eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Pelvic

C Crawford Mechem, MD, MS, FACEP, Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department

Updated: Sep 30, 2009

Introduction

Background

Pelvic fracture is a disruption of the bony structures of the pelvis. In elderly persons, the most common cause is a fall from a standing position. However, fractures associated with the greatest morbidity and mortality involve significant forces such as from a motor vehicle crash or fall from a height.

For related information, see Medscape's Fracture Resource Center.

Pathophysiology

The bony pelvis consists of the ilium (ie, iliac wings), ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy. Because of the forces involved, pelvic fractures frequently involve injury to organs contained within the bony pelvis. In addition, trauma to extra-pelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region.

Pelvic fractures are most commonly described using one of two classification systems.

The Tile classification system is based on the integrity of the posterior sacroiliac complex.

• In type A injuries, the sacroiliac complex is intact. The pelvic ring has a stable fracture that can be managed nonoperatively.
• Type B injuries are caused by either external or internal rotational forces resulting in partial disruption of the posterior sacroiliac complex. These are often unstable.
• Type C injuries are characterized by complete disruption of the posterior sacroiliac complex and are both rotationally and vertically unstable. These injuries are the result of great force, usually from a motor vehicle crash, fall from a height, or severe compression. 

The Young classification system is based on mechanism of injury: lateral compression, anteroposterior compression, vertical shear, or a combination of forces. Lateral compression (LC) fractures involve transverse fractures of the pubic rami, either ipsilateral or contralateral to a posterior injury.

• Grade I - Associated sacral compression on side of impact
• Grade II - Associated posterior iliac ("crescent") fracture on side of impact
• Grade III - Associated contralateral sacroiliac joint injury

Anterior-posterior compression (APC) fractures involve symphyseal diastasis or longitudinal rami fractures.

Anterior-posterior (AP) compression pelvic fracture.

• Grade I - Associated widening (slight) of pubic symphysis or of the anterior sacroiliac (SI) joint, while sacrotuberous, sacrospinous, and posterior SI ligaments remain intact
• Grade II - Associated widening of the anterior SI joint caused by disruption of the anterior SI, sacrotuberous, and sacrospinous ligaments; posterior SI ligaments remain intact
• Grade III (open book) - Complete SI joint disruption with lateral displacement and disrupted anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments

Vertical shear (VS) involves symphyseal diastasis or vertical displacement anteriorly and posteriorly, which is usually through the SI joint, though occasionally through the iliac wing or sacrum.

Vertical shear (VS) fracture pattern.

Acetabular fractures most commonly involve disruption of the acetabular socket when the hip is driven backward in a motor vehicle accident. Occasionally, they occur in a pedestrian struck by a vehicle moving at a significant rate of speed.

Falls in elderly persons may involve fractures (usually of the pubic rami) without disruption of the ring.

Frequency

United States

Pelvic fractures represent 3% of all skeletal fractures and 1-2% of fractures seen by orthopedists who care for children. Single pubic rami and avulsion fractures are most common.

Mortality/Morbidity

Over half of all pelvic fractures occur as a result of minimal-to-moderate trauma, such as a fall from a standing position. Of these, 95% are minor. On the other hand, the more severe pelvic fractures involve significant trauma. Most of this discussion relates to the severe pelvic fractures.

• Cited mortality rates for pelvic fractures range from 3-20%. One study of pelvic fractures in children aged 16 years or younger cited a mortality rate of 5%, with death most commonly due to hemorrhage or multiple injuries.¹
• Despite aggressive intervention, elderly patients with pelvic fractures have a worse outcome than younger patients with similar injuries.²
• Ultimately, the patient's Injury Severity Score, not the nature of the pelvic fracture, is the best predictor of mortality. Hemorrhage, either pelvic or extrapelvic, or associated severe head injury are the most common causes of early death, whereas multisystem organ failure and sepsis resulting from soft tissue infection near the fracture site are the main causes of delayed death.³
• The complication rate associated with pelvic fractures is significant and is related to injury of underlying organs and bleeding. Because of the tremendous force necessary to cause most unstable pelvic fractures, concomitant severe injuries are common and are associated with high morbidity and mortality.
• Pelvic fractures also increase the incidence of pulmonary emboli.

Sex

• In a 2007 study of a trauma registry in the United Kingdom, 58% of patients sustaining a pelvic ring fracture were male.⁴  A trauma registry review that same year from New South Wales, Australia, revealed that most patients sustaining high-energy pelvic ring fractures, such as from an motor vehicle crash (MVC), were male, whereas females predominated in low-energy injuries.⁵
• Associated genitourinary (GU) injuries vary greatly between men and women and are discussed in other articles. For many years, it was believed that women did not suffer urethral injuries. It is now known that, while women suffer urethral injuries at a much lower incidence than men, injuries do occur. Women suffer partial lacerations and partial disruption. Complete urethral disruption is rare.

Age

• Age distribution largely matches that of motor vehicle crashes, with car-car injuries more prevalent in adults, especially younger adults, and car-pedestrian injuries more likely to cause injury in children. The other group is the elderly, who tend to suffer pubic rami fractures without internal injuries as a result of falls from a standing position.
• In a 2007 study of a trauma registry in the United Kingdom, the median age of patients sustaining a pelvic ring fracture was 39 years.⁴
• In children, a recent study found that pelvic fractures were more likely when any of 4 factors were present: Caucasian, aged 5-14 years, a pedestrian struck by a vehicle, or an occupant in a motor vehicle crash.⁶

Clinical

History

• Basic mechanism of significant blunt trauma should prompt consideration of a pelvic fracture.

Physical

• Tenderness, laxity, or instability on palpation of the bony pelvis suggests fracture. However, while physical examination is specific for pelvic instability, it has a low sensitivity.⁷ Furthermore, in the later stages of pregnancy, the pelvic ligaments become stretched, mimicking bony instability. Finally, extensive manipulation of a fractured pelvis can increase the patient's discomfort and potentially increase bleeding. 
• Other signs that may suggest a pelvic fracture include hematuria; a hematoma over the ipsilateral flank, inguinal ligament, proximal thigh, or in the perineum; neurovascular deficits in the lower extremities; or rectal bleeding.
• Vaginal bleeding or palpable fracture line on careful bimanual examination suggests pelvic fracture in females.
• Instability on hip adduction and pain on hip motion suggests an acetabular fracture, with or without an associated hip fracture.
• Urethral injuries vary widely by age with injuries to the prostatic urethra and bladder neck limited to children. Direct lacerations to the urethra occur only in boys (small prostate) and women. Signs of urethral injury in males include a high-riding or boggy prostate on rectal examination, scrotal hematoma, or blood at the urethral meatus.
• Note that digital rectal examination has a very low sensitivity for diagnosing pelvic fractures. In fact, in a 2007 study assessing the utility of routine digital rectal examinations to diagnose injury in 1401 trauma patients, the rectal examination missed 100% of the 67 pelvic fractures.⁸

Causes

• Adults with significant pelvic fracture
  • Motor vehicle crash (50-60%)
  • Motorcycle crash (10-20%)
  • Pedestrian versus car (10-20%)
  • Falls (8-10%)
  • Crush (3-6%)
• Children
  • Pedestrian versus car (60-80%)
  • Motor vehicle crash (20-30%)

Differential Diagnoses

Workup

Laboratory Studies

• Serial hemoglobin and hematocrit measurements monitor ongoing blood loss.
• Urinalysis may reveal gross or microscopic hematuria.
• Pregnancy test is indicated in females of childbearing age to detect pregnancy as well as potential bleeding sources (eg, miscarriage, abruptio placentae).

Imaging Studies

• Radiography 
  • Anteroposterior pelvic radiograph is the basic screening test and uncovers 90% of pelvic injuries. However, as severely injured trauma patients often routinely undergo CT scans of the abdomen and pelvis, plain pelvic radiographs in this patient population are most appropriate for hemodynamically unstable patients to allow for rapid diagnosis of pelvic fractures and early notification of interventional radiology.

Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint are widened.

• Plain radiographs may also be used in patients who otherwise would not have a CT scan of the abdomen and pelvis performed.
• Computed tomography 
  • CT scan is the best imaging study for evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding. CT scan also confirms hip dislocation associated with an acetabular fracture.
  • CT scanning has largely replaced plain radiographs except for screening, and it has virtually eliminated the use of auxiliary views.

Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient sustained a left lateral compression injury with internal rotation of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis.

• Ultrasonography
  • As part of the Focused Assessment with Sonography for Trauma (FAST) examination, the pelvis should be visualized for intrapelvic bleeding/fluid.
  • In addition, the FAST examination may identify intraperitoneal bleeding to explain shock. However, recent studies suggest that ultrasonography has a lower sensitivity for identifying hemoperitoneum in patients with pelvic fractures than previously reported.⁹ Therefore, keep in mind that, although the positive predictive value of noting hemoperitoneum as part of a FAST examination is good, therapeutic decisions using FAST as a screening examination may be limited.
• Urethrography
  • Retrograde urethrography is necessary for males with a displaced or boggy prostate or blood at the urethral meatus and for females in whom a Foley catheter cannot easily pass on gentle attempts.
  • This study should also be used in females with a vaginal tear or palpable fracture fragments adjacent to the urethra.
• Arteriography
  • Consider this study in hemodynamically unstable patients when CT scanning or other appropriate diagnostic studies exclude significant intraperitoneal bleeding and after the external pelvis is stabilized.
  • Arteriography allows for determination of the bleeding site. In addition, embolization may be very effective for hemorrhage control.
• Cystography: Consider this study in any patient with hematuria and an intact urethra.

Procedures

• Use a suprapubic catheter for patients in whom urethral injuries are suspected but a urethrogram cannot be obtained.
• Early application of an external pelvic fixator may be necessary to control hemorrhage. 

Treatment

Prehospital Care

• Address acute life-threatening conditions. Be very aware that the amount of force necessary to cause a significant pelvic fracture is likely to have caused other significant injuries.
• Application of an external compression device to a grossly unstable pelvis will provide mechanical stabilization while controlling hemorrhage from the fracture site. A sheet or one of a variety of inexpensive, commercial products may be used.¹⁰
• Avoid excessive movement of the pelvis.
• Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance with local protocols.
• Closely monitor vital signs.

Emergency Department Care

• Treatment involves an algorithmic, multidisciplinary approach.
• Investigate associated intra-abdominal and intrapelvic injuries. A FAST examination should be performed as soon as possible, as well as a chest radiograph to look for other injuries or bleeding sources, especially in the unstable patient.
• Avoid excessive movement of the pelvis.
• If not done by prehospital providers, the pelvis should be rapidly stabilized with a sheet or commercial pelvic external stabilizer.
  • This is very important prior to neuromuscular blockade because the muscles may be the only thing maintaining pelvic stability.
• In some patients, such as those with truncal obesity, internal rotation of the lower extremities and taping together the knees may be more effective than a compression binder.¹¹
• In the case of unstable pelvic fractures, early application of an external fixation device by the appropriate surgical consultant should be considered.
• Administer fluid replacement and analgesics as needed.
• Do not place a urinary catheter until urethral injury has been ruled out or determined to be unlikely by physical examination or retrograde urethrography.

Consultations

• Consult an orthopedic surgeon when a pelvic fracture is diagnosed. Hemodynamically unstable patients with unstable pelvic fractures require emergent orthopedic consultation for possible external fixation. In addition, pelvic or retroperitoneal packing may be required for hemorrhage control.¹²
• Consult an interventional radiologist for embolization in the unstable patient.
• Consult a urologist for any suspected urethral injury.

Medication

Primary treatment of pelvic fracture is for pain with narcotic analgesics. Administer antibiotics whenever disruption of bowel, vagina, or urinary tract is suspected. Since bleeding is the major life-threatening complication of pelvic fractures, avoid nonsteroidal anti-inflammatory drugs in initial treatment. They may be considered later if inflammation is a concern.

Analgesics

Narcotic analgesics are the treatment of choice in the acute setting. Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures. Adequate pain control helps keep the patient quiet and avoids movement of the pelvis.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained. Titrated doses especially useful in trauma patients to avoid oversedation or hypotension. Caution in hypotensive patients as may worsen hypotension because of histamine release. Consider fentanyl in this setting.

Dosing

Adult

Starting dose: 0.1 mg/kg IV
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV and reassess hemodynamic effects of dose

Pediatric

Neonates: 0.05-0.2 mg/kg IV/IM/SC q2-4h prn
Children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn

Interactions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Fentanyl (Sublimaze, Duragesic)

Excellent drug for analgesia in patients with hypotension or whose cardiovascular condition is unstable. Does not release histamine. Short-acting acutely, duration becomes longer with repetitive dosing.

Dosing

Adult

1-2 mcg/kg IV then titrate to pain relief

Pediatric

1-3 mcg/kg IV then titrate to pain relief

Interactions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome (never reported in analgesic dosages, <200-mcg bolus), may require neuromuscular blockade to increase ventilation

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or those at high risk of bleeding, with upper GI disease, or taking oral anticoagulants. DOC for pain relief in noninflammatory conditions.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-P deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn based on hydrocodone content 5-10 mg dosage

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; be careful when adding to other drugs that contain acetaminophen

Oxycodone and acetaminophen (Percocet, Tylox, Roxicet, Roxilox)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity

Oxycodone and aspirin (Percodan, Roxiprin)

Drug combination indicated for relief of moderately severe to severe pain. Avoid in early treatment because of platelet inhibition from aspirin and increased risk of bleeding. See discussion under NSAIDs above.

Dosing

Adult

1-2 tabs/caps PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity; may potentiate anticoagulant effects of warfarin

Contraindications

Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, not for use in children (<16 y) who have flu

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis

Follow-up

Further Inpatient Care

• Monitor patients with pelvic fracture for signs of ongoing blood loss and signs of infection. In addition, patients should be closely observed for development of neurovascular problems in the lower extremities. For example, injury to the sacral nerves, lower lumbar nerves, and sympathetic chain may occur.
• Consider deep venous thrombosis (DVT) prophylaxis in all patients. Pelvic fractures give an odds ratio for venous thromboembolic events (VTE) of 2.93.
• Pain management is very important to facilitate early mobilization, thereby reducing the risk of thromboembolic disease.
• Management of urethral injuries should be directed by a urologic consultation. If a urinary catheter is required prior to the urologist's arrival, a suprapubic catheter should be placed.

Further Outpatient Care

• Elderly patients with isolated pubic rami fractures can be safely discharged if they can be cared for at home or in another facility. They will require sufficient pain management to allow them to ambulate, or they should have sufficient help. If they are nonambulatory, DVT prophylaxis should be considered.

Inpatient & Outpatient Medications

• Inpatient medications should be determined by the orthopedic specialist or trauma surgeon depending on associated injuries. Pain medications as outlined above will be required (see Medication); other medications depend on associated injuries.

Transfer

• If possible, hemorrhage should be controlled and the pelvis stabilized prior to transfer.
• Transfer all patients except those with minor pelvic fractures to a trauma center.
• Complex acetabular fractures may require transfer to a specialist in acetabular fractures.

Deterrence/Prevention

• Encourage use of seat belts, airbags, and other protective gear.
• Promote anti–drunk driving programs and laws.

Complications

Complications of pelvic fracture include the following:

• Increased incidence of deep venous thrombosis
• Continued bleeding from fracture or injury to pelvic vasculature
• GU problems from bladder, urethral, prostate, or vaginal injuries: The incidence of urethral injuries varies by the type of pelvic fracture. Straddle fractures associated with sacroiliac diastasis have the highest incidence (odds ratio of 24). Without diastasis, the odds ratio dropped to 3.85. Urethral injuries are uncommon in patients with fractures not involving the ischiopubic rami.
• Sexual dysfunction may develop
• Infections from disruption of bowel or urinary system
• Chronic pelvic pain

Prognosis

• Prognosis varies depending on severity of fracture and associated injuries.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Total Hip Replacement.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose concomitant genitourinary, intra-abdominal, or retroperitoneal injuries
• Failure to consider a urethral injury in a female
• Failure to clinically (or radiographically) exclude urethral injury prior to attempting to insert a urinary catheter or to cease attempts at Foley catheterization after encountering resistance
• Failure to obtain urethroscopy in women with suspected urethral injuries
• Failure to assess for vaginal bleeding in a female with a pelvic fracture
• Failure to diagnose a hip dislocation associated with an acetabular fracture
• Failure to appreciate ongoing blood loss
• Failure to obtain prompt orthopedic consultation for an unstable pelvic fracture
• Failure to promptly apply external stabilization to an unstable pelvic fracture

Special Concerns

• Pregnant patients
  • While the welfare of the fetus is most dependent on the clinical outcome of the mother, diagnostic imaging and therapeutic options may need to be modified in the pregnant patient. 
  • Patients in later stages of pregnancy are at increased risk for complications.
  • Placental abruption and uterine rupture are a concern.

Multimedia

Media file 1: Anterior-posterior (AP) compression pelvic fracture.

Media file 2: Vertical shear (VS) fracture pattern.

Media file 3: Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint are widened.

Media file 4: Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient sustained a left lateral compression injury with internal rotation of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis.

References

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Keywords

pelvic fracture, fracture of the pelvis, acetabular fractures, lateral compression fractures, transverse fractures of the pubic rami, avulsion fracture, Tile classification system, Young classification system, anterior-posterior compression fractures

Contributor Information and Disclosures

Author

C Crawford Mechem, MD, MS, FACEP, Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department
C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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