21: Resource Equity in a Pandemic

February 23, 2022March 10, 2022 ~ Global EM Student Leadership Program ~ Leave a comment

The Global Burden of Schistosomiasis presented by Farah Mechref

Endemic in 74 countries across Africa, the Middle East, South America, and Asia, schistosomiasis is a neglected tropical disease caused by flatworms or blood flukes known as schistosomes. About 440 million individuals are infected with these trematodes, which reside in the blood vessels of their definitive host and lead to different clinical manifestations depending on the species. In regions endemic for schistosomiasis, the most prevalent form of the disease is
chronic schistosomiasis, resulting from repeated immunological reactions to eggs trapped in organ tissues. Infection begins when individuals enter bodies of water that contain contaminated snails that have released infectious cercariae. These cercariae penetrate the skin of the human host and produce an allergic dermatitis at the site of entry or a “swimmer’s itch.” Antigens are then released from their eggs, which stimulates a granulomatous reaction composed of T cells, macrophages, and eosinophils, resulting in the clinical disease.

Acute schistosomiasis typically presents with sudden onset of fever, malaise, myalgia, headache, fatigue, and abdominal pain lasting 2–10 weeks, with eosinophilia noted on lab findings. Chronic infection cause granulomatous reactions and fibrosis in affected organs, which results in clinical manifestations
that include:

-In S. mansoni and S. japonicum: upper abdominal discomfort that then shows palpable, nodular hepato-spenlomegaly with eventual development of portal hypertension from fibrosis of portal vessels and resulting ascites and hematemesis from lethal esophageal varices.

-In S. haematobium: hematuria, which is so endemic that it’s thought to be a natural sign of puberty for boys and confused with menses in girls, with eventual development of squamous-cell carcinoma of the bladder.

Currently, the only control measures available include (1) mass treatment with Praziquantel (Biltricide) in communities where schistosomiasis is endemic, (2) introduction of public hygiene programs to provide safe water supplies and sanitary disposal of stool and urine, (3) snail eradication programs using molluscicides, and (4) vaccination development to create a more durable and sustained reduction in transmission.

Discussion Questions:

Knowledge of transmission and preventative measures play an important role in schistosomiasis control, what other endemic conditions could be better tackled with improved patient education?
With 230 million actively infected patients and another 200 million with latent infections, is a vaccine worth the resource distribution or should funding go towards expanding the anti-parasitic classes available for treatment?

Resource Equity in a Disease Outbreak by Alison Neely

The Ebola virus disease of 2013-2016, centered in West Africa, was considered one of the most threatening cases of infectious disease outbreak in modern history up until the emergence of Covid-19 in 2019. Due to the high case fatality rate of Ebola, the core element of the outbreak response was effective case identification and rapid isolation; treatment centers were quickly overwhelmed and experienced limited bed supply and staff time. A study drawing from interviews with senior healthcare personnel involved in this Ebola outbreak response aimed to identify the ethical issues involved in such a response and to create a framework of ethical guiding principles for future responses.

The framework proposed after analysis of the participants’ interviews was split into four categories: community engagement, experimental therapeutic interventions, clinical trial designs and informed consent. Community engagement stood out as a key element both in the framework and in the journal club discussion that followed. Engagement can include promotion of collaboration and open dialogue, incorporation of community insights into decision-making processes, encouragement of transparency, building trust, and reflecting on context-specific cultural values. As future physicians with special interest in global medicine, these ideas of respecting cultural context and complete inclusion of the local community in response efforts were highlighted as very relevant to our future practice.

Discussion Points:

Have the principles presented here been followed in the global response to the Covid-19 pandemic?
Our discussion also focused on the parallels and differences between this Ebola response and the global response to the Covid-19 pandemic, calling attention to the ways that the response both followed and diverged from the framework presented in this article. As the idea of a disease outbreak has become part of daily conversation in the last 2 years, investigations and discussions such as this will become increasingly relevant and important. We also touched on the idea that our global response to Covid-19 may have been very different, and potentially weaker, if the Ebola outbreak had not occurred when it did.

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings. Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Farah Mechref, MS4

Texas Tech University Health Sciences Center

Alison Neely, MS4

Albert Einstein College of Medicine

Keep in Touch:

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Research – Final Thoughts And Recommendations

February 21, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 19th episode is “Final Thoughts And Recommendations”

Prof Fikri Abu-Zidan - Short Bio

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.

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Question Of The Day #77

February 18, 2022February 12, 2022 ~ Joseph Ciano, USA ~ Leave a comment

	Test Value	Reference Range
pH	7.55	(7.35-7.45)
pCO₂	20	(35-45)
pO₂	84	(80-100)
HCO₃	18	(22-26)

Which of the following is the most appropriate next step in management?

Explanation

This patient presents to the Emergency department for altered mental status, nausea, and tinnitus (ear ringing). Her exam shows a confused female with tachypnea, tachycardia, borderline fever, wet skin, and normal pupil size. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. The immediate evaluation and treatment of this patient should focus on the ‘ABCs’, or an abnormality in the airway, breathing, and circulation. Any rapidly correctable causes of altered mental status, like hypoxia, hypoglycemia, hyperthermia, should be addressed appropriately at this stage (i.e., supplemental oxygen, IV dextrose, body cooling).

This patient’s exam mimics many aspects of a sympathomimetic toxidrome, however, having the awareness that oil of wintergreen is a potent salicylate will lead to the diagnosis. This patient has salicylate poisoning. Salicylates are present in many over the counter pain medications, including aspirin, oil of wintergreen (methyl salicylate), and Pepto-Bismol (bismuth subsalicylate). An acute overdose of salicylates may present as tachycardia, hypertension, and hyperthermia, similar to a sympathomimetic toxidrome. Other features include tinnitus, altered mental status, seizures, and coma.

The patient’s ABG shows a respiratory alkalosis (elevated pH, low pCO₂) mixed with a metabolic acidosis (low HCO₃). Salicylic acid disrupts the body’s ability to process energy at the cellular level by acting as an ‘uncoupler’ of the oxidative phosphorylation process. Salicylates directly stimulate the respiratory centers in the brainstem, triggering hyperventilation and increased lactic and pyruvic acid. Hyperventilation causes the initial respiratory alkalosis, and the elevated lactic and pyruvic acid later causes an increased anion gap metabolic acidosis or a mixed metabolic acidosis and respiratory alkalosis.

The treatment of salicylate overdose is prompt IV NaHCO₃infusion (Choice D) to alkalinize the urine and blood. This assists in the more rapid clearance of salicylates. Hemodialysis can be considered if salicylate levels are over 80-100mg/dL, or if there is persistent altered mental status, acidosis, or organ failure despite starting the NaHCO₃infusion. PO Activated charcoal (Choice A) is helpful in binding certain toxins and preventing their absorption through the GI tract. Charcoal is most beneficial when it is used early after drug ingestion. This patient was exposed to salicylates by a topical route, so PO charcoal would not be helpful. IM Glucagon (Choice B) is helpful in hypoglycemia and betablocker overdose. This patient is not hypoglycemic and was not exposed to betablockers. IV Atropine (Choice C) is helpful in patients with a cholinergic toxidrome (i.e., organophosphates, nerve gases), but would not be helpful in this patient. Atropine would likely worsen the patient’s tachycardia. The best next step would be IV NaHCO₃infusion (Choice D).

References

Berger, M. (2018). Salicylate Toxicity. CORE-EM. https://coreem.net/core/salicylate-toxicity-salicylism/

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Answering Reviewers’ Comments

February 14, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 18th episode is “Answering Reviewer’s Comments”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #76

February 11, 2022February 12, 2022 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management?

Explanation

This patient arrives to the Emergency department 10 hours after ingesting 11grams of paracetamol (APAP). She has mild symptoms of nausea and upper abdominal discomfort and has normal vital signs.

Paracetamol, also known as acetaminophen or APAP, is a commonly used pain medication safe for use in childhood, pregnancy, and breastfeeding. Paracetamol is an ingredient present in many over the counter pain, headache, and cold medications. Toxic paracetamol doses are acute ingestions over 150mg/kg, or about 10grams in adults. Toxic paracetamol doses for children are 150mg/kg. Multiple ingestions of paracetamol over 24 or 48 hours can also cause toxicity. Ingestions of 10grams over 24hours or 6 grams/day over 48hours can also cause toxicity in adults. Symptoms of acute poisoning can be absent or mild in the first 24 hours as seen in this patient. After 24 hours, AST, ALT, bilirubin, and INR levels begin to increase, and over 72 hours post-ingestion, hepatic failure ensues. 5 days after an acute ingestion is when multi-organ failure occurs or hepatotoxicity resolves (less common). Toxicity of APAP is thought to be caused by a toxic metabolite produced during APAP breakdown in the liver known. This toxin is known as NAPQI.

APAP overdose can be fatal without treatment with the antidote commonly known as NAC, or N-acetylcysteine. NAC is a free radical scavenger and prevents the damage caused by NAPQI. If serum APAP testing is available, APAP levels drawn 4 hours after the time of an acute ingestion are used to determine if NAC is warranted. APAP levels over 150mcg/mL at 4hours are the threshold for starting NAC. This is based on use of the Rumack-Mathew Nomogram for APAP (see below).

Hendrickson RG, McKeown NJ. Acetaminophen. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e. McGraw Hill; 2019.

Since this patient’s acute ingestion is above the known 10gram toxic dose, it is reasonable to start N-acetylcysteine therapy (Choice B) without first knowing the exact serum APAP level. PO Activated charcoal (Choice A) can be used after oral ingestions to help bind some toxic substances and prevent their absorption through the GI system. The majority of APAP is absorbed 2-4 hours after ingestion, so charcoal would not be helpful in this case where the ingestion was 10 hours ago. Liver transplantation (Choice C) may ultimately be required for this patient depending on the liver function tests and how the patient responds over the coming days. However, the best next step is NAC treatment to prevent liver failure and death. IV Sodium bicarbonate (Choice D) is used in salicylate and tricyclic antidepressant overdose, but it has no role in APAP overdose. The best next step is IV N-Acetylcysteine (Choice B).

References

Abdrabbo, M. (2018). TOXCard: Acetaminophen toxicity and management. EM Docs. http://www.emdocs.net/toxcard-acetaminophen-toxicity-and-management/
Hendrickson RG. Acetaminophen. In: Goldfrank’s Toxicologic Emergencies 9^th edition. Nelson LS, et al (Eds). New York, NY, McGraw-Hill 2011.

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Submitting A Manuscript To A Journal

February 7, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 17th episode is “Submitting A Manuscript To A Journal”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #75

February 4, 2022March 20, 2022 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with altered mental status after ingestion of an unknown agent as part of a suicide attempt. Her exam demonstrates hypertension, tachycardia, elevated temperature, disorientation, dilated pupils, and dry and hot skin. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s history and exam support the presence of a toxidrome. See the chart below for a review of the most common toxidromes (toxic syndromes).

*Treatment of all toxic ingestions should include general supportive care and management of the airway, breathing, and circulation of the patient. Examples include administration of supplemental oxygen in hypoxia, IV fluids in hypotension, cooling measures in hyperthermia, etc.
**Flumazenil is the antidote for benzodiazepine overdose, but it is rarely used clinically as it can trigger benzodiazepine-refractory seizures.

Paracetamol (Choice A) is often accompanied with little to no symptoms in the first 24hours. Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given. The symptoms exhibited by the patient do not correlate with APAP overdose. Dextroamphetamine (Choice B) is a sympathomimetic agent that could be responsible for many of the patient’s symptoms, like elevated heart rate, hypertension, agitation, and dilated pupils. However, dextroamphetamine should cause diaphoretic skin, not the dry skin that the patient has. Ethanol (Choice C) may be a co-ingested agent in this scenario that could lead to agitation and confusion, but ethanol alone should not cause fever. Diphenhydramine (Choice D) is an antihistamine agent, but it also has anticholinergic properties, especially when taken in excess. This patient has all the signs of an anticholinergic toxidrome. The presence or absence of dry skin can help differentiate a sympathomimetic toxidrome from an anticholinergic toxidrome. Diphenhydramine (Choice D) is the most likely agent responsible for this patient’s symptoms. Correct Answer: D

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/
Srisuma, S. (2015). Physostigmine for management of anticholinergic toxidrome. EM Docs. http://www.emdocs.net/physostigmine-for-management-of-anticholinergic-toxidrome/

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Selecting The Right Journal

January 31, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 16th episode is “Selecting The Right Journal”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #74

January 28, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

This patient presents to the Emergency Department with altered mental status, difficulty breathing, vomiting, and hypersalivation after an unknown ingestion. His exam shows an ill patient with constricted pupils (miosis), wet skin (diaphoresis), bradycardia, and tachypnea. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s constellation of signs and symptoms support the presence of a cholinergic toxidrome due to organophosphate poisoning. See the chart below for a review of the most common toxidromes (toxic syndromes).

Cholinergic toxidromes can be caused by organophosphate or carbamate pesticides, as well as nerve gas agents (i.e., sarin gas). These agents cause poisoning by increasing the amount of acetylcholine at the neuromuscular junction, causing stimulation at muscarinic and nicotinic acetylcholine receptors. This causes a dramatic increase in bodily secretions with increased respiratory secretions and airway compromise as the most common cause of death in this population. The cholinergic toxidrome can be remembered with the mnemonic “DUMBBELLS” (diarrhea/diaphoresis, urination, miosis, bradycardia, bronchorrhea, emesis, lacrimation, low BP, salivation).

The first step in treating any patient who has the potential cause to harm or expose staff members to the poisoning agent is patient decontamination (Choice C). This patient should be undressed and adequately decontaminated by staff members who are wearing personal protective equipment (PPE). Once the patient is decontaminated, the airway should be established with endotracheal tube placement (Choice A) and IV atropine (Choice B) should be given to reverse the toxidrome. Atropine can be started at 2-4mg IV and repeated every 5-10 minutes until respiratory secretions are cleared. Pralidoxime (Choice D) should also be given as soon as possible to prevent irreversible changes (“aging”) to the acetylcholinesterase at the neuromuscular junction. This timeframe varies from minutes to hours after exposure, depending on the agent. All choices provided in this question are important actions to take, but patient decontamination (Choice C) is the most important initial next step. Correct Answer: C

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/
Sahi, N. (2018). TOXCard: Nerve agents. EM Docs. http://www.emdocs.net/toxcard-nerve-agents/

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Fine-Tuning Your Manuscript

January 24, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 15th episode is “Fine-Tuning Your Manuscript”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #73

January 21, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with a depressed mental status and normal sized pupils after an unknown toxic ingestion. Many different agents can act as Central Nervous System depressants and cause this clinical presentation. Some examples include ethanol, toxic alcohols (methanol, ethylene glycol, isopropyl alcohol), benzodiazepines, barbiturates, opioids, and muscle relaxants.

Of the choices listed, Heroin (Choice A) and Alprazolam (Choice B) are the most likely. Heroin is an opioid, and Alprazolam is a benzodiazepine (a sedative-hypnotic agent). The clinical presentation caused by overdoses of opioids versus sedative-hypnotic agents overlaps in many areas, but the pupillary exam can help the most in differentiating the type of ingestion. Opioids will can constricted, pinpoint pupils, while benzodiazepines should not cause change in pupillary size. See the chart below for a review of the most common toxidromes (toxic syndromes).

Cocaine (Choice C) is a sympathomimetic with a CNS excitatory effect, not a CNS depressant effect as in this patient. A large ingestion of paracetamol (Choice D) is often accompanied with little to no symptoms in the first 24hours. Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given. Correct Answer: B

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/

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Approach to the trauma patient – ABCDE of trauma care

January 19, 2022February 19, 2022 ~ Maryam Bagherzadeh, Canada ~ Leave a comment

Case

Jane Doe, 22-year-old female, was in a major car crash and is approaching the trauma bay via an ambulance. You are aware that the patient’s condition is critical, so you do a quick run-through in your head about the approach that you will have to care for them once they arrive to your emergency department. What should your approach to a trauma patient be?

The ABCDE of Trauma Care

The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a clinically proven approach to any critically ill patient that needs emergent care and treatment. It has been proven to improve patient outcomes, optimize team performance and save time when patients are in life-threatening conditions [1]. This approach is applicable to all patients (both adults and children), regardless of their underlying condition. However, the ABCDE approach is not applicable to patients who are in cardiac arrest, in which case the cardiopulmonary resuscitation guidelines should be used [2].

With the ABCDE approach, initial assessment and treatment are performed simultaneously. Once the entire survey is completed, reassessment should be conducted until the patient is stable enough for the care team to be able to move on to the secondary survey and look for a definitive diagnosis.

A - Airway

First, the care team should assess if the patient’s airway is patent. If the patient responds to the team in a normal voice, then that is a good sign that the airway is intact. It is important to note that airway obstruction can be complete or partial, and can be caused by upper airway obstruction or reduced level of consciousness.

Signs of complete airway obstruction are lack of respiration despite great effort. Signs of partial airway obstruction include:
– Changes in the patient’s voice
– Snoring or gurgling
– Stridor (noisy breathing)
– Increased breathing effort

Assess the patient’s airway by looking for rocking chest wall motion and any signs of maxillofacial trauma or laryngeal injury. Perform the head-tilt and chin-lift maneuver to open the airway (note that caution should be conducted in patients with C-spine injury). If there is anything that is noticeably obstructing the airway, suction or remove it. If possible, remove foreign bodies that are causing airway obstruction. Provide high-flow oxygen to the critically ill patient and perform definitive airway if needed [1].

B – Breathing

Generally, airway and breathing are examined simultaneously. Determine if breathing is intact by assessing the respiratory rate, inspecting the chest wall movement for symmetry, depth, and respiratory pattern. Additionally, assess for tracheal deviation and use of respiratory muscles. Percuss the chest for dullness or resonance, auscultate for breath sounds and apply a pulse oximeter [1].

Injuries that impact breathing should be immediately recognized, and life-threatening injuries should be addressed and managed [3]. For example, tension pneumothorax must be promptly relieved by needle thoracocentesis, bronchospasms should be managed with inhalation and assisted ventilation should be considered if breathing continues to be insufficient [1].

C – Circulation

Conditions that threaten the patient’s circulation and can be fatal include shock, hypertensive crises, vascular emergencies such as aortic dissection and aortic aneurisms. These conditions should be immediately identified and managed [1].

Circulation can be assessed by looking at the general appearance of the patient, including signs of cyanosis, pallor, flushing and diaphoresis. Assess for any obvious signs of hemorrhage, blood loss and level of consciousness. Additionally, capillary refill time and pulse rate should be assessed. Auscultate the chest for heart sounds, and blood pressure measurement and electrocardiography should be performed as soon as possible [1].

Additionally, assess for signs of hypovolemia and shock. If these are identified, obtain an intravenous access and infuse saline to restore circulating volume [1]. If there are life-threatening conditions that are compromising the patient’s circulation, promptly identify and treat them as needed. For example, tension pneumothorax should be immediately treated with needle decompression and cardiac tamponade can be relived with pericardiocentesis.

D - Disability

The main disability in the primary survey to be assessed for is the brain. Abnormal neurological status can be caused by primary brain injury or systemic conditions that effect brain perfusion, such as shock, hypoxia, intoxication etc. Assess the level of consciousness by using the Glasgow Coma Scale [4], look for pupillary response and limb movement.

The best way to prevent injury to the brain is to maintain adequate airway, breathing and circulation. Glucose levels can be assessed at bedside for decreased level of consciousness due to low blood glucose levels, and corrected with oral or infused glucose [1].

E – Exposure

The exposure portion of the ABCDE approach involves assessment of the whole-body to avoid any signs of missing injuries. During this part of the management, undress the patient fully and examine the back for any signs of C-spine precautions. Additionally, check for clues for any signs of underlying conditions, such as:

Signs of trauma (i.e. burns, gunshot wounds, stab wounds)
Rashes
Causes of sepsis (i.e. infected wounds, gangrene)
Toxins and drugs (i.e. needle track marks, chemicals, patches)
Other wounds such as bite marks, insect bites, embedded ticks
Iatrogenic causes (i.e. catheters, tubes, implants, surgical sites and scars)

Concluding Remarks

The ABCDE approach to the critically ill patient is a strong and proven clinical tool for initial assessment and treatment of patients in medical emergencies. Widespread knowledge of this skill is critical for healthcare workers and any team providing emergent care to trauma patients.

*Note that this is a general approach to the trauma patient. Always consult your care team for adequate management of trauma patients and resort to reliable resources for more information on the ABCDE approach.

References and Further Reading

Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117.
Koster, R. W., Baubin, M. A., Bossaert, L. L., Caballero, A., Cassan, P., Castrén, M., … & Sandroni, C. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation, 81(10), 1277-1292.
Subcommittee, A. T. L. S., & International ATLS Working Group. (2013). Advanced trauma life support (ATLS®): the ninth edition. The journal of trauma and acute care surgery, 74(5), 1363-1366.
Sternbach, G. L. (2000). The Glasgow coma scale. The Journal of emergency medicine, 19(1), 67-71.