common emergency department (ED) complaint, leading to more than 1.5 million outpatient visits and 200,000 hospital admissions in the United States alone. Although concomitant dehydration also exists in some cases, there are no standard clinical criteria to aid in identifying those children who merit intravenous resuscitation. Current pediatric volume repletion guidelines are based primarily on the estimated degree of volume depletion per the World Health Organization, Centers for Disease Control and Prevention, and American Academy of Pediatrics criteria. These practice guidelines stratify patients into mild (3 to 5% volume depletion), moderate (5 to 10% volume depletion), and severe (> 10% volume depletion). The vast majority of pediatric patients presenting with nausea, vomiting, and/or diarrhea suffer from virus-mediated enterocolitis and require no testing or intravenous fluid resuscitation due to the self-limiting nature of these syndromes; rotavirus and Norwalk virus are two of the most common causes of infectious diarrhea in both developing and developed countries. Although bacterial pathogens rarely cause infectious colitis, children who present with more severe symptoms, including fever, bloody stool, and significant abdominal discomfort, warrant additional diagnostic evaluation. Obtaining a careful history, including exposures to livestock, well water, travel, and antibiotic use, as well as recent intake of undercooked meat, is key to identifying patients who may be at higher risk for bacteria-mediated illnesses. Tables identify common diarrheal pathogens, diarrheal subtypes, and clinical abnormalities associated with volume depletion and more severe syndromes, such as hemolytic-uremic syndrome.

This review contains 5 figures, 9 tables, and 79 references.

Key words: Clostridium difficile, dehydration, diarrhea, gastroenteritis, hemolytic-uremic syndrome, pediatrics

Pediatric abdominal emergencies represent a diverse group of conditions affecting children of all ages and are a common cause of emergency department visits. The challenge for emergency physicians is discerning which child presenting with the common complaints of abdominal pain, nausea, vomiting, and diarrhea has an abdominal emergency. The emergency physician must use a thorough history, developmentally appropriate examination skills, and integration of his or her knowledge base to arrive at the correct diagnosis. This review evaluates the most common pediatric abdominal emergencies organized by chronicity from birth to adolescents: midgut volvulus, infantile hypertrophic pyloric stenosis, incarcerated inguinal hernia, ileocecal intussusception, Meckel diverticulum, and appendicitis. Readers will understand common presentations as well as the evaluation and treatment options for each diagnosis.  

This review contains 7 figures, 9 tables and 64 references

Key words: abdominal pain, appendicitis, hernia, hypertrophic pyloric stenosis, intussusception, Meckel diverticulum, midgut volvulus

Seizures represent a common neurologic complaint among pediatric patients in the emergency department (ED). They can be classified as generalized or focal. In terms of etiology, seizures are most basically broken down into “acute symptomatic” seizures, which are due to another primary medical cause, and unprovoked seizures which occur as a primary pathology. Febrile seizures are the most common types of seizures in children, which themselves can be simple or complex. The most concerning seizures are those which associate with meningismus, encephalitis, metabolic derangements, intracranial mass, and, of course those which progress to status epilepticus. Significantly, it is appropriate and even critical to assume status epilepticus and intervene accordingly whenever a child arrives to the ED seizing for an unspecified period of time. This review covers the initial evaluation, resuscitation, management, work-up, and disposition of pediatric patients who present to the emergency room with seizures. Figures in this chapter illustrate stepwise and algorithmic approaches to initial management, expanded differential, systematic diagnostic approach, and disposition for pediatric patients presenting with seizures and status epilepticus. Tables list important physical exam components for evaluating children with seizures, classifications of seizures, common seizure look-alikes in children, features of febrile seizures, etiologies of pediatric seizures.

Key Words: Pediatric seizures, febrile seizures, pediatric neurologic emergencies, pediatric emergency medicine, status epilepticus 

Proper care of orthopedic injuries and emergencies in children and adolescents requires knowledge of the altered bone and ligament characteristics, varying stages of skeletal development, and potential for congenital or developmental abnormalities. Pediatric fractures affecting the growth plate require unique management to maintain optimal growth. Whereas some specific fractures in these skeletally immature patients require urgent surgical repair, other fractures remodel extremely well and can be managed with a simple splint. Particular dislocations are common in this population and may have concomitant fractures. There are several overuse injuries seen primarily in children, and treatment aims to keep the patient active while allowing the injury to heal. Potentially devastating osteoarticular infections occur in the pediatric population and must be differentiated from more benign causes of joint pain, such as transient synovitis or congenital abnormalities. Children are also at risk for abnormalities such as slipped capital femoral epiphysis or Legg-Calvé-Perthes disease, which are rarely diagnosed in the adult population. It is imperative for a clinician to be aware of these and other nuances to optimally care for orthopedic injuries and emergencies in the pediatric population.

This review contains 9 figures, 19 tables and 51 references

Keywords: bone, musculoskeletal, orthopedic, skeletal, osteomyelitis, pediatrics, fracture, Legg-Calvé-Perthes disease

Respiratory illnesses account for a significant proportion of pediatric morbidity and mortality. Respiratory complaints are a common cause of emergency department visits and hospital admissions. They range from mild and self-limited to severe and rapidly progressive. This review discusses the pathophysiology, assessment, stabilization, and management of asthma, community-acquired pneumonia, and bronchiolitis. Given the prevalence of these conditions and the morbidity and mortality attributed to them, it is important for clinicians to be familiar with their presentations and up to date on evidence-based management recommendations.

This review contains 7 figures, 25 tables and 80 references

Keywords: antibiotics, asthma, bronchiolitis, community-acquired pneumonia, pediatric respiratory, pneumonia, respiratory emergency, respiratory illness, respiratory syncytial virus

Sepsis accounts for approximately one in three hospital deaths, and is associated with very high health care costs due to prolonged lengths of stay in the intensive care unit and hospital. Sepsis is essentially an immunologic response to infection that is propagated systemically, leading to diffuse cellular and microcirculatory dysfunction, vasodilation, vital organ hypoperfusion, and eventual failure. This review covers the pathophysiology, stabilization/assessment, diagnosis, treatment, and disposition and outcomes of sepsis. Figures show the inflammatory and thrombotic response to infection, the action of nitric oxide on vascular smooth muscle cells, accelerated glycolysis and increased lactate production as a result of the catecholamine surge seen in septic shock, sepsis mortality associated with number of organ failures identified in the emergency department (ED), and protocolized therapy for septic shock. Tables list definitions of sepsis syndromes; frequently cited scoring systems for mortality prediction in emergency department patients with sepsis; Sequential Organ Failure Assessment (SOFA) score; current recommendations regarding treatment bundles at 3 and 6 hours of resuscitation; antibiotic recommendations based on suspected source; and vasopressors used in septic shock with recommended dosing, mechanism of action, and indications.

This review contains 5 figures, 7 tables, and 57 references

Keywords: Sepsis; Surviving Sepsis Campaign guidelines, definitions, SEP-1 sepsis quality measure, time-to-antibiotics, volume resuscitation, lactated ringers

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and death worldwide. This edition reviews the epidemiology and etiologies of COPD, including the gender effects, racial differences, and more recently identified genetic factors associated with this condition. It details the many pathogenetic mechanisms thought to be associated with this disease state, such as increased airway inflammation and turnover of extracellular matrix. There is a detailed discussion about diagnosis, classification, and the therapeutic options available for both stable disease and acute exacerbations. The recent evidence supporting various treatments, such as vaccinations, inhaled bronchodilators, inhaled corticosteroids, oral corticosteroids, antibiotics, supplemental oxygen, pulmonary rehabilitation, and surgery, is reviewed in depth. There is further evaluation of experimental approaches, such as bronchoscopic lung reduction procedures and the use of extracorporeal carbon dioxide removal for hypercapnic respiratory failure. The many complications associated with COPD are described, acknowledging that evidence continues to suggest that COPD has a significant systemic component associated with increased rates of psychiatric illness, cardiovascular disease, osteoporosis, and skeletal muscle dysfunction along with lung cancer. Overall this text serves as an excellent evidence-based guide to better understand, diagnose, and manage COPD and its array of associated complications.

Key words: chronic obstructive pulmonary disease (COPD), COPD complications, COPD diagnosis, COPD management, COPD pathophysiology, Global Initiative for Chronic Obstructive Lung Disease (GOLD)

This review contains 6 highly rendered figures, 4 tables, and 239 references.

The human body is programmed to maintain constant homeostasis of all body systems through a complex neuroendocrine and autonomic network. Through a variety of exaggerated autonomic and cytokine responses, illness and injury alter this homeostasis. Mechanisms that are impaired include glucose cellular transport and peripheral and hepatic insulin uptake. Over the past several decades, numerous reports have described the deleterious effects of glucose variability and hyperglycemia. In a randomized prospective study of critically ill patients, Van den Berghe first reported that intensive glucose control (≤ 110 mg/dL) significantly decreased morbidity and mortality. This study was a catalyst for a multitude of subsequent reports evaluating the effects of glycemic control in other patient populations. 

This review contains 1 figures, 5 tables, and 90 references.

Keywords: Hyperglycemia, critical illness, intensive care unit, tight glycemic control, stroke, myocardial infarction, postoperative period, sepsis

Inotropes and vasopressors play a key role in the management of shock. The goal of therapy is to restore end-organ perfusion by augmenting cardiac output (CO) and vascular tone. Clinical trial data have thus far failed to identify precise hemodynamic end points associated with better outcomes; in any event, such end points are highly likely to be determined on an individualized basis, reflecting patients’ chronic arterial blood pressure, baseline cardiac function, and other pathophysiologic factors (e.g., end-stage renal failure, cardiac ischemia).¹ Inotropes enhance cardiac contractility and CO; vasopressors raise blood pressure. The impact of these drugs in restoring hemodynamic parameters to “normal” values has principally been used to evaluate their effectiveness, with clinical practice guided by extrapolation from animal studies and pharmacologic trials.² However, these drugs have important extra-cardiovascular effects on metabolic, neurohormonal, and autonomic regulation that are also injurious. This review discusses the mechanisms and evidence base for inotropes and vasopressors in various types of shock.

This review contains 3 figures, and 39 references.

Keywords: inotropes, vasopressors, catecholamines, monitoring, shock states, cardiogenic, hemorrhagic, septic, neurogenic

Acute respiratory failure (ARF) is fundamentally a dysfunction of gas exchange and can be due to either inadequate carbon dioxide elimination causing hypercapnia or poor oxygen exchange and delivery causing hypoxemia. A variety of etiologies exist that cause ARF in the surgical patient, including previous lung disease, such as chronic obstructive pulmonary disease or asthma, neurologic compromise of respiratory drive, nutritional and metabolic derangements that can alter respiratory metabolism and mechanics, direct lung injury, and infection. The type of surgery and the time since surgery are other key factors that influence medical decision making and that will influence priorities in the assessment and management of ARF. This review explores the full spectrum of ARF in the surgical patient, focusing particularly on its assessment and initial management. Figures illustrate algorithms in the approach to the surgical patient with ARF and show example radiographic images of acute respiratory distress syndrome (ARDS), a common complication. Tables summarize indications for emergent intubation, key etiologies of ARF, and the evolving definitions of acute lung injury and ARDS.

Key words: acute respiratory distress syndrome, acute respiratory failure, hypercapnia, hypoxemia, mechanical ventilation 

The respiratory tract can be infected by a diverse group of viruses that produce syndromes ranging in severity from mild colds to fulminant pneumonias. Respiratory viral infections are a leading cause of morbidity, hospitalization, and mortality throughout the world; influenza and pneumonia were the most prevalent infectious causes of death during the 20th century in the United States.

This review contains 8 figures, 26 tables and 87 references.

Keywords: Virus, infection, respiratory tract, antiviral, pneumonia, croup, pharyngitis, epidemic, pandemic, outbreak

Acute respiratory failure (ARF) is a common reason for admission to the intensive care unit (ICU), and is associated with significant morbidity and mortality. Failure of one or more components of the respiratory system can lead to hypoxemia, hypercabia, or both. Initial evaluation of patients with ARF should include physical examination, chest imaging, and arterial blood gases (ABG) sampling. As ARF is often a life-threatening emergency, a patient’s oxygenation and ventilation will need to be supported at the same time that diagnostic and therapeutic interventions are planned. The priorities for early treatment are essentially those of basic life support: airway and breathing. The first step is to assess a patient’s airway and ascertain that it is patent. This is followed by efforts to support both oxygenation and ventilation. This can include non-invasive or invasive mechanical ventilatory support. As with all interventions, there are risks inherent in the use of mechanical ventilation, which may be minimized by the use of lung protective ventilation (i.e., with low tidal volumes and airway pressures). Finally, due to the potential complications associated with mechanical ventilation, it is important to regularly assess whether a patient continues to require the assistance of the ventilator, and to liberate patients from mechanical ventilation at the earliest opportunity when clinically safe and feasible to do so. Figures depict pressure-time curve. Tables list the clinical causes of hypoxemic respiratory failure, oxygen delivery devices, indications for noninvasive positive pressure support, common causes of abnormal respiratory mechanics, and common causes of acute respiratory distress syndrome (ARDS).

This review contains 2 highly rendered figures, 5 tables, and 86 references.

Hypertension is the most common chronic medical condition, affecting more than 1 billion people worldwide. When acute hypertension causes end-organ damage, this is termed a hypertensive emergency. Hypertension can result in a variety of life-threatening clinical scenarios, including aortic dissection, intracerebral hemorrhage, renal dysfunction, pulmonary edema, acute coronary syndrome, and eclampsia. These require aggressive management, whereas asymptomatic hypertension can be managed on an outpatient basis. This review covers the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition of patients with hypertensive crises, including a discussion of the various pharmacologic agents available to the emergency physician. Figures show the types of hypertensive emergency, clinical manifestations, and pharmacologic treatment. 

This review contains 3 figures, 21 tables, and 37 references.

Key words: acute coronary syndrome, aortic dissection, asymptomatic hypertension, eclampsia, hypertension, hypertensive crisis, hypertensive encephalopathy, stroke

A seizure is a sudden change in behavior that is accompanied by electrical discharges in the brain. Many patients presenting with a first-ever seizure are surprised to find that it is a very common event in both children and adults. Epilepsy, a chronic disorder of the brain characterized by recurrent unprovoked seizures, is far less common. Patients who present to the emergency department with seizures vary considerably in underlying etiology, symptoms, and prognosis. Optimal care of the seizure patient in the emergency department requires differentiating those who need little intervention from those requiring intensive resuscitation. This review presents the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of seizure. Figures show the progression of selected neuronal pathophysiologic mechanisms involved over time during and after status epilepticus, tongue bite from seizure, a general emergency department management strategy for patients with seizure presentations, an electroencephalogram of a patient who experienced convulsive syncope after placement of an intravenous line, and staged treatment of status epilepticus. 

This review contains 5 figures, 8 tables, and 55 references. 

Key words: Acute seizure, convulsion, epilepsy, seizure, status epilepticus, antiepileptic drug, neuroimaging

Heart failure is a syndrome related to abnormal cardiac performance with a consequence of impaired cardiac output at rest or with exertion and/or congestion, which usually leads to symptoms of fatigue, dyspnea, and edema. The syndrome is characterized by various phenotypes related to a vast array of etiologies with diverse management targets. The current broad categorization of heart failure separates patients based on ejection fraction. Further description of the phenotype beyond ejection fraction is imperative to correctly identify the etiology of heart failure and, ultimately, to choose medical, device, and surgical therapies appropriately. This review covers the epidemiology of heart failure, defining the phenotype and etiology of heart failure, recognition and management of acute decompensated heart failure, management of chronic heart failure with a reduced ejection fraction, implantable cardioverter-defibrillators in heart failure with a reduced ejection fraction, management of heart failure with a preserved ejection fraction, and advanced heart failure. Figures show the evolution of therapy in chronic heart failure from the symptom-directed model, the complex pathophysiology and principal aberrations underlying heart failure with preserved ejection fraction, and concepts underlying surgical therapy in advanced heart failure using Laplace’s law. Tables list various etiologies of heart failure; sensitivity and specificity of clinical, biomarker, and radiographic data in the diagnosis of acute decompensated heart failure; drugs and devices with a demonstrated survival benefit in heart failure with a reduced ejection fraction; neurohormonal antagonist dosing in heart failure with a reduced ejection fraction; randomized, placebo-controlled trials in heart failure with a preserved ejection fraction; categorization of heart failure according to American Heart Association/American College of Cardiology heart failure stage, New York Heart Association functional class, and Interagency Registry for Mechanically Assisted Circulatory Support level; and poor prognostic indicators in heart failure.

This review contains 4 figures, 8 tables, and 114 references.

Under physiologic conditions, the acid-base balance of the body is maintained via changes in ventilation that eliminate carbon dioxide, buffering of acid loads, and renal excretion of hydrogen ions. Failure to maintain the pH of the blood between 7.35 and 7.45 can result in life-threatening conditions. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of acid-base disorders. Figures show the relationship between hydrogen ions and blood pH, proximal tubular bicarbonate reabsorption, the secretion of hydrogen ions, renal ammonia production, ammonium diffusion, metabolic alkalosis, electrocardiographic changes in hypokalemia and hyperkalemia, pseudoinfarction caused by hyperkalemia, and an algorithmic approach to suspected acid-base disorders. Tables list causes of high–anion gap metabolic acidosis, metabolic acidosis with a normal anion gap, type 1 renal tubular acidosis, type 4 renal tubular acidosis and aldosterone resistance, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis; treatment of hyperkalemia; and a stepwise approach for the evaluation of suspected acid-base disorders.

This review contains 9 highly rendered figures, 9 tables, 64 references, and a list of pertinent Web sites.

The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. 

This review contains 2 figures, 6 tables, 51 references

Keywords: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

Acute kidney injury is a common disease that affects critically ill patients and increases morbidity and mortality. Even though there have been extensive efforts to prevent this disease, the incidence has steadily increased over the last decade. This could be attributed to better recognition or to overestimation of the disease based on the most recent consensus criteria. Complications of acute kidney injury have a significant effect on quality of life, morbidity, and mortality. Despite advances in the field, this disease continues to be a challenge, and decreasing the mortality associated with it remains difficult. Plenty of literature has been published about the appropriate definition, diagnosis, and treatment of the disease. One of the topics of ongoing discussion deals with the lack of consensus about the exact timing for initiation of renal replacement therapy (RRT). Even though RRT adds more complexity to the treatment, recent publications suggest that early versus late initiation of RRT is related to reduced mortality in critically ill patients. Further high-level studies of this intervention are warranted to standardize treatment.

This review contains 5 figures, 8 tables, and 78 references          

Keywords: Acute Kidney Injury Network (AKIN), acute kidney injury, chronic kidney disease, Kidney Disease: Improving Global Outcomes (KDIGO), renal biomarkers, replacement therapy, Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE)

Each year, as many as 98,000 hospital deaths in the United States can be attributed to medical error. Considering that at least half of all medical errors go unreported, the impact they have on mortality, morbidity, prolonged hospital stay, rising hospital costs, and the doctor-patient relationship cannot be overemphasized. At the heart of the dilemma are patients and their family members, who rely on clinicians to provide optimal medical care, devoid of mistakes and error, and want an apology if an error has taken place. In this review, we discuss the moral obligation of hospitals to disclose medical error, no matter what the impact. Whereas in the past, a paternalistic approach to medicine viewed this acknowledgment as weakness, there is now a consensus to advocate for full disclosure, apology, and discussions that facilitate early disclosure of error using teams representing administration, patient care liaisons, and treatment providers. Many institutions now recognize that medical errors are commonly the result of a breakdown of checks and balances, and an increasing number are implementing protocols that target system errors to prevent similar future occurrences. We examine institutions across the United Statesthat take a proactive approach by assembling “communication and resolution” programs to address the concerns of patients and their families through the process of disclosure. We also explore barriers to disclosure, which are attributed to lack of training, fear of litigation, and the “shame and blame culture.” We discuss the benefit, to both patient and provider, of disclosure of accountability as we move toward a culture of strengthening systems and improving patient care and patient-provider relationships.

Key words: apology, culture, disclosure, error, resolution

Mechanical circulatory support (MCS) involves the use of intra-aortic balloon pump (IABP), short-term percutaneous ventricular assist devices, long-term surgically implanted continuous-flow ventricular assist devices (cf-LVADs), and extracorporeal membrane oxygenation (ECMO) for the treatment of acute and chronic heart failure and cardiogenic shock. IABP is increasingly recognized as an important adjunct in the postoperative treatment arsenal for those patients with severely reduced left ventricular systolic function. Short-term percutaneous options for the treatment of acute right and left heart failure include both the Impella and Tandem Heart, whereas the Centrimag is often used in the surgical setting for acute cardiogenic shock and heart failure. Long-term surgical MCS options include the total artificial heart and the cf-LVADs HeartWare and Heartmate II. ECMO is frequently used for the treatment of acute cardiogenic shock and may be placed peripherally via a percutaneous approach or with central cannulation. ECMO is also increasingly used in the setting of acute cardiac life support, known as extracorporeal life support.

This review contains 6 figures, 13 tables and 119 references

Keywords: cardiac critical care, extracorporeal membrane oxygenation, long-term ventricular assist device, mechanical circulatory support, short-term ventricular assist device 

Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy.

This review contains 12 figures, 7 tables, and 38 references

Keywords: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology

Rhabdomyolysis is a condition that results from the breakdown of skeletal muscle. The etiologies can be broken down into three main categories of causes: traumatic, atraumatic exertional, and atraumatic nonexertional. Patients with rhabdomyolysis often present with myalgia and are found to have myoglobinuria with elevations in serum creatine kinase levels. The mainstay in therapy is focused on restoration of intravascular volume with large-volume fluid resuscitation using isotonic fluids. Adequate hydration is necessary to prevent the potential complications of rhabdomyolysis, including the development of acute kidney injury. Practitioners should maintain a high level of suspicion of compartment syndrome in patients with rhabdomyolysis. If extremity compartment syndrome is diagnosed, prompt decompressive fasciotomies should be performed to preserve muscle and nerve viability. The early use of renal replacement therapy in patients with rhabdomyolysis has been described in the literature and may represent another modality of therapy to prevent the adverse sequelae of rhabdomyolysis.

This review contains 8 tables and 42 references

Keywords: acute kidney injury, compartment syndrome, creatine kinase, disseminated intravascular coagulation, rhabdomyolysis

Knowledge regarding the practical aspects of managing continuous renal replacement therapy (CRRT) in the surgical intensive care unit is a prerequisite for achieving desired physiologic end points. Familiarity with the initiation, dosing, adjustment, and termination of CRRT is a core skill for surgical intensivists. Modalities, terminology, and components of CRRT are discussed in this review, with an emphasis on the practical aspects of dosing, adjustments, and termination. Filter selection and management of electrolyte and acid-base derangements are emphasized.

This review contains 4 figures, 9 tables and 32 references

Keywords: continuous renal replacement therapy, continuous venovenous hemofiltration, continuous venovenous hemofiltration dialysis, dialysis, intensive care unit

Trauma accounts for almost 10% of deaths worldwide and is the fourth most common cause of death in the United States. Treatment of the injured patient requires multiple unique resources, including multidisciplinary teams, surgical subspecialties, and dedicated resuscitation areas. Evaluation and initial management of the trauma patient is performed systematically to quickly identify and treat life-threatening injuries. This review serves as an introduction to care for the critically injured patient. It covers the initial steps for evaluation, resuscitation, diagnosis and treatment of the trauma patient and provides a brief overview of various injury patterns resulting from both blunt and penetrating trauma.

This review contains 6 figures, 21 tables and 50 references

Keywords: blunt trauma, damage control resuscitation, FAST exam, lateral canthotomy, penetrating trauma, primary survey, rapid sequence intubation, secondary survey, trauma systems

The use of interventional procedures in trauma has increased steadily over the past 10 years. With advancements in both imaging and device technology, endovascular techniques have become part of the treatment algorithm for both large and small vessel injury. Endovascular therapy in trauma involves a minimally invasive, catheter-based approach, which can be used as a temporizing measure in patients in extremis or as definitive therapy in a wide variety of diagnoses. Sheaths, catheters, and guide wires are universal instruments, regardless of procedure. Devices passed over guide wires form the basis of diagnosis and treatment. Using this technology provides many advantages to traditional open surgical therapy, namely the avoidance of large and potentially morbid incisions. Angioembolization, stent grafting, and resuscitative endovascular balloon occlusion of the aorta (REBOA) are being used with increasing frequency in trauma centers, with established algorithms, multiinstitutional trials, and more published data available, particularly for solid-organ and pelvic hemorrhage.

This review contains 5 figures, 2 tables and 56 references

Keywords: angiography, embolization, hemorrhage, resuscitative endovascular balloon occlusion of the aorta, stent graft

Health care–associated infections (HAIs) are those that are acquired while patients are being treated for another condition in the health care setting. HAIs are associated with substantial morbidity and mortality, with 75,000 deaths attributable to HAIs each year. This review outlines the evolution of HAI as a quality metric and introduces key governmental and professional organization stakeholders. The role of the local infection control program is also discussed. Using the example of surgical site infection, we detail the multitude of factors that contribute to the occurrence of an HAI, evidence-based preventive strategies, and systems-based programs to reduce preventable infections. Specific diagnostic criteria and preventive strategies are also introduced for catheter-associated urinary tract infection, central line–associated bloodstream infection, ventilator-associated pneumonia, Clostridium difficile infection, and various multidrug-resistant organisms.

This review contains 3 figures, 11 tables, and 76 references

Keywords: catheter-associated urinary tract infection, central line–associated bloodstream infection, Clostridium difficile, hospital-acquired infection, infection, quality, surgical site infection, ventilator-associated pneumonia 

Patients facing serious or life-threatening illness experience challenges to their psychological, social, and spiritual lives as well as to their physical function and comfort. Physicians may be accustomed to focusing on the biomedical aspects of illness, but they have a critical role in assessing the patient's psychosocial issues to identify sources of distress and help implement a plan for mitigating them. An appropriate psychosocial assessment requires a methodical and rigorous approach and includes assessment of any psychosocial issue affected by or affecting a patient's experience of illness. This chapter outlines a structured approach to addressing psychosocial issues by discussing (1) the doctor-patient relationship; (2) coping with illness; (3) family dynamics and caregiving; (4) ethnic and cultural issues; (5) religious, spiritual, and existential issues; (6) mental health issues, including adjustment disorder, depression, anxiety, personality disorders, aberrant drug behaviors, and major mental health issues; and (7) grief and bereavement. Tables outline psychosocial assessment questions, factors predisposing patients with serious illness to depression, risk factors for suicide in patients with terminal illness, and classes of antidepressants, anxiolytics, and sedatives. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire is provided, as well as a list of Web sites with further resources about psychosocial issues in serious illness.

This review contains 1 highly rendered figure, 6 tables, and 216 references.

Brain death is the state of irreversible loss of the clinical functions of the brain. A patient must meet strict criteria to be declared brain dead. They must have suffered a known and demonstrably irreversible brain injury and must not have a condition that could render neurologic testing unreliable. If the patient meets these criteria, a formal brain death examination can be performed. The three findings in brain death are coma or unresponsiveness, absence of brainstem reflexes, and apnea. Brain death is closely tied to organ donation, because brain-dead patients represent approximately 90% of deceased donors and thus a large majority of donated organs. This review details a definition and overview of brain death, determination of brain death, and controversy over brain death, as well as the types of organ donation (living donation versus deceased donation), donation after brain death, and donation after cardiac death. A figure presents a comparison of organ donation after brain death and after cardiac death, and a table lists the American Academy of Neurology Criteria for Determination of Brain Death.

This review contains 1 highly rendered figure, 3 table, and 20 references.

Advance care planning (ACP) is defined by the Institute of Medicine as an iterative process that involves discussing end-of-life issues, clarifying relevant values and goals of care, and embodying preferences through written documents and medical orders. ACP is predicated on the principle of respect for autonomy, which recognizes an individual’s right to accept or decline medical therapies. With the development of medical technologies that can sustain life (including mere physiologic existence), effective ACP has become a critical yet underused process for patients, their families, and clinicians. This review discusses the emergence of ACP, promises and pitfalls of advance directives, and promising approaches, including ACP interventions and research, as well as a focus on public engagement and future directions. Figures show a timeline of important advances in ACP since 1990, key features of the comprehensive ACP process, the three core aspects or pillars for implementation of ACP, stages of change for ACP behaviors, and two commercially available end-of-life games. Tables list theoretical pros and cons of advance directives, ACP resources, examples of recent research studies on ACP interventions, types and examples of ACP resources, and public engagement campaigns.

This review contains 5 figures, 12 tables, and 101 references

Keywords: Advance care planning, advance directive, end-of-life

A clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention.  Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.

This review contains 2 figures, 3 tables, and 38 references

Keywords: Clinical trial, study design, type I error, type II error, double-blind study, ethics

Life support technologies have the potential to save many lives. However, in some cases – particularly when disease is advanced or incurable – the use of these interventions may simply prolong the dying process while causing significant pain and suffering. The ethical basis for withdraw of life support has been clearly elucidated in medical ethics and the law, but given the emotions surrounding these issues, it is not surprising that controversy still exists.  This review discusses withdrawal of life support and withdrawal of artificial nutrition. Additionally, this review explores medical futility, including the historical background, futility and the law, focus on process: hospital futility policies and ethics committees, and current practice and the future of medical futility. Illustrative case reports are presented. The table lists some examples of responding to requests for non-beneficial care from patients or surrogates.

This review contains 1 figure, 4 tables, and 28 references

Key Words: Withdrawal of life support; Withdrawal of care; Medical futility  

The role of genetics in medicine is changing quickly. New discoveries are rapidly bridging the chasm from bench to bedside, and in addition to medical advances, thousands of people are exploring their genetic traits and ancestry through direct-to-consumer companies. Staying abreast of these changes and their potential implications for patient care can be difficult. To help, we suggest several high-level points of reference regarding the current state of genomic medicine, with a focus on the ethical and social issues raised by these technologies. This review covers the rise of genomic medicine, information overload, direct access to genetic information, genetic discrimination, and informed consent. Tables list the American College of Medical Genetics and Genomics recommendations for reporting of incidental findings in clinical exome and genome sequencing, an excerpt from the Genetic Information Nondiscrimination Act, and genetics education resources for physicians.

This review contains 3 tables, and 44 references.

Key words: Genomic medicine, genetic medicine, medical genetics, genetic testing, direct-to-consumer genetics, genetic discrimination

So rapidly has the field of health care ethics continued to grow that, when recently “googled,” the term produced 28.2 million hits. The challenge is to address the ethical and social issues in medicine in this very limited article space. It remains an impossible task to present more than a superficial discussion of these complex issues and the complicated cases in which they are to be found. Like good medicine, good ethics cannot be practiced by algorithm. The authors have opted to provide an operational guide to help clinicians sort through the ethical and social quandaries they must face on a daily basis. To that end, the authors have chosen to divide this chapter into the following sections:
1. A brief description of the biopsychosocial nature of ethics and how it differs from personal morality
2. A method for identifying and dealing with ethical issues
3. A discussion of the role of bioethicists and ethics committees
4. The professional fiduciary role of clinicians
5. Listings of some of the common key bioethical and legal terms (online access only)
6. A very brief discussion of the terms cited in the above listings (online access only)

This reviews contains 4 tables, 8 references, 1 appendix, and 20 additional readings.

Keywords: Ethical, social, right, wrong, good, bad, obligation, moral authority, critically reflective, and multiperspectival activity, Curiosity, Honesty, Patience, Open-mindedness