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  Ta rlan Hedayati, MD Negean Afifi, DO Key Points • A normal ejection fraction does not exclude congestive heart failure (CHF), as CHF can occur secondary to either systolic or diastolic dysfunction. • Nitroglycerin is the initial treatment of choice because it reduces both preload and afterload and rapidly improves patient symptoms. INTRODUCTION Congestive heart failure ( CHF) is the leading cause of hospitalizations in the United States in patients older than 65 years. Once symptomatic, up to 35% of patients will die within 2 years of the diagnosis, and more than 60% will succumb within 6 years. The annual costs of treatment are more than $27 billion and will only increase given the aging population. Heart failure occurs when the myocardium is unable to provide sufficient cardiac output to meet the metabolic demands of the body. As the myocardium can no longer keep up with the return of venous blood, pulmonary and systemic vascular congestion occurs. Common causes of CHF include myo

Ch ristopher Ross, MD Key Points • Consider acute coronary syndrome (ACS) in the initial assessment of all patients presenting with chest pa in and/or d ifficu lty breathing. • Atypical presentations are common, especially in women, the elderly, and diabetics. • Obta in an emergent el ectroca rdiogram in all patients with concern for ACS to ra pidly identify INTRODUCTION Acute coronary syndrome (ACS) encompasses a spectrum of disease that includes unstable angina (UA), nonST-segment elevation myocardial infarctions (NSTEMI), and ST-segment elevation myocardial infarctions (STEM!). The distinction between the 3 is based on historical factors, electrocardiogram (ECG) analysis, and cardiac biomarker measurements. ACS is the leading cause of mortality in the industrialized world and accounts for more than 25o/o of all deaths in the United States. More than 5 million patients per year present to U.S. emergency departments with symptoms concerning for ACS, although fewer than lOo/o will be d

Jonathon D. Pa lmer, MD Key Points • Chest pain is a very common complaint in emergency department patients. • A rapid electrocardiogram and chest x-ray will help distinguish between multiple emergent causes of chest pain. INTRODUCTION Chest pain is one of the most common presenting complaints in the emergency department (ED). As several fatal � onditions present with chest pain, it is imperative to rapIdly and thoroughly evaluate these patients to distinguish between emergent and nonemergent causes. Approach chest pain with a broad differential diagnosis and utilize your history, physical exam, and ancillary testing to narrow down the etiology. The pathophysiology of chest pain will vary tremendously depending on the specific etiology. Regardless of the source, pain sensation ultimately occurs owing to stimulation of either visceral or somatic nerve fibers. Somatic nerve fibers innervate the skin and parietal pleura. Patients will typically complain of a pain that is sharp in nature a

La u ren M. Smith, MD Nihja 0. Gordon, MD Key Points • Do not wait for hypotension to diagnose shock. • Early ide ntification and i n itiation of aggressive therapy can significantly improve patient survival. INTRODUCTION More than 1 million patients present to U.S. emergency departments annually with shock, and despite continued advances in critical care, mortality rates remain very high. Shock occurs when the circulatory system is no longer able to deliver enough 02 and vital nutrients to adequately meet the metabolic demands of the patient. Although initially reversible, prolonged hypoperfusion will eventually result in cellular hypoxia and the derangement of critical bio ­ chemical processes. From a clinical standpoint, shock can be divided into the following subtypes: hypovolemic, cardiogenic, obstructive, and distributive. Hypovolemic shock results from an inadequate circulating blood volume owing to either profound dehydration or significant hemorrhage. Traumatic hypovolemia is

Theresa M. Schwab, MD Key Points • Rapid-sequence intubation (RSI) is the preferred method for endotracheal tube placement in the emergency department. • The decision to intubate should always be made on clinical grounds. Time permitting, assess for factors predictive of a difficult airway before RSI. INTRODUCTION Successful airway management depends on the prompt recognition of an inadequate airway, the identification of risk factors that may impair successful bag-valve-mask (BVM) ventilation or endotracheal t ube (ETT) placement, and the use of an appropriate technique to properly secure the airway. The decision to intubate is a clinical one and should be based on the presence of any 1 of 3 major conditions: an inability to successfully protect one's airway against aspiration/occlusion, an inability to successfully oxygenate the blood (hypoxemia), or an inability to successfully clear the respiratory byproducts of cellular metabolism (hypercapnia). Additional indications includin