EM Clerkship

Latest Episodes:

Round 32 (Pediatric Vomiting) Apr 01, 2022

Show notes

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 DigiBind* Treat subsequent anaphylaxis
Further Reading:
EMCrit – Digoxin Toxicity
The Tox and the Hound – Digoxin: to bind or not to bind

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

Show notes

* 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) had retention in treatment – meaning NNT of 2!
Further Reading:
TheNNT – Opioid Use Disorder

Round 31 (Altered Mental Status) Mar 01, 2022

Show notes

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

Show notes

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 is by treating the underlying process.
Unstable Primary AFib – The presence of hypotension, altered mental status, or pulmonary edema. Treatment is immediate cardioversion, second line agents include digoxin or amiodarone.
Stable Primary AFib (
Stable Primary AFib ( >48hours or unknown duration) – Treatment is by rate control by CCB (diltiazem or verapimil), or by BB (metoprolol or esmolol)
Anticoagulation – Calculate CHADS2VASC and HASBLED score. Weigh risk of stroke versus risk of major bleeding prior to starting anticoagulation
Further Reading:
Atrial Fibrillation (EMCrit)
Atrial Fibrillation (ACEP Guidelines)
CHADS2VASC Score (MD Calc)
HASBLED Score (MD Calc)

Round 30 (Chest Pain) Feb 01, 2022

Show notes

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 with Heparin* Consult Vascular Surgery for further management (possible thrombectomy, bypass, etc)
Further Reading:
EMDocs – Acute Limb Ischemia
EMDocs – Systematic Approach to the Peripheral Vascular Exam

tPA (Deep Dive R29) Jan 15, 2022

Show notes

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 – BMJ
Alteplase for Stroke: Money and Optimistic Claims Buttress the “Brain Attack” Campaign
Tissue Plasminogen Activator (tPA) for Acute Ischemic Stroke: Net benefits and harms unclear due to uncertainty in data – the NNT

Round 29 (Weakness) Jan 01, 2022

Show notes

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 of prior cva)* ECG looking specifically for AFib* Stat Imaging: CT Head noncontrast, followed by CTA Head/Neck and/or CT Perfusion
Treatment:
* tPA / TNK if significant neurologic deficits are present and no contraindications exist* Thrombectomy if large vessel occlusion present without contraindications* Admission to stroke unit to…* Workup the etiology of stroke (usually carotid US, Echo /w bubble study, telemetry monitoring), * Optimize treatment of risk factors such has HLD, HTN, AFib, etc* Obtain early PT/OT/Rehab
Post-tPA Complications: Angioedema (2-5%) and Hemorrhage (2-7%)
* Have a high index of suspicion for hemorrhage – monitor for headaches, change in mental status, signs of ICP, etc* Stop tPA immediately* If concerned for hemorrhage, elevate head of bed and obtain STAT CT Head* For hemorrhage, consider TXA, Platelets, Cryoprecipitate (as recommended by the AHA, however evidence is extremely poor) and consult Neurosurgery* For Angioedema, monitor airway closely, intubate if necessary, and consider medical treatment (FFP, Antihistamines, Steroids, Epinephrine, TXA – all of which have poor evidence for benefit)
Further Reading:
MD Calc- tPA Contraindications
EMDocs – Post tPA Complications
EMRA – Post tPA Hemorrhage

Trauma (Deep Dive R28) Dec 15, 2021

Show notes

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 scans
Tertiary Survey
* Repeat the examination portion of the secondary survey to ensure no minor injuries were missed
Further Reading:
Unbound Medicine – ATLS Outline

Round 28 (Burn) Dec 01, 2021

Show notes

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* Give hydroxycobalamine for cyanide toxicity* Obtain head CT to diagnose SDH
Further Reading:
Cyanide Poisoning (LITFL)
Carbon Monoxide Poisoning (EMCrit)

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

Show notes

* 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 should be initiated for sexually active women if they are experiencing pelvic/lower abdominal pain and if…* No alternative explanation can be found to explain patient’s pain, OR* ANY one of the three following findings are discovered on pelvic examination: cervical motion tenderness, adnexal tenderness, uterine tenderness* All antibiotics used to treat PID should also be effective against Gonorrhea and Chlamydia because negative endocervical screening for these organisms do not rule out upper genital tract infection* Many antibiotic treatment combinations exist: Ceftriaxone, Doxycycline, and Metronidazole is a common regimen
Further Reading: CDC STI Treatment Guidelines

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