Management of Emergencies in Critical Care

 

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Every day, emergency departments are looking more like intensive care units (ICUs). A number of forces are acting to redefine the delivery of acute care in emergency departments in the United States. To control health care costs, great effort is being directed toward managing a number of acute conditions, once considered ``inpatient illnesses,'' outside of the hospital. At the same time, improvements in the management of many chronic illnesses have enhanced the quality of life for many Americans. The result of these changes has been a growing population of increasingly medically complex outpatients who, when crisis precipitates evaluation in an emergency department, may possess very limited physiological reserve and require extensive resources for successful stabilization, diagnosis, and treatment.

Unfortunately, advances in the sophistication of medical care have outpaced efforts to make health care available to all Americans. Therefore, coincident with the increase in the number of well-managed, chronically ill patients there has been a sharp rise in the number of patients presenting to emergency departments having had little or no preventive medical care. These patients, often having put off medical attention until a moment of crisis, pose a different diagnostic and therapeutic challenge.

Lastly, economic constraints at many medical centers have limited the number of critical care beds to the point where patients requiring mechanical ventilation, vasopressors, or invasive hemodynamic monitoring may spend hours or even days in emergency departments awaiting an available ICU bed.

In this issue of Seminars, we present discussions of a variety of acute conditions that hold in common the frequent need for aggressive, prolonged, and often complex resuscitation and, as such, represent areas of significant overlap between the practice of critical care and emergency medicine. Included are summaries of traumatic, environmental, and toxicological emergencies; a review of the rapidly changing therapy of acute stroke; and an overview of the state of the art in management of the difficult airway. We have also included a manuscript on interhospital critical care transport, an infrequently discussed matter that has become a prominent part of critical care, and one often managed through the emergency department. [*]