EM Clerkship

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

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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 Aortic Dissection (Type B)* Treat HR Appropriately (Esmolol drip)* Treat BP Appropriately (Cardene drip)* Treat Pain
Initial Vitals#2 (Ms. Thomas, 50F with Dysuria)
* Temp 101.0F* HR 120* RR 22* BP 106/65* O2 98%
Critical Actions #2 (Ms. Thomas, 50F with Dysuria)
* Obtain pregnancy test* Perform chaperoned pelvic exam* Diagnose PID /w Fitz Hugh Curtis & Treat /w abx* Treat pain* Council patient appropriately on +STD (treatment of partner, no intercourse until treated)
Initial Vitals#3 (Ms. Wells, 40F with Knee Pain)
* Temp 99.9F* HR 90* RR 18* BP 120/80* O2 98%
Critical Actions#3 (Ms. Wells, 40F with Knee Pain)
* Obtain appropriate workup (ESR, CRP, XRay, Cultures)* Treat pain* Perform Arthrocentesis* Gonococcal Arthritis* Treat with appropriate Antibiotics
Further Reading
Aortic Dissection – CoreEM
Pelvic Inflammatory Disease – EMDocs
Septic Arthritis – EMDocs

Cardiac Tamponade (Deep Dive R26) Oct 15, 2021

Show notes

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, uremia, hypothyroidism, trauma, aortic dissections, etc
Diagnosis on Exams:
* Becks Triad – Hypotension, JVD, Muffled Heart Sounds* Pulsus Paradoxus – SBP drops >10mmhg during inspiration* Electrical Alternans on ECG
Diagnosis in Real Life:
* Mix of clinical and cardiac ultrasound* Clinically patients usually complain of dyspnea, sometimes chest pain. They can have ALL, SOME, or NONE of the features of Beck’s Triad!* On ultrasound, RIGHT VENTRICULAR COLLAPSE DURING DIASTOLE is most specific for tamponade.* On ultrasound, a PLETHORIC IVC is most sensitive for tamponade (but is totally non-specific as we see this with many other conditions including CHF, PE, PNTX, etc)
Treatment:
* Initial fluid bolus (stop if they worsen clinically)* Vasopressors if needed to bridge unstable patient to definitive treatment* Definitive treatment is pericardiocentesis.
Further Reading:
NEJM – Diagnosis of Cardiac Tamponade and how to perform pericardiocentesis

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

Show notes

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 Steroids* Administer Racemic Epinephrine* Reassess patient after therapy* Discharge patient
Initial Vitals#2 (Ronnie, 3yo with vomiting)
* Temp 98.0F* HR 140* RR 38* O2 98%
Critical Actions #2 (Ronnie, 3yo with vomiting)
* Identify Iron overdose* Obtain abdominal XR * Obtain Iron level* Administer IVF bolus* Administer deferoxamine
Initial Vitals#3 (Carson, 55yo with shock)
* Temp 98.0F* HR 130* RR 28* BP 82/68* O2 92%
Critical Actions#3 (Carson, 55yo with shock)
* Obtain ECG* Identify pericardial tamponade* Administer IVF Bolus (tamponade is preload dependent)* Perform pericardiocentesis* Consult CT Surgery/CVICU
Further Reading
Life in the Fast Lane – Iron Toxicity
EMDocs – Croup
EMDocs – Pericardial Tamponade

Hyponatremia (Deep Dive R25) Sep 15, 2021

Show notes

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 their hyponatremia?* If yes, obtain serum osmolarity to rule out pseudohyponatremia* Is the patient dehydrated/hypovolemic?* If yes, treat with NS bolus* If euvolemic/hypervolemic, treat with fluid restriction
Further Reading:
EMCrit – Hyponatremia
EMDocs – Critical Hyponatremia

Round 25 (Seizure) Sep 01, 2021

Show notes

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 * Administer Hypertonic Saline* Diagnose Anterior Shoulder Dislocation* Perform & Describe Shoulder Reduction Procedure
Further Reading
EMDOCs – Anterior Shoulder
ALiEM – Park Method for Anterior Shoulder Dislocation
EMCrit – Hyponatremia

Acetaminophen Overdose (Deep Dive R24) Aug 16, 2021

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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* Workup:* Accucheck* ECG* CBC, CMP, VBG* Acetaminophen Level (now and at four hours); Salicylate Level* UDS* Consider specific drug levels (eg digoxin, lithium, valproic acid, etc) ; consider ammonia level for valproic acid OD* Management:* ABCs first* Consider decontamination (remove clothes, hose down with water if chemical exposure, consider activated charcoal or gastric lavage for early ingestions)* Consult poison control/toxicology* Consult psychiatry if it was an attempt at self harm* Administer NAC if considered to be a “toxic ingestion of acetaminophen”* Definition of an “Acetaminophen Toxic Ingestion”* Single ingestion of acetaminophen greater than 150mg/kg* Data point on Rumack-Matthew Nomogram that is above the treatment line* If UNKNOWN amount / UNKNOWN timing of ingestion, treat if LFTs are elevated or if serum acetaminophen level is above normal limits* Rule of 150* Toxic Ingestion is considered to be a single ingestion greater than 150mg/kg* Toxic Ingestion is considered to be if the acetaminophen level at the four hour mark is >150ug/mL (this would be above the treatment line on the Rumack-Matthew Nomogrom)* Dose of NAC is 150mg/kg IV
Further Reading:
Rumack-Matthew Nomogram (MDCalc)

Round 24 (Altered Mental Status) Aug 01, 2021

Show notes

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 Naloxone as needed for respiratory depression* Obtain 0-hour and 4-hour acetaminophen levels* Administer N-acetyl-cystine * Obtain psychiatry consult for suicidal ideation
Further Reading
Acetaminophen Toxicity (EMCrit)

Asymptomatic Hypertension (Deep Dive R23) Jul 15, 2021

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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 or treatments are indicated. * You risk causing HARM to your patients by treating these asymptomatic patients. For example, if you push IV hydralazine for asymptomatic hypertension in a patient who chronically lives at a BP of 230/120 and their blood pressure drops precipitously, you may cause a stroke/watershed infarcts. * ACEP clinical policy also states that in a patient who has poor access to followup (eg homeless), you may consider routine testing or initiation of long term anti-hypertensive treatment.
Further Reading:
ACEP Clinical Policy – Asymptomatic Hypertension
EM Docs – Hypertensive Emergency

Round 23 (High Blood Pressure) Jul 01, 2021

Show notes

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 Hypertensive Emergency* Start anti-hypertensive drip (usually Nicardipene)* Recheck patient’s blood pressure after intervention* Admit to ICU
Further Reading
Hypertensive Emergency (EMCrit)

Neonatal Resuscitation (Deep Dive R22) Jun 15, 2021

Show notes

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, place in warmer* OPEN AIRWAY – sniffing position, oral/nasal airway, suction if necessary* ASSESS HR (manually)* If HR>100, continue above interventions and move to PPV if not improving/if pulse ox low* If HR 60-100, attach to telemetry and pulse oximetry and begin PPV with room air at a rate of 60.* If HR
PEARL: At one minute of life, we expect an SpO2 of 60%. Every minute afterwards, we expect the SpO2 to increase by 5%, so by 5 minutes of life it should be around 80%.
Neonatal Resuscitation – Emergency Medicine Cases

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