EM Clerkship

Deep Dive R29 MW Feb 20, 2025

Round 29 (MW) Pediatric Respiratory Distress Feb 01, 2025

You are working at Clerkship General when the triage nurse walks back and gets you. “Hey doc, we just put a hypoxic infant in bed 7”. Initial Vitals: HR: 168 RR: 44 BP: 81/40 O2: 81% (Room Air) Critical Actions:

Deep Dive R28 MW Jan 16, 2025

Round 28 (MW) Child Found in the Woods Jan 02, 2025

You are working at Clerkship General on New Year’s Day when you see a nurse running from triage. He is carrying an unresponsive child to the resuscitation bay. Initial Vitals: HR: 43 BP: 47/20 Temp: 66F RR: 4 O2: 95% (BVM) Critical Actions:

Deep Dive R27 MW Dec 16, 2024

Round 27 (MW) Geriatric Fever Dec 06, 2024

You are working at Clerkship General when you hear an EMS call on the base command radio. “Clerkship General. We are bringing you a minimally responsive 79 year-old female found lying on the floor inside her apartment. ETA 5 minutes” Initial Vitals: HR: 143 BP: 160/105 Temp: 106.3F RR: 22 O2: 99% Room Air Critical […]

Deep Dive R26 MW Nov 15, 2024

Round 26 (MW) Dizziness and Fatigue Nov 01, 2024

Introduction: You are working at Clerkship General when the next chart is handed to you. It’s a 35-year-old female with a chief complaint of dizziness and fatigue. She is here accompanied by her husband. Initial Vitals: HR: 118 BP: 150/91 Temp: 100.4F RR: 20 O2: 99% Room Air Critical Actions:

Deep Dive R25 MW Oct 17, 2024

Transcript/Summary coming soon!

Round 25 (MW) Laboring Mom in Triage Oct 01, 2024

You are working at Clerkship General when you hear a woman screaming from triage… It’s baby time! Initial Vitals: HR: 120 RR: Shallow O2: 58% Critical Actions:

Deep Dive MW R24 Sep 16, 2024

Transcript coming soon!

Round 24 (MW) Nursing Home Transfer Sep 02, 2024

You are working at Clerkship General when the nurse comes up to you and says, “Hey doc, EMS dropped off this guy named Randy from the memory care unit at the nursing home down the street. He’s in the hall bed outside of room 7. EMS says he’s here for confusion, we will get him […]

Deep Dive MW R23 Aug 17, 2024

Episode summary coming soon!

Round 23 (MW) Pediatric Altered Mental Status Aug 01, 2024

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General, we are bringing you a 3 year old female with complaints of altered mental status. We are pulling in now.” Initial Vitals: HR: 129 BP: 98/66 Temp: 99.7F RR: 35 O2: 99% Room Air Critical Actions:

Deep Dive MW R22 Jul 16, 2024

Guillain-Barre Syndrome (GBS) – Autoimmune polyneuropathy that results in widespread demylination of peripheral nerves Typically occur 1 week after a triggering infection Paresthesias/Neuropathic Pain -> Ascending symmetric paralysis -> Respiratory Failure Major Diagnostic Criteria Treatment – IVIG and monitor respiratory status

Round 22 (MW) Fall with Weakness Jul 03, 2024

Critical Actions:

Deep Dive MW R21 Jun 16, 2024

Orbital Compartment Syndrome – needs to be diagnosed CLINICALLY On exam, LOOK for: Proptosis, Ophthalmoplegia, Afferent Pupillary Defect, Vision Loss On exam, FEEL for: Rock hard globe, tense eyelids, resistance to retropulsion IOP > 40 means immediate canthotomy is indicated! Don’t perform if open globe is present Lateral Canthotomy Procedure: Anesthetize, Devascularize, Canthotomy, Cantholysis (inferior […]

Round 21 (MW) Geriatric Fall Jun 01, 2024

You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen. Initial Vitals: HR: 101 BP: 138/85 Temp: 98.0F RR: 20 O2: 99% (Room Air) Critical Actions:

Deep Dive MW R20 May 16, 2024

Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status. The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags. Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and […]

Round 20 (MW) Stroke Symptoms May 01, 2024

You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.” Initial Vitals: HR: 51 BP: 201/98 Temp: 98.0F RR: 18 O2: 99% (Room Air) Critical Actions:

Deep Dive MW R19 Apr 16, 2024

Round 19 (MW) Tummy Ache in Child with Diabetes Apr 02, 2024

You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting Initial Vitals: HR: 119 BP: 104/63 Temp: 98.0F RR: 20 O2: 99% (Room Air) Critical Actions: References: Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time […]

Deep Dive MW R18 Mar 16, 2024

Phase One: CNS Phase Two: Cardiopulmonary Phase Three: Renal Diagnosis: Treatment: Further Reading: EMCrit Toxic Alcohols

Round 18 (MW) Drunk Man Wants Pizza Mar 01, 2024

You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again Initial Vitals: HR: 116 BP: 150/70 Temp: 98.8 RR: 26 O2: 85% (Room Air) Critical Actions:

Deep Dive MW R17 Feb 16, 2024

Hypertensive Emergencies of Pregnancy PreEclampsia, Eclampsia, HELLP syndrome Diagnosis: BP >140/90 plus end organ dysfunction Treatment

Round 17 (MW) Headache Feb 01, 2024

You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache. Initial Vitals: HR: 56 BP: 172/93 Temp: 98.8F RR: 18 O2: 97% Critical Actions:

Deep Dive MW R16 Jan 17, 2024

Diagnosing PE: Step 1: Consciously consider the diagnosis Step 2: Risk Stratify into low, intermediate, and high risk Step 3: Choose appropriate testing based on pre-test probability Classification of PE Treatment of PE

Round 16 (MW) Leg Pain Jan 01, 2024

You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.” Initial Vitals: HR: 122 BP: 75/40 Temp: 100.1 RR: 24 O2: […]

Deep Dive MW R15 Dec 17, 2023

Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion

Round 15 (MW) MVA Dec 02, 2023

You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision” Initial Vitals: HR: 65 BP: 88/50 Temp: 97.0F RR: 20 O2: 96% Room Air Critical Actions:

Deep Dive MW R14 Nov 15, 2023

Round 14 (MW) Leg Pain Nov 01, 2023

You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury. Initial Vitals: HR: 112 BP: 97/67 Temp: 99.2F RR: 20 O2: 97% Room Air Critical Actions:

Deep Dive MW R13 Oct 15, 2023

Round 13 (MW) Respiratory Distress Oct 01, 2023

You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes” Initial Vitals: HR: 123 BP: 142/78 Temp: Unknown RR: 36 O2: 97% (NonRebreather) Critical Actions:

Deep Dive MW R12 Sep 16, 2023

Introduction Clinical Presentation Treatment

Round 12 (MW) Respiratory Distress Sep 01, 2023

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General. We are bringing you an unresponsive 6-year-old female found foaming at the mouth by her babysitter. ETA 2 minutes.” Initial Vitals: BP: 125/80 HR: 62 RR: 34 O2: 81% (Non Rebreather) Critical Actions:

OBGYN: The Vaginal Delivery (Pt 2) Aug 15, 2023

Shoulder dystocia is an OB emergency. Remember McRobert’s maneuver and suprapubic pressure. For more information, take a look at the resources below. References ACOG- Shoulder Dystocia AAFP- Shoulder Dystocia

OBGYN: The Vaginal Delivery (Pt 1) Aug 01, 2023

Maddie’s 7 Cardinal Movements of a Successful Delivery: 1. Head comes out 2. Head turns 3. Cord Assessment 4. Anterior shoulder delivered 5. Posterior shoulder delivered 6. Body delivered. 7. Baby on mom’s chest T’s of Postpartum Hemorrhage: 1. Tone 2. Trauma 3. Tissue 4. Thrombosis

Deep Dive MW R11 Jul 15, 2023

The 6 STEMI Equivalents: Other atypical ischemic EKG findings: Further Reading (see photos in the article): ECG Diagnosis of Life-Threatening STEMI Equivalent’s: Journal of the American College of Cardiology

Round 11 (MW) Chest Pain Jul 02, 2023

You are working at Clerkship Rural when the nurse hands you your next chart to see. It’s a 59 year old farmer with chest pain. Initial Vitals: BP: 156/97 HR: 110 RR: 22 O2: 98% (Room Air) Temp: 98.8F Critical Actions:

Deep Dive MW R10 Jun 17, 2023

Consider removing the terminology “Agitated Delirium” from your vocabulary, as there is significant racial bias behind this term.

Round 10 (MW) Agitation Jun 01, 2023

You are working at Clerkship General when you hear an EMS call on the radio… “CLERKSHIP GENERAL – We are bringing you an agitated and combative 30 year old male, we’ll see you in 5 minutes.” Initial Vitals: BP: 192/105 HR: 134 RR: 22 O2: 99% (Room Air) Temp: 98.8 F Critical Actions: Dangerous Actions: […]

Deep Dive MW R9 May 16, 2023

Indications for LP: CNS infection, SAH, Guillian Barree, IIH Contraindications for LP: Space occupying lesion with mass effect ; severe thrombocytopenia and coagulopathy; cellulitis over LP site or concern for epidural abscess ; traumatic injury to spine Complications for LP: Post LP Headache, spinal hematoma, brainstem herniation Technique for LP: Positioning is everything. Use US […]

Round 9 (MW) Altered Mental Status May 01, 2023

You are working at Clerkship General when the charge nurse comes and grabs you… “Hey doc, we need you in room 2, this kid looks sick…” Initial Vitals: BP: 68/40 HR: 128 RR: 22 O2: 99% (Room Air) Temp: 103.5F Critical Actions: Check Out: Pearson Ravitz Webinar – “Disability Insurance 101 for Residents” https://us06web.zoom.us/webinar/register/1416806357023/WN_ziYRNc0kT8yAyOOJZ-Xk2g

Deep Dive MW R8 Apr 16, 2023

Round 8 (MW) Groin Pain Apr 01, 2023

You are working at Clerkship General on an overnight shift when the next chart is handed to you. It’s a 35 year old male with a chief complaint of groin pain. Initial Vitals: BP: 150/90 HR: 107 RR: 20 O2: 99% (Room Air) Temp: 98.0F Critical Actions:

Deep Dive MW R7 Mar 16, 2023

Obtain IV Access – get two large bore IVs (18g or larger) Resuscitate – un-crossmatched blood at first, don’t forget type and screen! Medicate – Give Pantoprazole always, Octreotide and Ceftriaxone if hx liver disease, reverse anticoagulation if indicated Imaging – Upright CXR to assess for perforation, CTA if concerned for lower GIB Consult – […]

Round 7 (MW) – Vomiting Blood Mar 01, 2023

You are working at Clerkship General when the charge nurse grabs you – “hey we got a real sick one, a 57yo Male who I just put in the resuscitation bay, he is vomiting blood”. Initial Vitals:BP: 77/34 HR: 135 RR: 24 O2%: 95% Temp: 98.8F Critical Actions: Further Reading: EMDocs – GI Bleed

Flash Pulmonary Edema (aka SCAPE) Feb 19, 2023

Opioid Use Disorder – What You Do Matters! Feb 01, 2023

In this long-form episode we will discuss opioid use disorder, the leading cause of death in young adults in the United States. What you do matters! References

The Rank List Jan 20, 2023

This episode will answer 3 big pre-Match Day questions: 1. How do I go about making my rank list? 2. What about post-interview communication both from and to programs? 3. How does this whole thing called the Match actually work? Resources: https://www.emra.org/books/msadvisingguide/preparing-and-submitting-your-rank-list/

Deep Dive MW R6 Jan 16, 2023

Aortic Dissection – when there is a tear in the intima layer of the aorta and the blood dissects the intima away from the media creating a false lumen in the aorta Further Reading: Core EM – Aortic Dissection LITFL – Aortic Dissection

Round 6 (MW) – Weakness Jan 02, 2023

You are working at Clerkship General when the base command phone rings – “Hey doc just wanted to give you a heads up on this stroke alert we’re bringing you – we have a 70yo M with sudden onset left arm numbness and weakness, last known well 2 hours ago, we’ll be there in about […]

New Years Resolutions Dec 16, 2022

Not your typical wellness episode – by Zack

Round 5 (MW) – Leg Pain Dec 02, 2022

You are working at Clerkship General Hospital when EMS calls in a female with opioid overdose, but she won’t stop complaining of leg pain… Initial Vitals: Temp: 98 BP: 120/80 HR: 89 RR: 20 O2 Sat: 100% Critical Actions:

Deep Dive MW R4 Nov 15, 2022

Diabetic Ketoacidosis – hyperglycemia, ketosis, and anion gap metabolic acidosis Don’t forget about euglycemic DKA (especially in setting of SGLT2 inhibitor) or mimics such as alcoholic ketoacidosis Treatment of the ketoacidosis Insulin (usually a drip or bolus + drip) – only once K>3.5 Volume Resuscitation (NS initially, change to LR) Bicarb drip (poor evidence, only […]

Round 4 (MW) – Shortness of Breath Nov 01, 2022

You are working a shift at Clerkship General when the charge nurse comes and grabs you to see a 24yo male who appears to be in respiratory distress. Critical Actions: Diagnose DKA Replete potassium Start insulin AFTER potassium repletion EITHER place central line for faster K repletion OR initiate bipap to allow time for potassium […]

Interviews Part 2 – Acing your interview Oct 24, 2022

Before interview day, do your research on programs and interviews and reflect on the way in which you want to portray yourself. On interview day, have a cheat sheet with notes about your conversations, questions, and pro-cons. Remember to stay calm, take a pause if you need to, and above all be authentic to who […]

Deep Dive MW R3 Oct 19, 2022

show notes coming soon

Round 3 (MW) – MVC Oct 03, 2022

Show comments to be posted shortly

Interviews Part 1 – Crafting your schedule Sep 29, 2022

Understand the timeline – research programs to find out when they extend invites and when they host interviews Prepare for invitations – set up email and text notifications, get a calendar Accept invitations – respond promptly and keep your calendar updated Optimize invitations – any interview date you get is a good one, but planning […]

Deep Dive MW R2 Sep 18, 2022

Summary of Key Points 1. You should consider ectopic pregnancy in every patient who is capable of bearing children 2. If a patient of child bearing age presents with severe abdominal pain or vaginal bleeding and is either hemodynamically unstable or very ill appearing, this is a ruptured ectopic pregnancy until proven otherwise and I […]

Round 2 (MW) – Abdominal Pain Sep 01, 2022

You are working at Clerkship General when the next chart gets handed to you – a 31 year old female presenting with abdominal pain. Initial Vitals: BP: 109/65 HR: 96 RR: 21 O2: 99% Temp: 99.1F Critical Actions: Obtain pregnancy test Confirm IUP Administer Rhogam Treat UTI Counsel the patient and discharge them Further Reading: […]

Selecting Programs Aug 17, 2022

Things to consider when selecting residency programs to apply to: 1. What type of program (County, Community, Academic) 2. What length of program (3 year vs. 4 year) 3. Location 4. Culture and Lifestyle 5. Niches in EM Further Resources: EMRA Residency MapDoximity NavigatorSAEM Residency FairEMRA Residency Fair

Competitiveness Aug 17, 2022

3 Steps to assessing your competitiveness for matching in an EM residency: 1. Get a good advisor. 2. Look at the data. 3. Maximize your potential. Further Reading: EMRA – Apply smarter not harderEMRA HangoutsEMRA Student-Resident Mentorship ProgramNRMP Charting the OutcomesNRMP Residency DataALiEM – Match AdviceUTSW Texas STAR

Should I go into EM? Pt 2 Aug 15, 2022

The future of emergency medicine seems bleak. Listen to Zack’s perspective on the future of our beloved specialty in part TWO of this two-part series.

Round 1 (MW) – Shortness of Breath Aug 01, 2022

You are working your FIRST SHIFT EVER at Clerkship General hospital when a 60 year old female presents with shortness of breath. Initial Vitals: HR: 92 RR: 28 BP: 120/80 O2%: 89% Temp: 101.2F Critical Actions: Obtain full set of vital signs Diagnose PNA and COPD exacerbation Administer appropriate antibiotics Treat symptoms with steroids and […]

Should I go into EM? – Part 1 Jul 19, 2022

The future of emergency medicine seems bleak. Listen to Zack’s perspective on the future of our beloved specialty in part one of this two-part series.

Round 35 (Pediatric Trauma) Jul 01, 2022

You are working at *rural* Clerkship General when you receive a radio call from EMS – 7yo male from a severe bus accident with a large scalp laceration, unable to control the hemorrhage. Initial Vitals HR: 136 RR: 22 BP: 80/35 O2%: 100% Temp: 98F Critical Actions: Perform ATLS Algorithm Control Hemorrhage Transfuse pRBCs Replete […]

Bradycardia (Deep Dive R34) Jun 15, 2022

Asymptomatic Bradycardia – usually don’t treat Symptomatic Stable Bradycardia – atropine, further workup Symptomatic Unstable Bradycardia – SIMULTANEOUS treatment with medications and electricity Meds: Trial of atropine, then either epinephrine, dopeamine, or isoproterenol Electricity: Transcutaneous Pace –> TVP DDX of Bradycardia – BRADIE Blocks (av blocks) Reduced vital signs (hypoxemia, hypothermia, hypoglycemia) Acs (acute coronary […]

ERAS 2 of 2 – How to fill out the CV section Jun 09, 2022

What is most important to programs from ERAS? SLOEs, clinical grades on EM rotations and residency interviews. How do you look good on interviews? Have a thorough ERAS application that gives interviewers lots to ask about! On ERAS, there are four sections in the curriculum vitae portion: Education – honorary societies, medical school awards, other […]

ERAS 1 of 2 – The 8 parts of the application Jun 03, 2022

ERAS Pt 1: The 8 Parts of the ApplicationThere are 8 parts to the application: Personal and Biographic Information – mostly self-explanatory Curriculum Vitae (Resume) – keep an updated CV throughout medical school to makethis easy to fill out, be concise but specific Personal Statement – start early Letters of Recommendation – should ideally have […]

Round 34 (Shortness of Breath / Bradycardia) Jun 01, 2022

You are working at Clerkship General when you are called to see a 70 yo male who is presenting with shortness of breath. Initial Vitals Temp 98.0 HR 36 RR 28 BP 80/35 O2 82% Critical Actions Interpret ECG Correctly (3rd degree AV block) Order a troponin Perform and Describe transcutaneous pacing Perform and Describe […]

Ventilator Alarms (Deep Dive R33) May 15, 2022

DOPES D-Displacement – endotracheal tube dislodges from trachea, or falls into right mainstem bronchus O-Obstruction – Mucous plugging, bronchospasm, patient biting tube P –Pneumothorax – Look out for pneumothorax, it can be subtle E – Equipment – Disconnected/unpowered equipment, ensure everything is powered on and connected appropriately S – Stacking – common in asthma/COPD due […]

Personal Statement Pt 2 – Brainstorming Ideas May 02, 2022

Brainstorming ideas – how to make it personal What makes me unique? 2. What are some specific experiences I’ve had in my life that have either made me want to do EM or given me the skills that will prepare me well for training in EM? 3. If a family member or a friend were […]

Personal Statement Pt 1 – Dos and Donts May 02, 2022

Welcome to EM Clerkship Maddie Watts! The personal statement should be *personal* and should *make a statement*. Start early Use solid organizational structure Address the big three questions – who? what? why? Check for grammar mistakes Explain any red flags Further Reading: EMRA / CORD Advising Guide NRMP Program Director Survey ALiEM Match Advice Series

Round 33 (Respiratory Distress) May 01, 2022

You are working at Clerkship General when you are called to the resuscitation bay for a 55yo M presenting in respiratory distress. Initial Vitals Temp 99.9 HR 110 RR 22 BP 122/82 O2 82% on BiPAP 10/5 100%FiO2 Critical Actions Correctly interpret CXR #1 (multifocal PNA) Correctly interpret CXR #2 (bilateral PNTX) Treat with Oseltamivir […]

Toxic Plants (Deep Dive R32) Apr 15, 2022

Cardiac Glycoside containing plants : Foxglove, Lilly of the Valley, Oleander, Squill Contain cardiac glycosides, which act as a negative chronotrope as well as a positive inotrope. Patients present with nausea, vomiting, visual changes, bradycardia/arrhythmia, and may develop hyperkalemia – a poor prognostic factor Treatment is Digibind/DigiFAB – look out for the side effects of […]

Round 32 (Pediatric Vomiting) Apr 01, 2022

You are working at Clerkship General when you see your next patient : a 3 year old male accompanied by his father with chief complaint of vomiting. Initial Vitals Temp 98.6 HR 50 RR 20 BP 95/55 O2 100% Critical Actions Identify the history of ingestion Check a blood glucose Call Poison Control Treat with […]

Opioid Use Disorder (Deep Dive R31) Mar 15, 2022

Opioid overdose is the number one leading cause of death in adults under the age of 50. Many ED Physicians fail to recognize that offering MAT (medication assisted therapy) to victims of opiate overdose is one of the most effective interventions we can offer in medicine. 1 in 2 using high-dose buprenorphine (≥ 16 mg) […]

Round 31 (Altered Mental Status) Mar 01, 2022

Critical Actions: Administer Naloxone Minimize Unnecessary Testing Discuss options for Rehab Offer opioid replacement therapy Provide Social Support Further Reading: Buprenorphine – EMDocs Naloxone – EMDocs Initiating Opioid Treatment in the ED – ACEP

Atrial Fibrillation (Deep Dive R30) Feb 15, 2022

AFib with Rapid Ventricular Rate (RVR) – Rate >110 Primary AFib – Patients symptoms or their hemodynamic instability is due to the AFib itself. Treatment is by rate or rhythm control. Secondary AFib – Patients AFib rate or their hemodynamic instability is due to an underlying secondary process (eg thyrotoxicosis, PE, sepsis, drugs, etc). Treatment […]

Round 30 (Chest Pain) Feb 01, 2022

You are working a shift at Clerkship General Hospital when you go see your next patient, a 70 year old male presenting with chest pain. Initial Vitals Temp 98.7 HR 140 RR 20 BP 125/85 O2 99% Critical Actions Obtain EKG Treat AFib RVR via rate control (and not cardioversion) Diagnose Acute Arterial Occlusion Treat […]

tPA (Deep Dive R29) Jan 15, 2022

tPA usage is controversial. Listen to find out why. Read more to form your own opinions. Episode Sources: After Re-Analysis, No Trials Show Efficacy of tPA in Acute Ischemic Stroke Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department Why we can’t trust clinical guidelines […]

Round 29 (Weakness) Jan 01, 2022

Initial Assessment: Obtain Vitals and blood glucose level Time of onset (important for tPA/TNK vs thrombectomy) Neurologic and Cardiac Examination / NIHSS do not delay head CT to complete NIHSS, can always finish after CT Assess contraindications for tPA Workup: Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck CXR and UA (infections can cause recrudescence […]

Trauma (Deep Dive R28) Dec 15, 2021

ATLS – Advanced Traumatic Life Support Primary Survey Airway Breathing Circulation Disability Exposure Secondary Survey Head to Toe Examination Look for injury patterns and important injuries, such as Battle Sign (post auricular ecchymosis) Raccoon Eyes (infraorbital ecchymosis) Hemotympanum Nasal Septal Hematoma Urethral Injuries Circumferential Burns Obtain a basic medical history Obtain XRs, FAST exam, CT […]

Round 28 (Burn) Dec 01, 2021

You are working a shift at ABEM General when you receive a call from EMS over the radio for a patient involved in a house fire. Initial Vitals Temp 99.0 HR 150 RR 40 BP 90/50 O2 95% Critical Actions Administer 8L IVF in first 8 hours Administer supplemental oxygen for CO poisoning Administer TDAP […]

Pelvic Inflammatory Disease (Deep Dive R27) Nov 15, 2021

50% of cases of Pelvic Inflammatory Disease (PID) is caused by common STIs (Gonorrhea, Chlamydia ) but up to 50% is caused by native vaginal flora/other organisms No SINGLE historic, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID Women with PID may be asymptomatic!! Presumptive treatment of PID […]

Round 27 (Back Pain, Dysuria, Knee Pain) Nov 05, 2021

You are working a shift at ABEM General when three patients check in simultaneously at the start of your shift at 6AM. Initial Vitals#1 (Ms. Taylor, 65F with Back Pain) Temp 98.8 HR 120 RR 22 BP 210/110 O2 97% Critical Actions#1 (Ms. Taylor, 65F withBack Pain) Obtain Medication/Social Hx (Ciprofloxacin use, Cocaine use) Diagnose […]

Cardiac Tamponade (Deep Dive R26) Oct 15, 2021

Cardiac Tamponade Cardiac Tamponade – A physiological state caused by a pericardial effusion in which the pressure in the pericardial sac is higher than the pressure inside the right sided chambers of the heart, leading to impaired filling, decreased cardiac output, and hemodynamic collapse. Pericardial Effusions – Can be caused by infections, rheumatologic diseases, malignancy, […]

Round 26 (Stridor, Vomiting, Shock) Oct 01, 2021

Case Introduction You are working a shift at your local free-standing emergency room when a family of three checks in to be seen (a father and his two sons). Initial Vitals#1 (Chris, 18mo with stridor) Temp 100.4F HR 120 RR 40 O2 93% Critical Actions#1 (Chris, 18mo with stridor) Check pulse oximetry (hidden) Administer PO […]

Hyponatremia (Deep Dive R25) Sep 15, 2021

Hyponatremia in the ED Four questions to ask yourself: Is the patient symptomatic from their hyponatremia (confusion, nausea/vomiting, ams, seizures, etc)? If not, outpatient followup (unless super low) Is the patient having severe neurologic symptoms from their hyponatremia? (seizures, AMS) If yes, treat with hypertonic saline (3%) Is the patient going to be admitted from […]

Round 25 (Seizure) Sep 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you are called to the waiting room by the charge nurse for a seizing patient. Initial Vitals Temp 99.0F HR 97 RR 16 BP 120/80 O2 90% Critical Actions Perform airway maneuvers to clear obstruction Administer IV Benzodiazepines […]

Acetaminophen Overdose (Deep Dive R24) Aug 16, 2021

Acetaminophen Overdose & Toxicology Pearls History: Figure out how much was taken, what time the ingestion occurred, and if any other toxins were ingested Physical Exam: Perform a regular physical exam, and in addition, perform the toxicologic physical exam! Check pupil size Assess neuromuscular status for rigidity/clonus Perform the “toxicologist handshake” Listen to bowel sounds […]

Round 24 (Altered Mental Status) Aug 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you receive a radio call from EMS who are bringing in a young female who was found unresponsive. Initial Vitals Temp 98.0F HR 97 RR 16 BP 120/80 O2 98% Critical Actions Obtain collateral history from EMS/friends Administer […]

Asymptomatic Hypertension (Deep Dive R23) Jul 15, 2021

Asymptomatic Hypertension Make SURE the patient isn’t having symptoms of end organ dysfunction, which could make this hypertensive emergency (confusion, severe headache, blurry vision, weakness, chest pain, shortness of breath, seizures during pregnancy, etc). ACEP clinical policy states, that in the patient with true asymptomatic hypertension who presents to the emergency department, no routine testing […]

Round 23 (High Blood Pressure) Jul 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you are handed the next chart, a 60 year old male presenting with high blood pressure. Initial Vitals Temp 98.0F HR 90 RR 18 BP 220/120 O2 98% Critical Actions Perform thorough neurological exam (and find papilledema) Diagnose […]

Neonatal Resuscitation (Deep Dive R22) Jun 15, 2021

Neonatal Resuscitation *THIS IS A BASIC FRAMEWORK AND IS NOT COMPREHENSIVE* EVALUATE Is the newborn crying/breathing spontaneously? Does the newborn have good tone? Is the newborn a term infant? If YES, hand baby to mom for direct skin-to-skin. If NO, proceed to step 2. INTERVENE STIMULATE – dry vigorously WARM – place cap on head, […]

Round 22 (Cardiac Arrest) Jun 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkship General when the triage nurse runs and grabs both you and your attending for a patient in triage who has active CPR in progress. Initial Vitals Temp 98.0F HR 0 RR 0 BP unmeasurable O2 70% Critical Actions Identify pregnancy […]

Torsades de Pointes (Deep Dive R21) May 15, 2021

Torsades de Pointes (TdP) A type of polymorphic ventricular tachycardia that is inherently unstable and often quickly degrades into ventricular fibrillation. It usually occurs in the setting of a prolonged QT interval, which can either be genetic or acquired. Treatment Defibrillation – per ACLS, ventricular tachycardia with a pulse should receive synchronized cardioversion. But in […]

Round 21 (Drowning) May 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkship General when EMS calls you on the radio… “Hey doc we’re bringing a young female who drowned in a pool ETA 1 minute”. Initial Vitals Temp 95.0F HR 55 RR 5-6 BP 110/82 O2 90% Critical Actions Evaluate for traumatic […]

Kawasaki Disease (Deep Dive R20) Apr 15, 2021

Kawasaki Disease A small vessel vasculitis that affects children, usually

Round 20 (Dehydration) Apr 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when the next chart is handed to you – a four year old male named Tommy with chief complaint of dehydration. Initial Vitals Temp 100.4F HR 132 RR 22 BP 98/64 O2 98% Critical Actions Identify key historical findings […]

Beta Blocker Overdose (Deep Dive R19) Mar 15, 2021

“The Brady Bunch” – Beta-Blockers, Calcium Channel Blockers, Digoxin, Clonidine Treatment of Beta Blocker OD Activated Charcoal – Only if ingestion time was

Round 19 (Bradycardia) Mar 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when you are called to the resuscitation bay to see an elderly patient with unstable vitals brought in by EMS. Initial Vitals Temp 98.0F HR 43 RR 18 BP 60/40 O2 98% Critical Actions Diagnose the etiology for the […]

Deep Dive - Round 18 Feb 16, 2021

Four definitions you must know: SIRS – Must have at least 2 of 4 SIRS criteria (listed below): Fever (>38C) or Hypothermia (12k or 10% Tachycardia > 90 Tachypnea > 20 SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc) SEVERE SEPSIS […]

Round 18 (Fatigue) Feb 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a 20yo female accompanied by her mother checks into the ER with chief complaint of fatigue. Initial Vitals Temp 101.2F HR 122 RR 22 BP 110/90 O2 98% Critical Actions Obtain travel history in patient presenting with fever […]

Round 17 (Postpartum Fever) Jan 01, 2021

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a sepsis alert is paged overhead for a young female who appears diaphoretic and confused. Initial Vitals Temp 102.7F HR 145 RR 32 BP 141/85 O2 93% Critical Actions Workup and treat for sepsis upfront (Cultures, Lactate, IVF, […]

Round 16 (Allergic Reaction) Dec 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise beautiful Friday afternoon when a mother brings her 16 year old son to the ED with chief complaint of allergic reaction. Initial Vitals Temp 98.7 HR 155 RR 28 BP 125/85 O2 99% Critical Actions Interpret ECG Interview […]

Round 15 (Syncope) Nov 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at Clerkship General when a 51 year old female is brought in after a syncopal episode. Initial Vitals Temp 100.2 HR 132 RR 28 BP 105/69 O2 85% Critical Actions Give supplemental Oxygen Diagnose Pulmonary Embolism Administer Heparin Assess contraindications for tPA Administer […]

Round 14 (Shortness of Breath) Oct 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise quiet night when a young male is brought into your ED in obvious respiratory distress. Initial Vitals Temp 98.6 HR 99 RR 34 BP 105/69 O2 95% Critical Actions Give Albuterol + Ipratropium + Steroids Obtain Chest Xray Give […]

Round 13 (Dizziness) Sep 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working at your local hospital when the next chart gets put in your rack. You groan. The chief complaint is dizziness.. Initial Vitals Temp 98.6 HR 109 RR 20 BP 105/69 O2 100% Critical Actions Diagnose Upper GI Bleed Initiate IV Proton Pump Inhibitor Obtain Type […]

Announcement Aug 01, 2020

The website it updated! Please check it out and email me with any technical issues or other comments/concerns. Enjoy your shift!

Round 12 (Difficulty Breathing) Jul 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A young gentlemen runs out to triage yelling “I can’t breath!” and collapses to the floor in front of the nurse… Initial Vitals Temp 98.8 HR 145 RR 45 BP 60/30 O2 85% Critical Actions Give Supplemental Oxygen Identify Pneumothorax Prior to Imaging Correctly Perform Needle Thoracostomy Correctly […]

Round 11 (Headache) Jun 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are having a busy day in the department when you are paged overhead to the resuscitation bay for an ill appearing patient with a headache… Initial Vitals Temp 98.9 HR 99 RR 18 BP 180/110 O2 94% Critical Actions Verbalize a Full Neurologic Examination Obtain CT Scan […]

Round 10 (Allergic Reaction) May 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A 45 year old female is exposed to peanut butter and shrimp pizza and begins to have an apparent allergic reaction… Initial Vitals Temp 98.8 HR 130 RR 35 BP 70/40 O2 92% Critical Actions Verbalize Airway Evaluation Complete a FOCUSED History and Exam Normal Saline Bolus Epinephrine […]

Round 9 (Seizure) Mar 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse brings back a young adult male from the lobby who is having a seizure… Initial Vitals Temp 98.8 HR 90 RR 10 BP 120/80 O2 92% Critical Actions Verbalize ABCs on a Critical Patient Obtain Immediate Blood Glucose Level Give Benzodiazepine Initiate Workup of New-Onset Seizures […]

Round 8 (Fall) Feb 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction EMS brings in an elderly man who has fallen… Initial Vitals Temp 98.6 HR 58 RR 16 BP 105/60 99% Critical Actions Treat the patient’s pain Consult orthopedics for a hip fracture Obtain an EKG Treat Severe Hyperkalemia Consult nephrology for dialysis Final Diagnosis Ground level fall resulting […]

Round 7 (Headache) Jan 01, 2020

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction Just a routine day at your hospital, your next patient has a chief complaint of headache… Initial Vitals Temp 98.8 HR 88 RR 16 BP 130/80 O2 99% Critical Actions Identify Acute Angle Closure Glaucoma Initiate Appropriate Treatment for Acute Angle Closure Glaucoma Emergent Consult to Ophthalmology Recheck […]

Round 6 (Back Pain) Dec 01, 2019

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A notorious, disheveled frequent flyer presents to your emergency department for her back pain and is asking for more Dilaudid… Initial Vitals Temp 99.0 HR 99 RR 18 BP 118/78 O2 99% Critical Actions Ask about Red Flags for Spinal Infection Perform a Thorough Spinal Exam Obtain MRI […]

Round 5 (Geriatric Fall) Nov 01, 2019

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse is asking you to evaluate a 70 year old male who has been placed in a hall bed after hitting the back of his head. She wants to know if you would like to call a trauma alert… Initial Vitals Temp 103.7 (Hidden by Examiner) HR […]

Round 4 (Flank Pain) Oct 01, 2019

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse tells you that you have a new patient and is requesting a verbal order for nausea medicine. She advises you that the patient is the CEO of your hospital… Initial Vitals Temp 98.9 HR 99 RR 18 BP 120/80 O2 98% Critical Actions Perform Genitourinary Exam […]

Round 3 (Chest Pain) Sep 22, 2019

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction An ill appearing patient has been rushed back from the lobby, clutching his chest, you are needed immediately at the bedside… Initial Vitals Temp 99.1 HR 95 RR 20 BP 120/80 O2 98% Critical Actions Obtain Early EKG Notify Cardiology of Inferior STEMI Bring Crash Cart to Bedside […]

Round 2 (Seizure) Sep 16, 2019

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction EMS brings in a postictal 34 year old female after she has a seizure. She is complaining of a headache… Initial Vitals Temp 98.9 HR 110 RR 10 BP 175/115 O2 95% Critical Actions Articulate Full Neurologic Exam Early Blood Glucose Identification of Pregnancy Administer Magnesium Treat the […]

Round 1 (Altered Mental Status) Sep 08, 2019

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are called to the resuscitation bay for a poorly responsive patient that has been brought in by EMS. Initial Vitals Temp 98.8 HR 78 RR 4 BP 124/78 O2 98% Critical Actions Obtain Early Blood Glucose Administer Dextrose Obtain Salicylate and Acetaminophen Levels Admit for Further Observation […]

MUST LISTEN (re ABEM) Aug 25, 2019

ABEM-style cases presented on EM Clerkship are not my actual ABEM exam cases, and they are not derived from my actual exam cases. I will never be discussing my specific exam details with anybody, including on this podcast. The cases were created independently, by me, for the purpose of medical education and improving patient care. […]

ACS, Acidosis, AAA and Other Miscellaneous Causes of Abdominal Pain Aug 11, 2019

There are HUNDREDS of other non-GI/GU causes of abdominal pain… Acute coronary syndrome (ACS) Test with EKG and troponin Treat with aspirin and heparin Acidosis Diabetic Ketoacidosis (DKA) Respiratory Acidosis (COPD) Salicylate Toxicity (Remember MUDPILES) Abdominal Aortic Aneurysm (AAA) Older people with abdominal/flank/back pain or syncope Testing CT Scan Abdomen with contrast (Good) CTA Abdomen […]

Testicular Torsion and Prostatitis Aug 04, 2019

Testicular Torsion History Pain in the testicles Referred pain in the flank or lower abdomen Usually sudden and severe Usually WITHOUT urinary symptoms Exam Asymmetric testicular lie High riding testicle Tenderness and swelling of the testicle itself Cremasteric reflex Testing Testicular Ultrasound Treatment Immediate call to urology when suspected Manual detorsion (“Open the Book”) Prostatitis […]

PID and Ovarian Torsion Jul 28, 2019

Women have two additional diseases that must be added to the differential diagnosis of their abdominal pain. PID and ovarian torsion. Pelvic Inflammatory Disease (and Tube-Ovarian Abscess) Deep pelvic infections high in the reproductive tract frequently caused by sexually transmitted infection but can be caused by other infections (especially anaerobic infections) as well History Symptoms […]

Urinary Tract Infections Jul 21, 2019

How to Read a Urinalysis Signs of Inflammation Leukocyte Esterace WBCs Multiple conditions cause inflammation on a urinalysis. Anything that causes nearby inflammation (appendicitis, pelvic infections, diverticulitis) or slows urine output (dehydration, renal disease) can commonly elevate these markers. Signs of bacterial presence (not present in ~25% of proven urinary tract infections!!!) Nitrites Bacteria Asymptomatic […]

Ectopic Pregnancy Jul 14, 2019

All women of childbearing age who present with abdominal pain need a pregnancy test a core teaching of EMergency medicine Ectopic pregnancy is the leading cause of maternal death in the first trimester History Abdominal pain present in 90% of cases Amenorrhea present in 70% of cases Vaginal bleeding present in 50% of cases The […]

Bowel Perforation and Volvulus Jun 30, 2019

Bowel Perforations History Perforation takes time, frequently symptoms were either ignored or not noticed as can occurring in… Elderly, diabetic, or immunosuppressed patients (frequently have minimal symptoms) Pediatric patients (unable to or scared to mention symptoms) Exam Commonly have “peritoneal signs” Guarding Rebound Tenderness Rigidity Testing CT Scan X-Ray? (not your primary test, but a […]

Mesenteric Ischemia and Small Bowel Obstruction Jun 23, 2019

Mesenteric Ischemia Celiac truck supplies blood to the stomach and duodenum SMA supplies blood to the rest of the small bowel and proximal colon IMA supplies blood to the distal colon and rectum Arterial flow can be blocked because of emboli (atrial fibrillation) Venous flow can be blocked because of thrombosis (hypercoagulable states) Effective flow […]

Biliary Diseases and Pancreatitis Jun 09, 2019

Biliary Diseases Biliary Colic- A gallstone DOES NOT GET STUCK, but it slowly rolls out of the gallbladder, through the cystic duct, then the common bile duct and pancreatic duct. This results in several hours of crampy “colicky” pain as the stone passes. Cholecystitis- A gallstone gets stuck IN THE NECK OF THE GALLBLADDER OR […]

Appendicitis and Diverticulitis Jun 02, 2019

Appendicitis History Vague nonspecific abdominal cramping and nausea (Nonspecific Phase) gradually progresses to localized pain (Localized Phase). The pain most commonly localizes in the RIGHT LOWER QUADRANT near McBurney’s Point. Exam Focal tenderness in the right lower quadrant McBurney’s Point: 1/3 the distance traveled from anterior superior iliac spine (ASIS) to the navel. Psoas Sign: […]

Abdominal Pain Presentations (Exam, Plan, and Disposition) May 26, 2019

EM Clerkship’s 10 Step Patient Presentation Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint) At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors) Red Flags/Pertinent Positives and Negatives Vital Signs Focused Physical Exam of the Complaint Suspected Diagnosis Can’t Miss Diagnosis Testing Plan Treatment Plan (If Asked) Anticipated Disposition Vital Signs “Vitals […]

Abdominal Pain Presentations (History) May 19, 2019

EM Clerkship’s 10 Step Patient Presentation Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint) At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors) Red Flags/Pertinent Positives and Negatives Vital Signs Focused Physical Exam of the Complaint Suspected Diagnosis Can’t Miss Diagnosis Testing Plan Treatment Plan (If Asked) Anticipated Disposition Demographics (Age, Gender, […]

How to Crush Your SLOE (Tips 26-30) Apr 14, 2019

Tip #26 Update your attending when the nurse is having difficulty with your patient’s IV or drawing blood. Tip #27 Get the urine sample from your patient (there is no greater delay in patient flow than waiting on urine) Tip #28 Round on your patients and repeat your initial scripting. “It’s Zack the medical student […]

How to Crush Your SLOE (Tips 21-25) Apr 07, 2019

Tip #21 Review and note if the patient has any IMPORTANT old records. Any ED visit within the last month for a similar complaint (aka “Bouncebacks” and frequent fliers) Any echocardiogram or catheterization reports for a patient with cardiac symptoms H&P and discharge summary for recent hospitalizations Any large imaging studies (CT, MRI, etc) that […]

How to Crush Your SLOE (Tips 16-20) Mar 31, 2019

Tip #16 Recheck the patient’s heart rate and respiratory rate (and put in your presentation that you did so) Heart rate frequently falsely elevated when being triaged Respiratory rate frequently falsely normal when being triaged Tip #17 Fully examine the specific complaint. Some common misses include… Neurologic complaints (headache, paresthesias, dizziness, asymptomatic hypertension, seizures, visual […]

How to Crush Your SLOE (Tips 11-15) Mar 24, 2019

Tip #11 Give 4 descriptors/adjectives for each complaint Location Quality Duration Modifying Factors Severity Context Timing Associated Symptoms Tip #12 Get the ACTUAL story. Why did the patient come NOW? Did something change or worsen? Did family force them to come? Do they have a family history of something similar? Tip #13 Present the pertinent […]

How to Crush Your SLOE (Tips 6-10) Mar 10, 2019

Tip #6 Make your patient remember your name. Introduce yourself clearly Show the patient your badge Use a nickname if your name is difficult for people to remember/understand Repeat your name again and again Tip #7 Keep the patient informed about… Diagnosis Anticipated ED course/timeline Delays Tip #8 Keep your patient comfortable. Get them blankets […]

How to Crush Your SLOE (Tips 1-5) Mar 03, 2019

Tip #1 Introduce yourself. Attending? “Hello, my name is Zack, I’m one of the medical students” Resident? “Hello, my name is Zack, I’m one of the medical students” Nurse? “Hello, my name is Zack, I’m one of the medical students” Janitor? “Hello, my name is Zack, I’m one of the medical students” Tip #2 Be […]

Airway Part 4- What to Do If Intubation Fails Feb 03, 2019

Verbalize the out loud prior to performing rapid sequence intubation. The Bougie Ideal for situations when you’re view is suboptimal Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique). Video Laryngoscopy (Glidescope) Laryngoscope with […]

Airway Part 3- Rapid Sequence Intubation Jan 27, 2019

The most important thing to do when preparing for RSI is to PREOXYGENATE the patient. Step 1: Choose Your Equipment Miller or Mac blade? Miller blade is straight (like the ‘L’ in miller) Frequently used in kids Mac blade is curved (like the ‘c’ in mac) (Generally, this is the best choice to use on […]

Airway Part 2- Bag Valve Mask Adjuncts Jan 20, 2019

How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful? Pharyngeal Airways These tools bypass the posterior portion of the tongue to help with BVM ventilation Nasopharyngeal Airway (NP) Measure from earlobe to tip of nose TEST QUESTION: Don’t use in a […]

Common Fungal Infections Jan 13, 2019

Most Life Threatening Fungal Infection Mucormycosis Black facial discharge Cranial nerve dysfunction Facial swelling Eschar formation When to Suspect a Fungal Infection Immunocompromised (HIV, Diabetes, Organ Transplants, etc) Not getting better on typical antibiotics Other Fungal Infections Aspergillus Aspergilloma Bronchopulmonary Aspergillosis Invasive Aspergillosis Coccidiomycosis Southwestern United States Histoplasmosis North Central United States Blastomycosis Southeast United […]

Psychiatric Complaints Dec 23, 2018

The Two Objectives During Every Psychiatric-Type Complaint Medical Clearance Psychiatric Risk Assessment Medical Clearance Required by EMTALA to perform a “screening exam” regardless of complaint Most psychiatric facilities have poor diagnostic/treatment capabilities for non-psychiatric conditions and will want patient to be “medically cleared” Sometimes they will require specific tests to be performed, blood pressure to […]

NBME Shelf Review (Part 11) – OBGYN Dec 09, 2018

Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age! It changes the differential diagnosis It changes the medications you can give It changes the tests you can order Vaginal Bleeding Pearls Non-pregnant vaginal bleeding Order a pelvic ultrasound (for structural causes) Order a CBC and coagulation panel (for anemia and coagulopathy) […]

NBME Shelf Review (Part 10) – Miscellaneous Dec 02, 2018

Stroke Most appropriate initial tests Blood Glucose Hypoglycemia is a common stroke mimic CT Head without contrast Rules out HEMORRHAGIC strokes Subarachnoid Hemorrhage Classic description “Worst headache of life” “Sudden and maximal in onset” “Thunderclap” Testing CT Head without contrast (If negative CT) Lumbar puncture Xanthochromia (yellowish fluid) Treatment Nimodipine (Given orally) Prevents vasospasm Causes […]

NBME Shelf Review (Part 9) – Cardiopulmonary Nov 25, 2018

Pulmonary Embolism Three types of pulmonary embolism “Massive” Hypotension or severe bradycardia Treat with tPA or thrombectomy “Submassive” Normotensive but with Right Heart Strain S1Q3T3 on EKG Elevated BNP Elevated troponin Dilation of RV on ultrasound Treat with heparin/lovenox and admit “Low Risk” Treat with anticoagulation Outpatient vs inpatient treatment Testing CTA of the Chest […]

NBME Shelf Review (Part 8) – Abdominal Pain Nov 18, 2018

Acute Mesenteric Ischemia History of atrial fibrillation “Pain out of proportion to exam” Bowel Obstruction History Abdominal pain Bloating/Distention Vomiting Decrease stool/flatus Exam Abdominal tenderness and distention If guarding/rigidity/rebound tenderness (aka peritonitis) Consider perforated bowel Testing Obtain CT abdomen with IV contrast Treatment Fluids NPO NG Tube Acute Diverticulitis NOTE: DiverticulOSIS is what causes GI […]

NBME Shelf Review (Part 7) – Abdominal Pain Nov 11, 2018

Hernia 3 classifications for hernia Reducible Able to be reduced (placed back into the abdomen) at bedside Incarcerated Cannot be reduced but not severely tender or erythematous Can occasionally cause bowel obstructions Strangulated Cannot be reduced but LOSING BLOOD SUPPLY Extremely tender and abnormal exam Needs emergent surgical consult Esophageal Varices Classic presentation Hematemesis/Melena Chronic […]

NBME Shelf Review (Part 6) – Common Arrhythmias Nov 04, 2018

“Unstable” Arrhythmias Arrhythmias that cause Hypotension Pulmonary Edema Chest Pain Altered Mental Status Supraventricular Tachycardia (SVT) Stable Vagal maneuver Adenosine Beta blocker or calcium channel blocker Unstable SYNCHRONIZED cardioversion Monomorphic Ventricular Tachycardia (VT) Stable Amiodarone Procainamide Lidocaine Unstable SYNCHRONIZED cardioversion Pulseless Defibrillation Polymorphic Ventricular Tachycardia (aka Torsades de Pointes) Known complication of prolonged QTc Side […]

NBME Shelf Review (Part 5) – Ophthalmology and Toxicology Oct 28, 2018

Corneal Abrasion Stain the eye with fluorescein and use woods lamp Look for fixed staining (“uptake”) on the cornea Acute Angle Closure Glaucoma Symptoms Eye Pain Headache Check for intraocular pressure greater than 20 Commonly precipitants OTC cough/cold medicine (anticholinergic effect) Dark environment (such as movie theater) Treatment Timolol Pilocarpine Acetazolamide Apraclonidine Giant Cell Arteritis […]

NBME Shelf Review (Part 4) – Environmental Oct 21, 2018

General Bite Wound Management Irrigate thoroughly Update tetanus LOW RISK bites get sutured High risk bites to cosmetic areas (face) get sutured AND antibiotics High risk bites to non-cosmetic areas are left open AND get antibiotics Rabies Give vaccine if… ANY suspicion for bat bite (bat in room, cave, etc) Bite by wild animal that […]

NBME Shelf Review (Part 3) – Pediatrics Oct 14, 2018

Febrile Seizures Simple (All features must be present) Age 6 months – 5 years Febrile Lasts less than 15 minutes Only one seizure in 24 hour period No focal neuro deficits on exam Generalized seizure (must have LOC) Treat with acetaminophen and reassurance Complex Does not meet ALL of the criteria for a simple febrile […]

NBME Shelf Review (Part 2) – Trauma Oct 07, 2018

Penetrating Abdominal Trauma Anything below the 4th intercostal space (nipple) is potentially an abdominal injury Gunshot wounds to the abdomen Needs immediate exploratory laparotomy Stab wounds to the abdomen Needs immediate exploratory laparotomy IF… Hemodynamically unstable Peritonitis on exam (rebound, rigidity, guarding) Organs hanging out of abdomen Blunt Abdominal Trauma If the patient is unstable […]

NBME Shelf Review (Part 1) – General Concepts Sep 30, 2018

General Approach to a Test Question Read the last sentence of the question Read the answer choices THEN read the vignette Common Scenarios with Quick Answers Hypotensive patients Give a fluid bolus Altered mental status Check a blood glucose Hypoglycemia Orange juice if can swallow safely D50 if patient cannot swallow and mildly altered IM […]

When to Stop CPR Sep 09, 2018

Why is this Important? It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal. Hospitals need to steward their resources to distribute equitable care between its patients When is it Appropriate to Stop CPR on a Pulseless Patient? Patient shows signs of irreversible death Rigor mortis Decapitation Rotting/decaying […]

Abdominal Aortic Aneurysm Sep 02, 2018

Kidney Stones are a Diagnosis of Exclusion!!! History Risk factors Age >60 Tobacco use Classic presentations Stable with sudden flank/back/abdominal pain or syncope Unstable with pallor, hypotension, and ill appearance Exam Pulsatile abdominal mass Unstable vitals Testing Plan Labs TYPE AND SCREEN CBC Electrolytes Coagulation studies Lactic acid Imaging Bedside ultrasound (optimal) Aorta protocol Look […]

Testicular Torsion Aug 26, 2018

Kidney Stones are a Diagnosis of Exclusion!!! Introduction Testicular torsion is a time sensitive diagnosis (risk of infertility, etc) Commonly mimics kidney stones History Sudden onset pain Epididymitis tends to be slower in onset Flank/lower abdomen/scrotal pain Frequently causes vomiting Uncommon in geriatric patients Exam Perform a GU exam and look for Unequal/horizontal “lie” Testicular […]

Flank Pain and Kidney Stones Aug 19, 2018

Kidney Stones are a Diagnosis of Exclusion!!! Step 1: Consider the Differential Diagnosis for Flank Pain Appendicitis Abdominal Aortic Aneurysm Ectopic Pregnancy Testicular/Ovarian Torsion Kidney Stone Step 2: Diagnose the Kidney Stone Option 1- Renal Ultrasound Findings consistent with kidney stone diagnosis Hydronephrosis Lack of ureteral jets (in bladder) Kidney stones (poor sensitivity for this) […]

Ventilator Basics Jul 08, 2018

Step 1: Start Patient on Volume Assist-Control Ventilation The most basic mode of ventilation Provides a FIXED VOLUME at a FIXED RATE If the patient over-breaths… The ventilator will give another FULL breath Can cause breath stacking and be uncomfortable in patients who are poorly sedated This is not a problem in the ED because […]

Rabies Prophylaxis Jun 24, 2018

Introduction What is rabies? A very rare and aggressive encephalitis Global impact with exception of UK/Australia Animals whose bites/scratches may require prophylaxis Bats Dogs, Cats, Ferrits Other carnivorous animals Foxes, Coyotes, Skunks, Raccoons Post exposure prophylaxis Both Rabies vaccine and immunoglobulin When Do You Give Rabies Prophylaxis? Step 1: Bitten or scratched by domesticated pet? […]

Occupational Exposures Jun 17, 2018

The only chief complaint that you are guaranteed to eventually have to manage in a colleague Respiratory Exposures Meningococcus (meningococcemia, meningitis, etc) Give prophylaxis (ceftriaxone) if… Intubated a pt without a mask Suctioned a pt without a mask Performed mouth to mouth resuscitation Tuberculosis CDC recommends testing if exposed Treat if positive CDC recommends prophylaxis in.. […]

Breast Complaints Jun 10, 2018

All breast complaints are cancer until proven otherwise!!! History Increased risk of breast cancer Family history of breast cancer (especially 1st degree) Delayed childbearing (no children until after 30) Age >50 Associated with menstrual cycle Exam Asymmetric appearance of breasts Palpable mass Red Flags Non-mobile Overlying skin changes Lymphadenopathy Located in upper/outer quadrant of breast […]

Neonatal Conjunctivitis Jun 03, 2018

The 3 Worst Causes of Neonatal Conjunctivitis Gonorrhea Causes corneal ulcers and sepsis Red flags 1st week of life Copious purulent drainage Diagnose with cultures Treatment Cefotaxime (3rd generation cephalosporin) Admit Chlamydia Occurs in 1st month of life Treat with PO erythromycin HSV Can disseminate to the brain Red flags Mother tested positive (or had […]

Subarachnoid Hemorrhage May 20, 2018

History Sudden and maximal in onset Compared to previous headaches Family history of aneurysm Associated Symptoms Photophobia Visual Changes Neck Stiffness Exam Full neuro examination Cranial nerves Visual fields Speech Cerebellar (finger-nose) Motor Sensation Gait Testing Plan Non-contrast head CT Excellent sensitivity 100 RBCs in tube 4 Can be […]

Blood in the Diaper May 13, 2018

The 4 Most Common Causes of Blood in Diaper Urinary crystals Will be guaiac negative Common in first few weeks of life Vaginal bleeding Common in newborn females as they withdraw from maternal estrogen Maternal blood Swallowed during birthing process Breastfeeding with cracked/bleeding nipples Anal fissures Common and will improve on its own Basic Approach […]

Nutritional Emergencies May 06, 2018

Consider In High Risk Patients Alcoholics GI disorders Eating disorders Starvation/poor diet Extremes of age Thiamine (B1) deficiency Causes damage to neurons and cardiac myocytes Manifestations Dry beriberi Neuropathy Paresthesias Wernicke’s encephalopathy Ophthalmoplegia Ataxia Altered mental status Korsakoff syndrome Ophthalmoplegia, ataxia, altered mental status PLUS Confabulation Memory loss Wet beriberi Heart failure from cardiac damage […]

Complications of Myocardial Infarction Apr 29, 2018

Mnemonic: DARTH VADER Death Arrhythmia ACS patients need to be placed on cardiac monitor Frequently degenerate into non-perfusing rhythms Rupture of Ventricle Occur within a few days of myocardial infarction Rapid decompensation Bedside ultrasound will show pericardial effusion and tamponade Tamponade Multiple etiologies Rupture of ventricle (see above) Pericarditis Becks Triad Jugular vein distension Muffled […]

tPA Basics Apr 15, 2018

My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated. Introduction tPA is one […]

Sepsis Apr 01, 2018

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information. Introduction Sepsis is bad and needs to be treated aggressively Confusion around multiple conflicting guidelines and requirements Surviving Sepsis Campaign recommendations CMS requirements Sepsis-3 SOFA/SIRS/qSOFA Institutional protocols Sepsis-3 Proposed Recommendations Screen for sepsis by applying […]

Neonatal Jaundice Mar 25, 2018

Physiology RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin Conjugated (direct) bilirubin -> Eliminated in stool Causes of Hyperbilirubinemia Increased RBC turnover Sepsis Rh incompatibility RBC disorders Maternal diabetes Scalp hematoma Decreased/slow conjugation by the liver Peaks around day 5 of life Congenital liver disorders Gilbert/Crigler Najjar […]

Thrombocytopenia Mar 11, 2018

Clinical Presentation Incidental finding on routing CBC Petechiae/purpura Mucosal bleeding Epistaxis Gingival bleeding Hematuria Vaginal bleeding 5 Major Causes of Thrombocytopenia Thrombotic Thrombocytopenic Purpura (TTP) Clinical presentation (pentad) Thrombocytopenia Fever Microangiopathic hemolytic anemia “schistocytes” Neurologic abnormalities Renal dysfunction Physiology Low ADAMTS13 results in impaired vWF breakdown Widespread “platelet plugs” Treatment Plasma exchange Hemolytic Uremic Syndrome […]

Nausea and Vomiting Mar 04, 2018

The hardest part about this chief complaint is expanding your differential beyond gastritis!!! Step 1: Expand Your Differential Diagnosis Early appendicitis Bowel obstructions Myocardial infarction Elevated ICP Diabetic Ketoacidosis Step 2: Give a Testing Plan High yield tests to consider EKG – older adults Pregnancy test – women of child bearing age Electrolytes – most […]

Complications of Cirrhosis Feb 25, 2018

Organ Failure Complications Hepatorenal syndrome (renal failure) Decreased urine output Labs show elevated creatinine Admit to hospital (high mortality) Hepatic encephalopathy (brain failure) Introduction Liver clears ammonia from body In advanced liver failure, ammonia increases Symptoms Altered mental status/confusion Asterixis Treatment Lactulose Binds ammonia and is excreted Rifaximin Eliminates bacteria responsible for producing ammonia Portal […]

Peds T- Tummy and Non-Accidental Trauma Feb 18, 2018

Non-Accidental Trauma Estimated 10% of pediatric patients are victims of abuse Sexual abuse Physical abuse Neglect Common red flags Changing story Story that doesn’t make since Delays in seeking care Unusual bruising locations Torso Ears Neck Common tests if non-accidental trauma suspected Skeletal survey x-rays Head CT Especially if altered mental status Abdominal CT Especially […]

Peds I- Inborn Errors of Metabolism and Endocrinology Feb 11, 2018

Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!! Inborn Errors of Metabolism (IEM) Almost always result in one of the following three clinical abnormalities Buildup of toxins Ammonia To test for this, obtain an ammonia level Buildup of acids Methylmalonic acidemia To test for this, obtain electrolyte […]

Peds H- Heart Failure and Congenital Heart Disorders Feb 04, 2018

Common Chief Complaints Cyanosis Difficulty feeding Failure to thrive Cyanotic Heart Lesions Truncus arteriosus Aorta and pulmonary artery are fused Single vessel comes from both ventricles Transposition of great vessels Aorta comes off RIGHT ventricle Pulmonary artery comes off LEFT ventricle Tricuspid atresia Blood unable to get from right atrium to right ventricle Tetrology of […]

Peds S- Sepsis and Serious Bacterial Infections Jan 28, 2018

Pediatric “Sepsis” Consider in any toxic appearing child/neonate Especially with fever (or hypothermia) Treatment Early antibiotics Fluid bolus “Serious Bacterial Infections” (SBI) Consider in any baby with fever Three classic categories Age

Peds H- Hyperglycemia and Hypoglycemia Jan 21, 2018

Introduction In pediatric patients, have a low threshold to check blood sugar Undiagnosed diabetics commonly identified in ED during first episode of DKA HYPOglycemia is very common in multiple conditions, especially in ill children Hyperglycemia DKA is different in kids They get cerebral edema Increased intracranial pressure with rapid fluid administration Common symptoms Headache Altered […]

Peds O- Oxygen, Airway, and Respiratory Disorders Jan 14, 2018

Applying oxygen is one of the first steps in treating any crashing child!!! Airway Emergencies Foreign body (FB) Patient presentation Stridor Choking episode Testing CXR May directly show foreign body May show secondary effects of a foreign body Hyperinflated/collapsed lobes of the lung Patient needs bronchoscopy if suspicion is high Peritonsillar abscess Visible in the […]

How to Save a Dying Baby Jan 07, 2018

When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!! Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies Foreign body Peritonsillar abscess Bacterial tracheitis Epiglottitis Retropharyngeal Abscess Bronchiolitis Asthma Croup Pneumonia Cystic Fibrosis Hyper/Hypoglycemia- Check Blood Glucose Hypoglycemia DKA Sepsis- Consider Sepsis and Serious Bacterial Infections Pediatric sepsis […]

Bleeding Disorders Dec 31, 2017

These are most important in trauma patients!!! Platelet Disorders Symptoms of SUPERFICIAL bleeding Mucosal bleeding GI bleeding Recurrent epistaxis Thrombocytopenia When the platelets ARE LOW Refer to THIS episode Von-Willebrand disease When the platelets CAN’T BIND Treatment Desmopressin (DDAVP) Causes increase in amount of von-willebrand factor (vWF) available Also causes free water retention Treatment of […]

How to Read an EKG Dec 03, 2017

Always remember…1, 2, 3, get an old EKG!!! Step 1: Identify the Rate and Rhythm Is it sinus rhythm? P wave before every QRS Is it one of the tachycardias? (Refer to THIS episode) Is it one of the bradycardias? (Refer to THIS episode) Step 2: Look for Signs of Ischemia Most consistent way is […]

Pediatrics Exam Nov 26, 2017

Mnemonic: ABCDEF Appearance The ‘A’ in the pediatric assessment triangle Interactive vs distant Good tone vs floppy Calm and happy vs inconsolable Breathing The ‘B’ in the pediatric assessment triangle Signs of respiratory distress Nasal flaring Retractions Abnormal respiratory sounds Color/Circulation The ‘C’ in the pediatric assessment triangle Pink = good Abnormalities Pallor Cyanosis Mottling […]

Pediatrics History Nov 19, 2017

Always ask about pediatric patient’s ‘P-I-S-S’ status!!! Core Function Questions (P-I-S-S Status) Peeing Evaluates for dehydration Number of wet diapers per day? Same number as usual? Intake Rule of 3s Estimates how much milk/formula an average infant should be taking 3oz of milk or formula every 3 hours Sleeping Is the patient sleeping MORE than […]

Fever in a Returning Traveler Nov 12, 2017

If a returning traveler has a fever, think malaria malaria malaria!!! Step 1: Ask your patient if they have traveled within the last year If yes… You should at least CONSIDER malaria Step 2: If patient says yes, take a travel history When did they go Where did they stay Where they exposed to anything […]

Diarrhea Nov 05, 2017

If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!! 3 Big (Non-Viral) Causes of Diarrhea The Icky ‘I’s Ischemia Frequently require surgery consult Infection Frequently require antibiotics Inflammatory bowel disease Frequently require GI consult, steroids, or salicylates 5 Red Flags Is it bloody? Consider […]

Appendicitis Oct 22, 2017

Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!! Three Stages of Appendicitis Stage 1: ~12 hours of “gastroenteritis” like symptoms Stage 2: Direct somatic irritation This is when pain over McBurney’s develops! Stage 3: Perforation Patient is now sick and septic Approach to Appendicitis Step 1: Consider getting labs […]

Eye Complaints Oct 15, 2017

Common Complaints Red Eye Decreased Vision Trauma to the Eye Approach to a Vision Complaint Step 1: Assess visual acuity Visual acuity is the “vital sign of the eye” Snellen eye chart is best If patient unable to see chart… Count fingers? Able to see light? Step 2: Examine the conjunctiva/cornea with fluorescein How to […]

Bradycardia Oct 08, 2017

Differential Diagnosis Mnemonic: HE DIES Hypothyroidism Elevated intracranial pressure (ICP) Cushings reflex Bradycardia Increased blood pressure Irregular breathing Drugs Beta blockers Calcium channel blockers Digoxin Ischemia Electrolytes Especially potassium!!! Sick Sinus Syndrome Approach to Bradycardia Step 1: Get an EKG Ischemia? Heart block? 1st degree = PR interval >200ms (5 small boxes) 2nd degree type […]

Anaphylaxis Oct 01, 2017

Airway and Epi! Airway and Epi! Airway and Epi! Introduction Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen” The antigen causes extensive mast cell and basophil cross-linking/activation Common antigens Foods Drugs Insect venoms Basic Approach Step 1: Diagnose anaphylaxis Consider anaphylaxis if the patient has TWO body systems involved Dermatologic […]

Tachycardia Sep 10, 2017

Basic Approach Step 1: Is this SINUS tachycardia? P before every QRS? Treat the underlying condition Step 2: Is this a NARROW and REGULAR rhythm? SVT Treat with vagal maneuvers or adenosine Another new trend is treating with calcium channel blockers!! ORTHOdromic Wolf Parkinson White Treat with adenosine Atrial flutter with fixed block Treat with […]

Status Epilepticus Sep 03, 2017

Introduction Simple seizure Seizure ends in 5 minutes OR Patient has a 2nd seizure before waking up from 1st Initiate status epilepticus pathway Approach to Status Epilepticus Step 1: Give a benzodiazepine Lorazepam (IV) Diazepam (IV or PR) Midazolam […]

Seizure Aug 27, 2017

Basic Approach Step 1: Describe the seizure Did patient have an aura? Was there loss of consciousness? What did the movements look like? Did they have postictal phase? Did they have a trauma as well? Step 2: Ask about TIME (mnemonic) Tongue biting Usually occurs on the lateral sides of tongue Incontinence Medication changes/adjustments Ethanol […]

Cardiac Arrest (ACLS) Aug 20, 2017

Hard, fast, unrelenting chest compressions are the core of ACLS!!! Step 1: Check the Patient’s Pulse If the patient does not have a pulse, start CPR Hard, fast, unrelenting compressions Intubated patients Continuous Compressions Non-intubated adults 30 compressions then 2 breaths… Repeat Non-intubated pediatrics 15 compressions then 2 breaths… Repeat Step 2: Determine if the […]

RUQ Abdominal Pain Aug 13, 2017

There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain. Cholelithiasis and Biliary Colic Cholelithiasis = Gallstones in the gallbladder Frequently seen on CT scan or RUQ ultrasound Present in 15% of the population Biliary colic = Intermittent episodes of pain if stone passes Classically colicky/crampy/spasmy pain in RUQ Frequently radiates […]

Gunshot Wounds (Arms and Legs) Jul 30, 2017

Evaluate 5 important structures when evaluating gunshot wounds in an extremity. Blood Vessel Injuries 3 Categories Hard-Signers Mnemonic: HARD Bruit Hypotension Arterial/pulsatile bleeding Rapidly expanding hematoma Deficits (pulse) Audible BRUIT/thrill These patients likely need OR Soft-Signers Significant vascular oozing/bleeding Large hematoma These patients need to be screened with ABI (ankle brachial index) ABI

Asthma and COPD Jul 23, 2017

5 core treatments and 5 MORE treatments 5 Core Treatments Albuterol Beta agonist Bronchodilator Core treatment for asthma Ipratropium Anti-muscarinic Relax muscles around the airways Works synergistically with albuterol Steroids Decrease inflammation in the airways Prednisone (PO) Methylprednisone (IV) BiPAP (COPD) Decreases work of breathing Decreases rates of intubation Decreases mortality Antibiotics (COPD) Infection common […]

GI Bleed Jul 16, 2017

Basic Categories Upper GI Bleed Symptoms Coffee ground emesis Melena Black tarry stool Digested blood Common causes Peptic ulcer disease Varices Lower GI Bleed Symptoms Bright red blood per rectum (BRBPR) Maroon/bloody stools Common causes Diverticulosis Colon cancer Angiodysplasia AV Malformations History Ask about risk factors for upper GI bleed Peptic ulcer risk factors NSAIDS […]

How to Transfuse Blood Jul 09, 2017

Type and Rh What information it provides Blood type (A, B, AB, O) Rh status (Rh positive or negative) When to order Pregnant patients with vaginal bleeding Need if Rh negative (prevents hemolytic disease of newborn) Type and Screen What information it provides Blood type (A, B, AB, O) Rh status (Rh positive or negative) […]

Pulmonary Embolism Jul 02, 2017

Introduction Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries Can cause pulmonary infarction (which mimics pneumonia on chest x-ray) Basic Approach to the Diagnosis of PE Step 1: Consider PE in any patient with signs or symptoms consistent with […]

Hemoptysis Jun 18, 2017

There are 3 main “categories” of hemoptysis… Mild, “Streaky” Hemoptysis Most common diagnosis Bronchitis Testing plan Chest xray Rules out alternative causes of hemoptysis Pneumonia Cancer Pulmonary Embolism Vasculitis Scary but Stable Hemoptysis Patient is coughing up frank blood Testing plan CTA of the chest CBC PTT/PT/INR Electrolytes Need renal function if giving IV contrast […]

Salicylate Overdose Jun 11, 2017

Salicylate toxicity is the great toxicologic mimicker!!! Step 1: When to Suspect Salicylate Overdose Signs of CNS stimulation Tachypnea Hyperthermia Altered mental status Signs of GI irritation Nausea/Vomiting Abdominal pain Common “mimicker” Sepsis Acute abdomen Step 2: Testing Plan Electrolyte panel Anion gap metabolic acidosis Sodium – Chloride – Bicarb Normal anion gap (AG) is […]

Acetaminophen Overdose Jun 04, 2017

Acetaminophen is the most important overdose in toxicology Step 1: Check a Serum Acetaminophen Level Common situations where testing is ordered Suicidal ideation Severe depression Overdose Step 2: Consult the Rumack-Matthew nomogram Only works for acute/single ingestions of acetaminophen Loses reliability if patient is on drugs that affect bowel motility If the time of ingestion […]

Non-Pregnant Vaginal Bleeding May 14, 2017

Common Causes Structural Cancer Post-menopausal bleeding is cancer until proven otherwise Fibroids Adenomyosis Polyps Coagulopathy Present in approximately 20% of non-pregnant vaginal bleeding Most common = Von Willebrand Disease Hormonal causes Dysfunctional uterine bleeding Basic Approach to Non-Pregnant Vaginal Bleeding Step 1: Pelvic exam The utility of this is debated It is best to sound […]

1st Trimester Vaginal Bleeding Apr 30, 2017

The pregnancy test is the most important test in females of reproductive age! Five Important Tests in 1st Trimester Vaginal Bleeding CBC Hemoglobin/Hematocrit Mild anemia in pregnancy is physiologic and normal Thrombocytopenia Type and Screen Required for blood transfusion Determines if patient needs RhoGAM Rho(D) immune globulin Binds fetal Rh antigens from a fetus so […]

Constipation Apr 23, 2017

Common Causes of Constipation Lifestyle Low fiber diet Minimal water intake Poor exercise Medications Especially opiates Endocrine/electrolytes Hypothyroidism Hypercalcemia Bowel obstruction Delayed colonoscopy Unintentional weight loss Previous abdominal surgeries Rectal problems Anal fissures Fecal impaction Masses How to Treat Constipation Fiber (ex. Metamucil, Citrucel) Adds structure to the stool Water (polyethylene glycol/miralax) Hydrates the stool […]

Diabetic Ketoacidosis (DKA) Apr 02, 2017

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!! Signs and Symptoms Vomiting Abdominal pain Polydipsia Polyuria Step 1: Test for DIABETIC-KETO-ACIDOSIS Diabetes Blood sugar Typically notably elevated (>250 mg/dL) Can be normal in certain circumstances Ketones Easiest test is a urinalysis Serum ketones also can be obtained Acidosis Blood gas (arterial […]

Laceration Repair Mar 12, 2017

Step 1: Pain Control Local anesthesia Most common agent is lidocaine (frequently already in laceration repair kits) Inject through wound edges (not through epidermis) This decreases pain Alternative is digital/regional nerve block Step 2: Irrigation Laceration repair is not a sterile procedure Copious irrigation is the best method to decrease chance of wound infection Faucet/sink […]

Laceration Evaluation Mar 05, 2017

Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!! To Close or Not To Close? Closing a wound with sutures, etc = Healing by “primary intention” INCREASES risk of infection but DECREASES scar Leaving a wound open = Healing by “secondary intention” DECREASES risk of infection but INCREASES scar Step […]

Sore Throat Feb 26, 2017

You must know the FOUR emergent causes of sore throat! Step 1: Apply the Centor Criteria Determines if patients is at risk for Group A strep (“strep throat”) 4 Criteria Fever No cough Tonsiller exudates Lymphadenopathy Interpretation If patient has ALL of the criteria Treat for strep throat If patient has NONE of the criteria […]

Procedural Sedation Feb 19, 2017

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship Common Scenarios Cardioversion Orthopedic reductions Painful procedures Three Step Approach to Procedural Sedation Step 1: Risk stratify the patient Mallampati score (aka “How visible is the uvula?”) Level 1: Can visualize THE WHOLE uvula Level 2: Can […]

Back Pain Feb 05, 2017

Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses Aortic Dissection and Abdominal Aortic Aneurysm (AAA) Age >50 Hypertension “Ripping” or “Tearing” pain Absent pulses in lower extremities Spinal Infections Fever Immunocompromized HIV Diabetes mellitus Transplant patients Spinal cord compression (especially cauda equina) Urinary retention Consider obtaining post-void residual Saddle anesthesia Fecal incontinence/decreased rectal […]

Dental Pain Jan 15, 2017

Minor complaint. Huge SLOE points! Step 1: Identify Which Tooth is Causing Pain Bonus points if you number teeth correctly! Number 1-32 Tooth #1 is top right Tooth #32 is bottom right Refer to dental chart for reference Step 2: Correct Terminology When Making Diagnosis Pulpitis Pain in the tooth itself Reversible Triggered by hot/cold […]

Vertigo Jan 08, 2017

Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo? Step 1: How Does Patient Describe the Vertigo? Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is) Central vertigo Mild Vague Peripheral vertigo Severe Sudden Step 2: What Are the Associated Symptoms? Central vertigo frequently associated with “The […]

Hyperkalemia Jan 01, 2017

Hyperkalemia = EKG… EKG changes = Calcium… Step 1: Recheck the Potassium Most common cause of hyperkalemia is PSEUDOhyperkalemia Caused by too aggressive/fast of a blood draw Causes RBCs to break open and falsely increase serum potassium Step 2: Get an EKG Earliest EKG change Peaked T waves Late EKG changes Flattened P wave Prolonged […]

How to Interpret a Chest X-Ray Dec 11, 2016

A-B-C-D-E-F-G Two Types of X-Rays Anterior-Posterior (“AP”) Classic “portable” xray The beam shoots from in front of the patient (anterior) TO The plate sitting behind the patient (posterior) Posterior-Anterior (“PA”) Requires trip to radiology Results in a better picture The beam shoots from behind the patient (posterior) TO The plate sitting in front of the […]

Trauma in Pregnancy Dec 06, 2016

Mom is Scared. You are Scared. Don’t Be Scared. General Principles Evaluate for intimate partner violence in all poorly explained traumas during pregnancy Get the scans you would order in a non-pregnant patient, even CTs! Shield the uterus if necessary Basic Approach to Trauma in Pregnancy Step 1: Place mother in left lateral decubitus position […]

Genitourinary Trauma Nov 13, 2016

Four important injuries. Four different imaging studies to obtain. Step 1: Obtain Pelvic X-Ray Commonly performed at bedside as part of initial trauma evaluation A pelvic injury significantly increases risk of GU injury Step 2: Examine the Perineum Common signs of GU injury Blood at urethral meatus Bruising of the perineum Step 3: Obtain Urinalysis […]

Abdominal Trauma Nov 06, 2016

Step 1: Does This Patient Need Surgery NOW? Obvious penetrating injury to abdomen Peritonitis Hypotensive Step 2: FAST Scan Performed with bedside ultrasound machine Blood/intra-peritoneal fluid is hypoechoic (black) in appearance Four views required Right upper quadrant Probe marker points towards patient’s head “Morrisons Pouch” Potential space between liver and right kidney Left upper quadrant […]

Cardiac Trauma Oct 30, 2016

Cardiac tamponade. Aortic Dissection. Blunt cardiac injury. Cardiac Tamponade Blood fills pericardial sac Increasing pressure on myocardium -> Decreased preload Decreased preload -> Hypotension -> Death Clinical exam shows Beck’s Triad Hypotension Muffled heart sounds Jugular venous distension (JVD) Diagnosed during FAST exam (subxiphoid view) Treat with pericardiocentesis Bedside thoracotomy if patient loses pulse Aortic […]

Thoracic Trauma Oct 16, 2016

Step 1: Perform ATLS Primary Survey (B- Breathing) Signs of respiratory distress/injury Shortness of breath Hypoxemia Tracheal deviation Diminished breath sounds Step 2: Consider Performing Bedside Tube Thoracostomy Insert at 5th intercostal space just anterior to mid-axillary line Step 3: Imaging Start with portable bedside chest x-ray Pneumothorax can also be diagnosed by thoracic ultrasound […]

Neck Trauma Oct 09, 2016

The hardest question… Should you get a CTA? Blunt Trauma of Neck Obtain CTA if… Patient has neurologic deficit Numbness Weakness Visual changes Patient sustained forceful impact to the neck Patient has fracture Basilar skull Facial bones Cervical spine Penetrating Trauma of the Neck Go to OR if patient is unstable Go to OR if […]

C-Spine Trauma Oct 02, 2016

Step 1: Protect the Spine Apply cervical collar Step 2: Apply NEXUS Criteria Use the “SPINE” mnemonic Spinal midline tenderness Painful distracting injury Intoxication Neurologic deficit Encephalopathy Step 3: If Patient Has None of the NEXUS Criteria… You Are Done! Step 4: If Patient Has Positive NEXUS Criteria… Obtain CT scan of the cervical scan […]

Facial Trauma Sep 25, 2016

There are 6 major areas/injuries to the face. Basic Approach to Facial Injury Step 1: Airway Indications for intubation after trauma Burns to the airway Rapidly expanding hematoma GCS

Head Trauma Sep 11, 2016

CT scan without contrast is your test of choice. Step 1: Consider Your Differential Diagnoses Five high-yield head trauma diagnoses Skull fracture External skull fracture Basilar skull fracture Epidural hematoma Subdural hematoma Traumatic subarachnoid hemorrhage (SAH) Concussion Step 2: Important Add-ons When Taking History Specific mechanism of injury Loss of consciousness Blood thinners/antiplatelet agents Step […]

Abdominal Pain Basics Aug 28, 2016

Elderly people die from abdominal pain Step 1: Risk Stratify Certain patient groups have VERY high mortality when having abdominal pain Geriatrics Immunocompromised Diabetics Step 2: Consider Genitourinary Causes Be especially cautious with lower abdominal/flank pain Mention that you performed or considered performing GU exam during presentation! Common GU causes of abdominal pain Testicular/ovarian torsion […]

Stroke Aug 21, 2016

Get your attending! Step 1: Obtain Last Known Well Stroke treatments including tPA and thrombectomy both require last known well

Shortness of Breath Aug 14, 2016

You need an organized, anatomical approach. Step 1: Consider Differential Diagnosis Upper airway Angioedema Foreign body Abscess Lower airway COPD Asthma Alveoli Pneumonia Pulmonary edema Blood Anemia Acidosis DKA Sepsis (lactic acid) Toxins (salicylic acid) Blood vessels Pulmonary embolism Aortic dissection Heart Myocardial infarction Acute heart failure Cardiac tamponade Step 2: Examine Anatomically Upper airway […]

Syncope Aug 07, 2016

6 EKG Findings. 6 Risk Factors. 6 Mimics. Step 1: Get an EKG This is the only “required” test for a patient with syncope Other common tests CBC Evaluate for anemia hCG If patient might be pregnant Step 2: Look For 6 High Risk EKG Patterns Mnemonic: QT-BRIDE QT prolongation Especially QTc >500 Brugada pattern […]

Common Pain Medications Jul 24, 2016

Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone. Oral Acetaminophen (Tylenol) Give every 4-6 hours Regular strength – 325mg Extra strength – 500mg Maximum Daily Dose – 3000mg Oral Ibuprofen (Advil) NSAID Give every 4-6 hours Regular strength – 200mg Therapeutic Ceiling – 400mg Oral Hydrocodone-Acetaminophen (Vicodin, Norco) Give ever 4-6 hours Common doses – 5-325mg, 7.5-325mg, […]

STEMI Jul 17, 2016

You have 90 minutes to restore blood flow. Step 1: Obtain EKG and Call STEMI Alert This activates ED resources as well as cath lab, interventional cardiology, etc Step 2: Stop the Platelets Dual anti-platelet therapy Aspirin 325mg chewed (or PR) Plavix 600mg (not usually given in ED) Complicates management if patient needs CABG Step […]

Altered Mental Status Jul 11, 2016

Mnemonic: AEIOU-TIPS Step 1: Evaluate the Airway General principles “If they can’t speak, they can’t control their airway” “If GCS is

Toxicology Jul 04, 2016

Poison Control Hotline: 1-800-222-1222 Step 1: Evaluate the Airway General principles “If they can’t speak, they can’t control their airway” “If GCS is

BRUE (Pediatrics) Jun 20, 2016

3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE. Step 1: Is This a BRUE? Brief

Trauma Jun 06, 2016

Airway/C-spine. Breathing. Circulation. Disability. Exposure. Secondary Survey. Airway and C-Spine General airway principles “If they can’t speak, they can’t control their airway” “If GCS is

Priapism May 30, 2016

The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock. Two Types of Priapism High flow (non-ischemic) Common causes Trauma AV malformations Tumors Priapism from too much blood coming IN Not painful Consult urology Low flow (ischemic) Common causes Sickle cell disease Drug side-effects Priapism from blood being unable to […]

Preeclampsia (Critical Diagnosis) May 23, 2016

Never ignore a pregnant woman’s blood pressure. Introduction Pre-Eclampsia Pathophysiology unknown Pregnancy induced multi-organ dysfunction Definition Pregnancy PLUS BP 135/85 PLUS Proteinuria Eclampsia Preeclampsia PLUS Seizures HELLP Syndrome Preeclampsia PLUS Hemolysis PLUS Elevated liver enzymes PLUS Low platelets Step 1: Evaluate For Four Big Symptoms Swelling/edema Headache Visual changes Abdominal pain Step 2: Testing Urinalysis […]

Headache May 16, 2016

With this complaint, it’s ALL about doing a good history and exam. Step 1: Write Out Your Differential Diagnosis The KING Subarachnoid hemorrhage The QUEEN Meningitis 3 Killers in the BRAIN Stroke Hematomas Elevated ICP/Tumors 3 Killers in the VESSELS Arterial dissection Brain DVT (Dural Venous Sinus Thrombosis) Giant cell/temporal arteritis 3 MISCELLANEOUS killers Preeclampsia […]

Tummy Ache May 03, 2016

Don’t forget to do a thorough GU exam! Step 1: Write Out Your Differential Diagnosis Remember 2-4-2-4 (2) In the upper abdomen Pyloric stenosis Pneumonia (4) In the lower abdomen Hirschsprung’s disease Intussusception Appendicitis Hernia (2) Genitourinary UTI Testicular/Ovarian torsion (4) Generalized Volvulus Necrotizing enterocolitis Henoch Schonlein Purpura Diabetic ketoacidosis Step 2: Do Pediatric History […]

Circulation (Shock) Apr 26, 2016

Tank. Clogged Pipes. Broken Pipes. Pump. Introduction “Tank” Hypovolemic shock Hemorrhagic shock “Clogged Pipes” Cardiac tamponade Tension pneumothorax Pulmonary embolism “Broken Pipes” Septic Shock Neurogenic Shock Anaphylactic Shock “Pump” Cardiogenic Shock Step 1: Fill the Tank Establish an IV IO line alternative in emergent situations Step 2: Consider Clogs Cardiac tamponade Diagnosis: Ultrasound Treatment: Pericardiocentesis […]

Breathing Apr 19, 2016

Hypoxemia fixed by only TWO things: FiO2 and PEEP Step 1: Add FiO2 If the patient is breathing… Nasal cannula Non-rebreather mask If the patient is NOT breathing… Bag-valve mask Step 2: Add PEEP *Cannot be completed in 60 seconds, but equipment can be requested If patient is breathing… BiPAP If the patient is NOT […]

Airway Apr 11, 2016

“Airway” does not necessarily mean “Intubation” Introduction In emergency medicine we are taught “A-B-Cs” These are actions that can be accomplished in first 60 seconds of patient encounter Intubation takes several minutes to accomplish Intubating a crashing patient might even KILL them! Resuscitate THEN intubate Step 1: Suction Immediately suction if patient is… Altered and […]

Epistaxis Apr 03, 2016

Don’t forget to wear protective gear. Gown up! Initial Encounter History Anticoagulants Easy bleeding/bruising Lightheadedness Exam Pallor Tachycardia/Hypotension Step 1: Put on Personal Protective Equipment Gown Gloves Mask Eye Protection Step 2: Clear Nose and Visualize Bleeding Have patient blow out/remove any clot and look for source of bleed Kiesselbachs plexus “Anterior” epistaxis Sphenopalatine artery […]

Chest Pain Mar 27, 2016

There are six cardiopulmonary causes of chest pain that you need to know. The SIX Causes Cardiac Acute coronary syndrome (ACS) Pericarditis with tamponade Pulmonary Pneumonia Pneumothorax Vascular Pulmonary embolism Aortic dissection Step 1: Core Measures Aspirin EKG Step 2: Look for the “King” (Acute Coronary Syndrome) Four high yield symptoms Radiation to the RIGHT […]

Patient Presentations Mar 27, 2016

Patient presentations are the single most important skill to develop for your Emergency Medicine rotation. General Principles Stay focused, thorough, and organized Write out the basic 8-step presentation for reference The 8-Step Patient Presentation Summary statement Demographics Risk factors/Past medical history Chief complaint History OPQRST Try to give at least 4 descriptors This is for […]

Introduction Mar 20, 2016

To Do Well On WRITTEN Exam Study the “Core 4” body systems Neurology Headache Strokes Meningitis Cardiology Chest pain ACS EKG interpretation Pulmonary Shortness of breath PE GI Abdominal pain Nausea/vomiting Appendicitis To Do Well In the DEPARTMENT Study the “other stuff” Epistaxis Foley catheter issues Rectal bleeding Laceration repair Rashes Geriatric falls Suicidal ideation […]

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