The Chief Complaint

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Edition: 2014

Copyright 2014 © 5150 Publishing. All Rights Reserved.

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Hermosa Beach, CA 90254

All rights reserved. This book is protected by copyright. No part of this

book may be reproduced in any form or by any means, without the written
permission of the copyright owner.

ISBN-10: 0989851915
ISBN-13: 978-0-9898519-1-6

Disclaimer:
Every effort was made to ensure the completeness and correctness of this
guide. However, errors are certain. The author disclaims any responsibility
for errors or omissions or the results obtained from the use of information
within this book. Readers are encouraged to confirm all information. If you
do not wish to be bound by the foregoing cautions and conditions, you may
return this book at any time. Application of this information in a particular
situation remains the professional responsibility of the practitioner. If errors
or omissions were noted, feedback would be appreciated so that we may
correct the oversight at info@[Link].
"Everything should be made as simple as possible, but not simpler."
Albert Einstein
 Resuscitation
PEA
VT/VF
Shock
Bradycardia
Tachycardia
Post-Cardiac Arrest

Cardiology
Chest Pain
Syncope

Pulmonary
Shortness of Breath
Procedural Sedation

Gastrointestinal
Abdominal Pain: General
Abdominal Pain: Upper
Abdominal Pain: Lower
Diarrhea

Genitourinary
Acute Scrotum

Infectious Disease
Sepsis

Neurology
Altered Mental Status
Weakness
Vertigo
Headache
Acute CVA
Seizure

Pediatrics
Fever: <29 days
Fever: 4-8 weeks
Fever: >8 weeks
Stridor
Crashing Neonate

OB/Gyn
Pregnant Vaginal Bleeding
Acute Pelvic Pain

Trauma
Trauma: Primary Survey
Trauma: Resuscitation
Trauma: Cardiac Arrest
Trauma: Blunt Head
Trauma: Cervical Spine
Trauma: Penetrating Neck
Trauma: Blunt Neck
Trauma: Penetrating Chest
Trauma: Blunt Chest
Trauma: Penetrating Abdomen
Trauma: Blunt Abdomen
Trauma: Pelvis

Orthopedics
Low Back Pain
Joint Pain

Environmental
Hypothermia
Burns
 Personally, I don’t like to refer to patients as complainers (I would
say a 55 yo male “presents with”, NOT “complains of”), but the
terminology is so ingrained in medicine and so widely used at the bedside
that the phrase has become iconic. Having noted that, Chris Feier’s book of
that title is really something totally new in the medical education world.
This pocket sized book does something many have tried to do but few have
achieved, which is to create an orienteering guide to the med-ed landscape
while launching your thought processes AT THE BEDSIDE when
confronted with a new undifferentiated and undiagnosed patient. And it is
truly pocket sized, not like some of the brick shaped (and brick weighted)
books you see dragging a residents white coat into a lopsided drape from
some Edvard Munch painting. This book can actually be put in your pocket
with reasonable ergonomics and retained balance. This is really important
for a book like this to be a functional companion to your stethoscope. When
I was medical student and intern it was The Washington Manual that served
this purpose, but now this book is too Internal Medicine oriented, and it no
longer fits in the pocket of a white coat.
The size also means that the book is not encyclopedic. Rosen’s it
isn’t, and that is good because you need BOTH a wheelbarrow and a
diagnosis to use that thing (or burning curiosity, a burning fire, and a long
cold winter night trapped inside a cabin with a good light source) and
Rosen’s is not chief complaint oriented. While this book will never replace
the comprehensive tomes of EM, it WILL follow students and residents into
the clinical landscape. This pocket manual also links young doctors to
dozens of updated algorithms, podcasts, CME Download, EM-Rap, HIPPO-
EM, the NNT, ACEP guidelines, AHA guidelines and the Abstracts of EM
and serves to orient them when faced with a patient. In this manner it is
more of a map and compass which are crucially important orienteering tools
when you are lost in a forest of differential diagnostic considerations. The
connectivity of this book is quite unusual because it rapidly bridges to a
place all new medical practitioners want to go which is the on-line world. It
lets the computer resources come to bear on the understanding process,
which lets this manual be both small AND powerful. This map and compass
leads directly into convenient computer resources. It also fits better into the
“real world” of on-line learning, visual comprehension, and on-line images
that the modern student and resident are so much more comfortable with.
The original cover of The Chief Complaint was a picture of the
old (1933) Los Angeles County hospital which is the site of the first
academic department of Emergency Medicine (1971), and the second oldest
training program in the country. Arguably it is the birthplace of academic
EM in the United States. Many of the links represent work by LAC+USC
physicians over the years including WR Bukata, Jerome Hoffman, Mel
Herbert, Stuart Swadron, Diku Mandavia, and me. Mel Herbert has been
busily making textbooks irrelevant and is “inverting” the classrooms of EM
medical education around the world with on-line teaching. “County
Hospital” as it is known has trained more EM residents than any other
training program in the US, and Chris Feier (class of 2008) drew heavily on
this heritage when creating his manual.
The audience for this book is clinicians at the beginning of their
careers. Medical students rotating on an EM clerkship, EM interns, Non-
EM interns with an EM service month, and junior EM residents will all find
The Chief Complaint to be a useful resource. This little book will open their
world to great educators, on-line resources, and help them answer the pesky
“What’s your plan?” question that will be asked of them repetitively when
they see a new patient with a common chief complaint in the ED. This book
will also lead them to data that challenges the traditional dogma like the
NNT (the Number Needed to Treat for benefit and harm) by David
Newman, and on-line debates by experts in Emergency Medicine. In this
manner The Chief Complaint moves quickly from the black and white
binary world of algorithms into the clinical reality of grey tones, study
design, evidence based medicine, expert opinion, and controversy while
retaining utility at the bedside.
I hope you will enjoy The Chief Complaint which will continue as
a living document in its on-line version where updates and rewrites can
keep it current. Print versions will follow annually. As a self-published
book on-line updates can be added seamlessly. I congratulate Dr. Feier on
what I see as a new type of clinical tool that fits the learning style of new
clinicians in the field I love, Emergency Medicine.
William K. Mallon MD DTMH FACEP FAAEM
Professor of Clinical Emergency Medicine
Keck School of Medicine at the University of
Southern California
LAC+USC Medical Center, Los Angeles, California
 PEER REVIEW

William K Mallon MD DTMH FACEP FAAEM

Professor of Clinical Emergency Medicine
Keck School of Medicine at the University of Southern California
LAC+USC Medical Center, Los Angeles, California

Stuart Swadron MD FAAEM

Professor of Clinical Emergency Medicine
Keck School of Medicine at the University of Southern California
LAC+USC Medical Center, Los Angeles, California

Mel Herbert MD MBBS FAAEM

Professor of Clinical Emergency Medicine
Keck School of Medicine at the University of Southern California
LAC+USC Medical Center, Los Angeles, California

Edward J Newton MD
Professor of Clinical Emergency Medicine
Chairman, Dept of Emergency Medicine
Keck School of Medicine at the University of Southern California
LAC+USC Medical Center, Los Angeles, California

Ilene Claudius MD
Associate Professor of Clinical Emergency Medicine
Keck School of Medicine at the University of Southern California
LAC+USC Medical Center, Los Angeles, California

Paul Jhun MD FAAEM

Associate Professor of Clinical Emergency Medicine
Keck School of Medicine at the University of Southern California
LAC+USC Medical Center, Los Angeles, California
Edward Kwon MD
Assistant Professor of Clinical Surgery (Trauma)
LAC+USC Medical Center, Los Angeles, California

SPECIAL THANKS

Creative consult: Ariel Bowman MD [PGY2 USC]

Editing: Craig Torres-Ness MD [PGY1 USC] & Erik Akopian MD [PGY1

USC]

Content: Ariel Bowman MD, Ryan Raam MD [PGY4 USC], Brian Doane
MD [USC class of 2014]

Illustrations: Sonia Johnson MD [USC Class of 2010]

Dr Mel Herbert for access to EM:RAP and Essentials of Emergency

Medicine

Dr Diku Mandavia for allowing access [Link] and

Resuscitation Conference

Dr David Newman for use of his website: [Link]

Figure1 for providing cover pictures ([Link])

Red Blanket Society for initial funding/donation of books

To my wife and daughter for all your love and support. Thank you for
putting up with me locking myself away in the office for hours on end.
Also, thanks to my wife for helping me edit the OB/Gyn section.
 WHY THIS BOOK?
(Adapted from: West J Emerg Med. Jan 2008; 9(1): 47–51)

"The Chief Complaint" book was born out of my frustration with

the educational process in medicine. In medical school, professors teach us
by a disease-based system. We read textbooks and learn about Takayasu’s
Arteritis and Diphyllobrohtium latum. We then enter our clinical rotations
with confidence that we know the minutiae about the most uncommon
disease processes. This is when it hits us--patients don’t walk into the
hospital saying they are having acute mesenteric ischemia in the
distribution of their superior mesenteric artery. They say their stomach
hurts.
This is when we learned of the “differential diagnosis,” a list of
diseases that may present with a certain symptom. This is not what I
needed; the differential for a patient with low back pain including zebras
like Scheurmann’s disease on the same list next to common entities like
Spondylolisthesis, which is next to emergent entities like Abdominal Aortic
Aneurysm. I am no better off in my understanding of how to approach these
complaints. What I needed was an algorithm. While searching through
different textbooks for algorithms, I became even more confused.
Traditional medical algorithms seem so complicated with arrows
in every direction. This is where the concept of "The Chief Complaint"
book was born. The goal was to structure algorithms in a way an emergency
physician would approach a patient’s complaint. They are very simple in
their structure and comply with the EM mantra of “worst first.” In
constructing them, I have found that each complaint is approached in its
own unique way and that “one size does not fit all.” They are not meant to
be all-inclusive, but rather to provide a framework upon which to build
future knowledge. They are ideal for those new to medicine or just
beginning emergency medicine training. They can even help experienced
practitioners to be more thorough and efficient.
I initially started writing this book just for myself as a 2nd year
resident so that I could become a better physician. Eight years later, I realize
that I am still learning new things every day and am continuing to expand
on the book.

HOW TO USE THIS BOOK

There is no set structure for each algorithm, much like an

emergency physician will approach each chief complaint (Chest pain,
Syncope etc...) differently. However, there are some general guidelines.
Each complaint is broken down into 3-7 steps that describe how to
approach the complaint. The first step is usually the ABCs which includes
resuscitation if they are critically ill. After that, you want to start ruling out
the major life threatening diseases. This is usually done by looking for red
flags for each disease that you are worried about. For example, in the Low
Back Pain algorithm, you would start by ruling out the life threatening
diseases (AAA, epidural compression, epidural abscess, vertebral fracture
etc...). Then, using the history and physical, evaluate what the likelihood of
each disease process would be. If your suspicion is high enough, you would
proceed with the work-up (PVR, MRI etc...).
The text based portion of the book follows the same outline as the
algorithm but allows a deeper dive into each of the steps with further
explanation and evidence based decision points. Where there is controversy
in medical decision making, (which is quite often in emergency medicine),
a review of the evidence is given in the form of a "Journal Club" box. Each
point in the algorithm is heavily evidence based and documented
throughout the text. References are also made to some of the best learning
resources (EM:RAP, CMEDownload etc...) in emergency medicine for
more details on a topic.

FROM THE AUTHOR

The Chief Complaint is my personal book that I use every day in

the ER. I originally started making this guide for myself as a 2nd year
resident to help me through my shifts. The algorithms then became so
popular with the other residents that I continued to make them and even
started a mini lecture series. I have continued to edit the book over the years
as more studies became available. Parts of this book have been internally
published for the USC residents as "The ER Survival Guide" since I was a
resident. One of the algorithms was also published in WestJEM (West J
Emerg Med 2008;9(1): 47-51). Due to ongoing demand from the residents,
I decided to make it available to the public. I interviewed multiple faculty
members about their own approaches, and integrated this with the literature
and my practice. I also sought after the residents about their greatest
difficulties with the workup and treatment of different complaints and set
out to help resolve those issues.

Everyone's medical practice and approach to patient care is

different. This book represents only one of many approaches. It represents
MY approach and should not be taken as gospel. I implore the reader to
check all facts/figures/doses/recommendations/sources etc. If you are not
willing to do that, then please do NOT buy this book. Immediately stop
reading and return this book for a full refund.

This book is and always will be a work in progress. Medicine is

an ever changing field and every effort has been made to ensure the
information in this book is accurate, easy to use, and up to date. Errors,
however, are expected. Even a misplaced comma can have life threatening
consequences as evidenced by the following statement:

Let's eat, Grandma

Let's eat Grandma

So, I urge readers of this book to give feedback, not only on grammatical
and typographical errors, but also on medical decision making. If a critical
study was left out or there is a better approach to a complaint, I implore you
to send feedback.

Please direct all comments and suggestions to:

Email: info@[Link]
Facebook: [Link]
Website: [Link]

All post publication errors/omissions/corrections will be placed on

[Link]

Thank you,

Chris Feier MD
 Reversible Causes of PEA
• H1-Hypoxia
• H2-Hypovolemia
• H3-Hypothermia
• H4-Hydrogen ion (acidosis)
• H5-Hypo/Hyperkalemia
• H6-Hypoglycemia
• T1-Toxins(TCA, Dig, CCB, β-blocker)
• T2-Tension pneumothorax
• T3-Tamponade, cardiac
• T4-Thrombosis (PE/MI)
• T5-Trauma
1. TRUE SHOCK?
(CMEDownload "Modern Concepts in Shock" USC Trauma 2009)(Essentials 2013 "US in Shock")
General
• The goal for the patient in shock is rapidly identifying that the patient
is in shock, finding the cause of shock and treating the cause while
simultaneously resuscitating the patient
Clinical Presentation
• Ill appearing/AMS
• Tachycardia /Hypotension>20min?
• Met acidosis (lactate>4 mg/dl or Base def <-5)
• Tachypnea (RR>22 or PCO2<32)
• Oliguria: UOP<0.5 ml/kg/h
• Base deficit, lactate and sublingual capnometry (SLCO2) can help
identify patients in early shock and are a predictor of mortality (J
Trauma 2007;62:120)

2. RESUSCITATION
• ABCs
• IV/O2/Cardiac monitor
• Foley
• Crystalloids
20ml/kg boluses
Caution in CLOCK (CNS, Liver, Older, Children, Kidney
disease)
• Antibiotics empirically
• Blood (before Pressors)
• Vasopressors (from α→β: PNEDDI) (EM:RAP 5/10 "Pressors")

PNEDDI (α→β)
• Phenylephrine
• Norepinephrine
• Epinephrine
• Dopamine
• Dobutamine
 • Isoproterenol

3. CAUSE OF SHOCK
Assessment
• Correct emergent and reversible causes
Tension PTX →needle thoracostomy
Cardiac tamponade → pericardiocentesis/thoracotomy
Arrhythmia → shock?
• Vital signs
Shock index: HR/SBP > 0.9 abnormal
SIRS: HR>90; RR>20; T<36 or >38; WBC<4 or >12 (>10%
bands); PaCO2 <32
• Pediatrics assessment
Pediatric assessment triangle
✓ Work of breathing
✓ General appearance
✓ Circulation to skin
• RUSH protocol for sonography (Emerg Med Clin N Am 2010 Feb;28(1):29-56)
The Pump: Pericardial effusion, LV contractility, RV strain
The Tank: IVC/Jugular vein fullness, FAST, Lung (PTX, Pleural
fluid, B lines)
The Pipes: AAA, Ao Dissection, DVT
Classification of shock
• Hypovolemic
Low CVP, Low CI (Cardiac index), High SVR
Volume depletion type
✓ Vomiting/Diarrhea, Heat stroke, Burns, decreased intake
✓ 3rd Spacing Pancreatitis, Burns
Hemorrhagic type
✓ GI bleed/Vaginal bleed, AAA rupture/Dissection, Trauma
• Cardiogenic
High CVP, Low CI-cardiac index, High SVR
Cardiomyopathy
✓ MI/Ischemia
Arrhythmias
 ✓ Tachy (AF/VT), Slow (Brady, blocks)
Mechanical
✓ Valve defect, atrial myxoma, ruptured ventricular
aneurysm
Obstructive
✓ Massive PE, tension PTX, constrictive pericarditis,
cardiac tamponade, pulmonary HTN
• Distributive
Low CVP, High CI, Low SVR
Sepsis/SIRS (See Sepsis Algorithm)
Anaphylaxis, Toxic shock
Drugs
Addisonian crisis
Myxedema coma
Neurogenic shock