Geriatrics, Dermatology, Sexually Transmitted Infections, Toxicology and Emergency Care

The associated clinical sciences are where a chiropractor proves to be a primary contact physician rather than a spine technician: the older patient who fell, the mole on the back you see every visit, the young adult whose "back pain" is reactive arthritis, the patient on warfarin who wants a high velocity thrust, and the patient who collapses in the waiting room. Part II tests whether you can recognize these situations, adapt care safely and act correctly in the first minutes of an emergency. This chapter pulls together geriatrics, dermatology, sexually transmitted infections, toxicology and office emergency care, with a constant eye on what must not be missed and when to refer.

Section 1Geriatrics

The physiology of aging

Aging is a gradual loss of physiologic reserve: organs work adequately at rest but have less capacity to respond to stress. This homeostenosis explains why a minor illness or new drug can tip an older patient into decompensation. Slower memory retrieval is normal; decline that impairs daily function is not.

A practical rule for the older patient is atypical presentation. Myocardial infarction may present as dyspnea or confusion, infection as delirium or a fall, and spinal infection as back pain without fever. Treat a sudden change in function as a symptom in its own right.

Falls

Falls are the leading cause of injury related death and of nonfatal injury in adults over 65. About one in four older adults falls each year, and a fall predicts another fall. Falls result from intrinsic factors (weakness, gait disorder, poor vision, neuropathy, orthostasis, cognitive impairment) and extrinsic factors (medications, lighting, rugs, stairs, footwear). The most modifiable are weakness, balance and medications, especially psychoactive drugs (benzodiazepines, sedative hypnotics, antidepressants, antipsychotics) and antihypertensives that cause orthostasis.

Screen every older patient by asking three questions: have you fallen in the past year, do you feel unsteady when standing or walking, and do you worry about falling? A yes to any prompts a gait, strength and balance assessment.

Fall prevention is multifactorial: strength and balance training (tai chi has good evidence), medication review, treatment of orthostatic hypotension, vision correction, home hazard modification and footwear.

Osteoporosis

Osteoporosis is low bone mass with deteriorated microarchitecture and raised fracture risk, defined by DXA of the hip or spine using the T score (comparison with a young adult mean). A T score of −1.0 or higher is normal, between −1.0 and −2.5 is osteopenia, and −2.5 or lower is osteoporosis; a fragility fracture of the hip or spine establishes osteoporosis regardless of T score.

The Z score compares the patient to age and sex matched peers and is used in premenopausal women, men under 50 and children. DXA screening is recommended for all women 65 and older, and FRAX estimates 10 year fracture probability.

Primary osteoporosis is postmenopausal (type I, estrogen loss accelerates trabecular bone resorption, so vertebral and distal radius fractures predominate) or senile (type II, after about 70, cortical and trabecular loss, hip fractures). Secondary causes include glucocorticoid use (the most common drug cause), hyperthyroidism, hyperparathyroidism, hypogonadism, celiac disease, chronic kidney disease, myeloma, alcohol, smoking, anticonvulsants and heparin. Laboratory values (calcium, phosphate, alkaline phosphatase) are normal in uncomplicated osteoporosis, which helps separate it from osteomalacia (low or normal calcium, low phosphate, high alkaline phosphatase, low vitamin D, Looser zones).

The classic presentation is a vertebral compression fracture: sudden midthoracic or thoracolumbar pain after trivial loading (lifting, a cough, bending), loss of height, and progressive thoracic kyphosis. Radiographically, osteoporosis shows generalized radiolucency (about 30 to 50 percent of bone must be lost before it is visible), thinned but sharply defined cortices ("pencil thin" or "picture framing" appearance), prominent vertical trabeculae, and anterior wedge, biconcave ("codfish") or crush deformities. A fracture above T7, a pedicle that is destroyed, or a convex posterior vertebral border raises suspicion of a pathologic fracture from metastasis or myeloma.

Management is shared with medical providers: calcium (about 1,200 mg daily over 50) and vitamin D (800 to 1,000 IU), resistance and balance exercise, fall prevention and drugs. Bisphosphonates (alendronate, risedronate, zoledronic acid) inhibit osteoclasts and are first line (esophagitis; rarely osteonecrosis of the jaw and atypical femoral fracture). Alternatives include denosumab, raloxifene and anabolic agents such as teriparatide.

Polypharmacy

Polypharmacy is commonly defined as taking five or more medications. Risk of adverse events, interactions, falls and confusion rises with each added drug, and age related declines in renal and hepatic clearance make "normal" doses toxic. A classic hazard is the prescribing cascade: a side effect is mistaken for a new condition and treated with another drug (for example, an NSAID raises blood pressure and an antihypertensive is added, or a calcium channel blocker causes ankle edema and a diuretic is added).

The Beers Criteria list potentially inappropriate medications in older adults. High yield examples are benzodiazepines and sleeping pills, strongly anticholinergic drugs such as diphenhydramine, muscle relaxants such as cyclobenzaprine, and chronic NSAIDs. The chiropractor records every product, including supplements, recognizes likely adverse effects and communicates concerns to the prescriber rather than changing a prescription.

Dementia and delirium

Delirium is an acute, fluctuating disturbance of attention and awareness caused by an underlying medical condition, drug or withdrawal. Dementia is a chronic, progressive decline in cognition severe enough to impair independence. They often coexist, because dementia is the strongest risk factor for delirium. Delirium is a medical emergency with substantial mortality; it is often the first sign of infection, drug toxicity, hypoxia, metabolic derangement, urinary retention, stroke or subdural hematoma.

The Confusion Assessment Method (CAM) diagnoses delirium when there is (1) acute onset and fluctuating course and (2) inattention, plus either (3) disorganized thinking or (4) altered level of consciousness. Cognitive screens include the Mini Mental State Examination (MMSE, 30 points; 24 or below suggests impairment), the Montreal Cognitive Assessment (MoCA, 30 points; below 26 suggests impairment, more sensitive for mild cognitive impairment), and the Mini Cog (three word recall plus clock drawing).

The main dementias are Alzheimer disease (most common; early short term memory loss; amyloid plaques, tau tangles and cholinergic loss), vascular dementia (stepwise decline with focal signs), dementia with Lewy bodies (fluctuating cognition, visual hallucinations, parkinsonism, severe antipsychotic sensitivity), frontotemporal dementia (early personality change and disinhibition, younger onset) and normal pressure hydrocephalus (gait disturbance, incontinence and dementia with enlarged ventricles, potentially shunt responsive).

Always consider reversible contributors to cognitive decline: hypothyroidism, vitamin B12 deficiency, depression, drug effects, normal pressure hydrocephalus, chronic subdural hematoma and neurosyphilis.

Adapting chiropractic care for older adults

Adapting care starts with a thorough history and screen for red flags: history of cancer, unexplained weight loss, night pain, fever, new neurologic deficit, steroid use or known osteoporosis, anticoagulation, recent trauma, and symptoms of vascular disease.

• Technique selection: favor low force methods when bone quality is uncertain or poor: mobilization, instrument assisted adjusting, drop table, flexion distraction, and gentle soft tissue work. Reduce amplitude and lever length, avoid long lever rotational thrusts and avoid forceful posterior to anterior thrusts over the thoracic cage in osteoporotic patients.
• Exercise: emphasize balance, hip and quadriceps strength, posture (extension biased exercise for kyphosis, avoiding loaded spinal flexion in osteoporosis), and walking.
• Communication: give written instructions, involve caregivers with permission, and confirm capacity for consent in cognitive impairment.
• Contraindications to high velocity thrust at a region include osteoporosis with fracture risk, vertebral metastasis or myeloma, acute fracture, inflammatory arthritis with upper cervical instability (rheumatoid arthritis), advanced spondylotic myelopathy, and anticoagulation at high or unstable levels.

Section 2Dermatology

Chiropractors see more bare back skin than almost any other provider, which makes them well placed to notice a changing mole or a rash that signals systemic disease (psoriasis with spondyloarthropathy, a dermatomal eruption of shingles, a palmar rash of secondary syphilis). Describe a lesion by type, size, color, shape, border, arrangement and distribution before naming it.

Primary and secondary lesions

Primary lesions arise directly from the disease process. Secondary lesions develop from evolution of a primary lesion or from scratching, infection or treatment. The size cutoff between small and large lesions is 1 cm in most texts (some use 0.5 cm).

Skin infections

Dermatitis, papulosquamous and blistering disorders

Eczema and dermatitis are near synonyms for inflammation of the epidermis that is itchy, red and, when acute, vesicular and weeping, and when chronic, scaly and lichenified.

• Atopic dermatitis: chronic relapsing itch ("the itch that rashes"), flexural creases in older children and adults, cheeks and extensor surfaces in infants; part of the atopic triad with asthma and allergic rhinitis.
• Contact dermatitis: irritant (direct damage, most common, for example hand washing) or allergic (type IV delayed hypersensitivity to nickel, poison ivy urushiol, fragrance, latex additives, topical neomycin); allergic contact dermatitis has sharp geometric borders matching the exposure, appears 24 to 72 hours after contact, and may appear as linear streaks with poison ivy. In the clinic, think of massage oils, tape and electrode gels.
• Seborrheic dermatitis: greasy yellow scale on red skin of the scalp ("cradle cap" in infants), eyebrows and nasolabial folds; severe in Parkinson disease and HIV.

Pigment disorders

• Vitiligo: autoimmune destruction of melanocytes producing sharply demarcated depigmented patches, often periorificial and on the hands; associated with thyroid disease, type 1 diabetes, pernicious anemia and Addison disease.
• Cafe au lait spots: light brown patches; six or more over 5 mm (prepubertal) or 15 mm (postpubertal), with axillary freckling, suggest neurofibromatosis type 1 (also neurofibromas, Lisch nodules, scoliosis).
• Acanthosis nigricans: velvety dark thickening of the neck and axillae; insulin resistance, obesity and rarely gastric adenocarcinoma.
• Hyperpigmentation of skin creases and buccal mucosa suggests Addison disease (ACTH excess stimulates melanocytes); bronze skin suggests hemochromatosis.

Skin cancer and the ABCDE rule

Skin cancer is the most common cancer. Ultraviolet light is the dominant risk: intermittent blistering sunburns for melanoma and basal cell carcinoma, cumulative exposure for squamous cell carcinoma. Actinic keratosis (rough, sandpaper like scaly papules on sun exposed skin) is a premalignant lesion for squamous cell carcinoma. Seborrheic keratosis is a benign, "stuck on," waxy brown papule of older adults.

The ABCDE rule flags pigmented lesions that need referral for evaluation and biopsy:

Melanoma has four classic subtypes: superficial spreading (most common), nodular (rapid vertical growth, may not fit ABCD), lentigo maligna (sun damaged face of the elderly) and acral lentiginous (palms, soles and nail beds; most common type in darker skin; nail fold pigment is Hutchinson sign). The single most important prognostic factor in localized melanoma is Breslow thickness (depth of invasion in millimeters).

Hair and sebaceous disorders

Acne vulgaris is a disorder of the pilosebaceous unit (androgen driven sebum, follicular plugging, Cutibacterium acnes, inflammation) producing comedones, papules, pustules and cysts; isotretinoin is highly teratogenic. Rosacea gives central facial flushing, telangiectasias and papulopustules without comedones, late rhinophyma. Hidradenitis suppurativa causes recurrent axillary and groin abscesses and sinus tracts and is linked to spondyloarthropathy. Hair loss may be androgenetic (patterned, nonscarring), alopecia areata (autoimmune round patches with "exclamation point" hairs), or telogen effluvium (diffuse shedding months after a stressor). Hirsutism in women most often reflects polycystic ovary syndrome.

Section 3Sexually transmitted infections

Several sexually transmitted infections reach the musculoskeletal and nervous systems: a hot knee or wrist in a young adult, heel pain with low back stiffness, dorsal column ataxia, or sacral radiculitis. Take a respectful, confidential sexual history when the presentation calls for it, refer for testing and treatment, and remember that partners need treatment and that several of these infections are reportable by the diagnosing provider.

Gonorrhea and chlamydia

Both cause urethritis and cervicitis, frequently coexist, and are diagnosed by nucleic acid amplification testing of urine or swabs. Ascending infection in women causes pelvic inflammatory disease (lower abdominal pain, cervical motion tenderness, adnexal tenderness, fever), which can lead to tubal scarring, infertility, ectopic pregnancy and Fitz Hugh Curtis syndrome (perihepatitis with right upper quadrant pain). In men, either can cause epididymitis.

Disseminated gonococcal infection follows bacteremia and is the most common cause of septic arthritis in sexually active young adults. It has two patterns: the arthritis dermatitis syndrome (triad of migratory polyarthralgia, tenosynovitis of the wrist, hand or ankle extensor tendons, and a few painless pustules on the distal limbs) and a purulent monoarthritis, typically the knee, wrist or ankle. Joint cultures are often negative, so mucosal sites are tested; treatment is ceftriaxone.

Reactive arthritis

Reactive arthritis is a sterile inflammatory arthritis that follows a genitourinary infection (chlamydia most often) or an enteric infection (Salmonella, Shigella, Campylobacter, Yersinia) by 1 to 4 weeks. It is a seronegative spondyloarthropathy associated with HLA B27. The classic triad is urethritis, conjunctivitis and arthritis ("can't see, can't pee, can't climb a tree"), but only a minority show all three.

• Arthritis: asymmetric oligoarthritis of the lower limbs (knees, ankles, toes), dactylitis ("sausage toe").
• Enthesitis: Achilles tendon and plantar fascia insertions; heel pain is common.
• Axial disease: inflammatory low back pain with asymmetric sacroiliitis and coarse, asymmetric, nonmarginal "jug handle" syndesmophytes (contrast with symmetric sacroiliitis and thin marginal syndesmophytes of ankylosing spondylitis).
• Mucocutaneous: keratoderma blennorrhagicum of palms and soles, circinate balanitis, oral ulcers.
• Radiographic: fluffy periosteal new bone and erosions at the calcaneus and metatarsophalangeal joints; preference for the feet.

Syphilis

Treponema pallidum is a spirochete too thin for Gram stain; it is seen by dark field microscopy and diagnosed mainly by serology. Nontreponemal tests (VDRL, RPR) are cheap screening tests whose titers track disease activity but give false positives in pregnancy, lupus and antiphospholipid syndrome. Treponemal tests (FTA ABS, TP PA) confirm infection and usually remain positive for life. Treatment is penicillin G (benzathine penicillin for early disease, intravenous penicillin for neurosyphilis); a fever and myalgia flare after the first dose is the Jarisch Herxheimer reaction.

Neurosyphilis can occur at any stage. Its late forms are classic board material:

• Tabes dorsalis: degeneration of the dorsal columns and dorsal roots. Findings are loss of proprioception and vibration, a broad based stamping gait, a positive Romberg sign, lightning (lancinating) pains in the legs, absent deep tendon reflexes, urinary retention, and the Argyll Robertson pupil (small irregular pupils that accommodate but do not react to light: "prostitute's pupil, accommodates but does not react").
• Charcot (neuropathic) joint: loss of pain and position sense leads to repeated unrecognized trauma and joint destruction. In tabes the knee, hip and lumbar spine are typical; in diabetes the foot and ankle; in syringomyelia the shoulder and elbow. The radiographic "6 D's" are distension, density (sclerosis), debris, disorganization, dislocation and destruction.
• General paresis: dementia, personality change and psychiatric symptoms from cortical involvement.

Herpes simplex and HPV

Genital herpes begins with tingling or burning, then grouped painful vesicles on an erythematous base that ulcerate and crust. The first episode is the most severe and may bring fever, tender inguinal nodes and sacral radiculitis (buttock and leg pain, urinary retention, constipation) because the virus travels to and becomes latent in the sacral dorsal root ganglia. Recurrences are milder and often preceded by a prodrome of tingling or buttock and thigh pain that can mimic sciatica. Asymptomatic viral shedding explains most transmission. Antivirals (acyclovir, valacyclovir) shorten episodes and suppress recurrences.

Human papillomavirus is the most common sexually transmitted infection. Low risk types 6 and 11 cause condylomata acuminata (soft cauliflower like genital warts); high risk types 16 and 18 cause most cervical cancer and many anal, penile and oropharyngeal cancers (oncoproteins E6 and E7 inactivate p53 and Rb). Prevention relies on vaccination before sexual exposure and cervical screening by Pap cytology and HPV testing; koilocytes are the cytologic hallmark. Do not confuse the flat, moist condylomata lata of secondary syphilis with the warty condylomata acuminata of HPV.

HIV and AIDS

Human immunodeficiency virus is an RNA retrovirus that infects CD4 helper T cells and macrophages and integrates into host DNA. Transmission is sexual, parenteral (shared needles, rarely transfusion) and vertical (pregnancy, birth, breastfeeding). Acute HIV 2 to 4 weeks after exposure resembles mononucleosis (fever, sore throat, lymphadenopathy, rash, myalgia). A long clinical latency follows while CD4 counts fall. AIDS is defined by a CD4 count under 200 cells/µL or an AIDS defining illness. Screening uses a fourth generation antigen and antibody test. With modern antiretroviral therapy, people with HIV who achieve an undetectable viral load have a near normal life expectancy and do not transmit the virus sexually ("undetectable equals untransmittable").

Musculoskeletal and neurologic manifestations relevant to a chiropractor include distal symmetric sensory polyneuropathy (painful feet; from HIV itself or older antiretrovirals), myopathy, reactive and psoriatic arthritis, osteoporosis, avascular necrosis, and spinal infection including tuberculous spondylitis. HIV is not transmitted by touch; universal precautions apply to every patient.

Section 4Toxicology and pharmacology for the chiropractor

Why drug knowledge matters without prescribing

Chiropractors do not prescribe, but drugs change the examination (masked pain, blunted heart rate), the risk of care (bleeding, bone fragility, tendon rupture, falls) and the differential diagnosis, because an adverse drug effect may be the complaint. Update the drug list at every re examination.

NSAIDs and acetaminophen

Nonsteroidal anti inflammatory drugs inhibit cyclooxygenase (COX), blocking conversion of arachidonic acid to prostaglandins and thromboxane. COX 1 is constitutive (gastric mucosal protection, platelet thromboxane A2, renal blood flow); COX 2 is induced by inflammation. Aspirin acetylates COX irreversibly, so its antiplatelet effect lasts the life of the platelet (7 to 10 days); other NSAIDs (ibuprofen, naproxen) are reversible. Selective COX 2 inhibitors (celecoxib) spare the stomach but raise cardiovascular risk.

• Gastrointestinal: dyspepsia, peptic ulcer and GI bleeding (black tarry stools, coffee ground vomitus); risk highest with age over 65, prior ulcer, anticoagulants, corticosteroids and SSRIs.
• Renal: loss of prostaglandin afferent arteriolar dilation can cause acute kidney injury, especially with ACE inhibitors and diuretics (the "triple whammy"); sodium retention and hyperkalemia.
• Cardiovascular: raised blood pressure, heart failure exacerbation, increased risk of myocardial infarction and stroke (except low dose aspirin).

Acetaminophen (paracetamol) is analgesic and antipyretic but not anti inflammatory and does not harm the stomach or platelets. Overdose saturates conjugation pathways, so more drug goes to the toxic metabolite NAPQI, which depletes glutathione and causes centrilobular hepatic necrosis 1 to 3 days later; the antidote is N acetylcysteine. Maximum adult dose is generally 4 g per day, lower with alcohol use or liver disease.

Opioids

Opioids act on mu receptors to produce analgesia, euphoria, sedation, respiratory depression, miosis, constipation (to which tolerance does not develop) and nausea. For chronic low back pain, long term use has weak evidence of benefit and clear harms (tolerance, opioid use disorder, hyperalgesia, falls, overdose); guidelines favor nonpharmacologic care, including spinal manipulation and exercise, first. Opioid overdose presents with the triad of coma, pinpoint pupils and respiratory depression; the antidote is naloxone, which is short acting, so the patient must still be transported because sedation can recur.

Corticosteroids

Long term systemic glucocorticoids (prednisone, dexamethasone) bring predictable problems: osteoporosis and vertebral fractures (the most common secondary cause), avascular necrosis of the femoral head, steroid myopathy (proximal weakness), tendon weakening, poor wound healing, infection risk with masked fever, hyperglycemia, hypertension, weight gain with Cushingoid features, cataracts and mood change. Chronic use suppresses the hypothalamic pituitary adrenal axis, so abrupt cessation risks adrenal crisis (hypotension, weakness, vomiting, collapse). A patient taking chronic steroids is a red flag case: consider fracture on new back pain, choose low force technique, and watch for infection.

Anticoagulants and antiplatelet drugs

Anticoagulated patients bruise easily and are at risk of epidural, retroperitoneal and intracranial hemorrhage. Use caution with forceful thrusts and deep soft tissue work, and remember that a sudden severe headache, a new neurologic deficit or acute severe back pain in such a patient may be a bleed. Ginkgo, garlic, high dose fish oil and vitamin E add to bleeding risk; St John's wort and vitamin K rich foods lower warfarin effect.

Poisoning and toxidromes

In any suspected poisoning, ensure scene safety, activate emergency services, support airway, breathing and circulation, and contact a poison control center (in the United States, 1 800 222 1222). Do not induce vomiting. Bring the container to the hospital.

Environmental and occupational toxins

• Carbon monoxide: binds hemoglobin about 200 times more avidly than oxygen and shifts the dissociation curve left; headache, dizziness, nausea and confusion, often in several household members; pulse oximetry reads falsely normal. Treat with 100 percent oxygen and remove from the source; hyperbaric oxygen for severe cases.
• Lead: old paint, pipes, battery work, firing ranges; inhibits ferrochelatase and ALA dehydratase, causing microcytic anemia with basophilic stippling, abdominal colic, constipation, peripheral motor neuropathy (wrist drop and foot drop), developmental delay in children and dense metaphyseal "lead lines" on radiographs of growing bones.
• Arsenic: garlic breath, diarrhea, Mees lines in the nails, painful sensory neuropathy.
• Asbestos: pleural plaques, asbestosis of the lower lobes, bronchogenic carcinoma (synergistic with smoking) and mesothelioma decades after exposure.
• Ergonomic hazards (vibration, repetitive motion, heavy lifting) are the occupational exposures chiropractors manage most often.

Section 5Emergency procedures

Scene safety and the primary survey

Every office needs a written emergency plan, BLS certified staff, an automated external defibrillator and glucose. In any emergency, first confirm the scene is safe (electrical hazards, toxic exposure, violence), then check responsiveness, shout for help, call emergency medical services (EMS) and send someone for the AED. The primary survey follows the ABCDE order: airway (with cervical spine protection in trauma), breathing, circulation (pulse, major bleeding, skin signs), disability (level of consciousness by AVPU: alert, responds to voice, responds to pain, unresponsive; pupils) and exposure. Stop major external bleeding with firm direct pressure; use a tourniquet above the wound for life threatening limb bleeding that pressure does not control.

CPR and AED

Adult cardiac arrest is most often due to ventricular fibrillation or pulseless ventricular tachycardia, which are shockable rhythms; survival falls by roughly 7 to 10 percent for each minute without CPR and defibrillation.

Begin compressions immediately for an unresponsive person who is not breathing or only gasping (agonal breathing is a sign of arrest). The sequence is C A B: compressions, airway (head tilt chin lift, or jaw thrust if spinal injury is suspected), breathing (each breath over 1 second with visible chest rise). Attach the AED as soon as it arrives, follow its prompts, make sure no one touches the patient during analysis and shock, and resume compressions immediately after the shock. Pads go below the right clavicle and on the left lateral chest; dry the chest and remove medication patches. Use pediatric pads for children under 8 if available.

Choking

Severe obstruction (cannot speak, cough or breathe; the universal choking sign of hands at the throat; cyanosis): for a responsive adult or child give abdominal thrusts (Heimlich maneuver) just above the umbilicus until the object is expelled or the patient becomes unresponsive; use chest thrusts in pregnancy or obesity. For an infant give cycles of 5 back blows and 5 chest thrusts with the head lower than the chest; never abdominal thrusts. If the patient becomes unresponsive, lower them to the floor, call EMS and start CPR, looking in the mouth for the object before each set of breaths and removing it only if seen (no blind finger sweeps).

Shock

Shock is inadequate tissue perfusion. Early signs are anxiety, tachycardia, tachypnea, cool clammy pale skin and delayed capillary refill; hypotension is a late sign, especially in young adults and children.

First aid: call EMS, lay the patient supine, control bleeding, keep warm, give nothing by mouth, and monitor airway and breathing.

Head and spinal injury

After trauma, any patient with altered consciousness, neck pain, midline tenderness, a neurologic deficit, a dangerous mechanism, intoxication or a distracting injury should be presumed to have a spinal injury: keep the head and neck still in neutral (manual in line stabilization), do not move the patient unless the scene is unsafe, and use a jaw thrust rather than head tilt to open the airway. The Canadian C spine rule and NEXUS criteria identify alert, stable patients who need imaging. A suspected concussion (headache, confusion, amnesia, dizziness, often without loss of consciousness) means removal from play that day and a graded return. Refer emergently for:

• Deteriorating consciousness, a lucid interval followed by decline (epidural hematoma from middle meningeal artery tear), repeated vomiting, seizure, or unequal pupils (a fixed dilated pupil suggests uncal herniation compressing cranial nerve III).
• Battle sign (mastoid bruising), raccoon eyes and clear fluid from the nose or ear (basilar skull fracture).
• Severe or worsening headache, slurred speech, weakness or numbness, or anticoagulation.
• Cushing triad (hypertension with widened pulse pressure, bradycardia and irregular respirations) signals raised intracranial pressure.

Thermal injuries

Burns are classified by depth: superficial (first degree; epidermis; red, painful, no blisters, like sunburn), partial thickness (second degree; into dermis; blisters, very painful), and full thickness (third degree; through dermis; white, leathery or charred, painless because nerve endings are destroyed). The rule of nines estimates adult body surface area burned: head 9 percent, each arm 9, front of trunk 18, back of trunk 18, each leg 18, perineum 1; the patient's palm is about 1 percent. Cool a burn with cool running water for about 20 minutes, remove jewelry, cover loosely with a clean dressing, and never apply ice, butter or ointment. Refer full thickness, large, circumferential, electrical, chemical and inhalation burns and burns of the face, hands, feet, genitals or joints.

Hypothermia (core below 95°F or 35°C) progresses from shivering and confusion to loss of shivering, bradycardia and arrhythmias; handle gently, remove wet clothing and rewarm. Rewarm frostbite in warm water only if refreezing will not occur, and never rub it.

Fractures, dislocations, sprains and strains

Signs of fracture include deformity, point bony tenderness, swelling, crepitus, loss of function and inability to bear weight. The Ottawa ankle rules call for radiographs when there is bone tenderness at the posterior edge or tip of either malleolus, at the base of the fifth metatarsal or the navicular, or inability to bear weight for four steps both immediately and in the office. Splint fractures in the position found, including the joint above and below, and check distal pulse, sensation and capillary refill before and after splinting. Open fractures need a sterile dressing and emergency transfer. Watch for compartment syndrome after tibial or forearm fractures and crush injuries: pain out of proportion and on passive stretch is the earliest sign, followed by paresthesia, pallor, pulselessness and paralysis; it is a surgical emergency.

Dislocations should generally be splinted and referred; do not attempt reduction of a first time dislocation where fracture or neurovascular injury has not been excluded. The shoulder dislocates anteriorly in about 95 percent of cases (axillary nerve at risk: numb "regimental badge" area over the deltoid); posterior shoulder dislocation follows seizures and electrocution. Posterior hip dislocation (dashboard injury) holds the limb flexed, adducted and internally rotated. Sprains (ligament) and strains (muscle or tendon) are graded I (microscopic tearing, stable), II (partial tear, some laxity) and III (complete rupture, gross laxity or a palpable defect). Acute care is protection, relative rest with early optimal loading, compression and elevation, then progressive rehabilitation.

Syncope, diabetic and allergic emergencies

Syncope is transient loss of consciousness from global cerebral hypoperfusion with spontaneous full recovery. The most common type is vasovagal (triggered by pain, fear or prolonged standing, with a prodrome of nausea, warmth and pallor). Orthostatic syncope follows standing up, especially in older adults on antihypertensives. Cardiac syncope (sudden, without warning, during exertion, while supine, with palpitations, or with a family history of sudden death) suggests arrhythmia or aortic stenosis and is dangerous. Lay the patient supine with legs raised and check breathing and pulse; call EMS for exertional or unexplained syncope, injury, chest pain or persistent confusion.

Anaphylaxis is a severe, rapid, systemic IgE mediated (or other mast cell) reaction: urticaria, flushing, lip and tongue swelling, wheeze, stridor, hypotension, abdominal cramps and a sense of doom, within minutes of exposure (insect sting, food, latex, drug). Call EMS, give intramuscular epinephrine into the anterolateral thigh with the patient's auto injector (0.3 mg adult, 0.15 mg small child), position supine with legs raised (or sitting if breathing is difficult), and repeat in 5 to 15 minutes if needed. Antihistamines do not treat airway or circulatory compromise. A biphasic reaction can recur hours later, so every patient needs emergency department evaluation.

Words worth knowing