EM Clerkship

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

Show notes

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)* Pregnant vaginal bleeding* If sick…* Think ectopic pregnancy (early pregnancy)* Think uterine rupture (late established pregnancy)* Think placental abruption (recent trauma or cocaine)* Don’t forget to order a type and screen* Rh- mothers will need RhoGam* If patient is unstable and you can’t wait for blood type…* Transfuse type O negative blood* Postpartum vaginal bleeding* Most common cause is retained products of conception* Order an ultrasound* Consider endometritis if patient also has fever* Treat with clindamycin and gentamycin
Vaginal Discharge Pearls
* Cervical motion tenderness?* Pelvic Inflammatory Disease (PID)* Thin, grey, and smells like fish?* Bacterial vaginosis (BV)* Treat with metronidazole* Warn patient not to mix metronidazole with alcohol* Thick like cottage cheese?* Vulvovaginal candidiasis* Diagnosis with KOH prep* Look for yeast and pseudohyphae* Treat with fluconazole* Thin Yellow/Green and “frothy”?* Trichomoniasis* Diagnose with wet prep* Look for mobile organisms* Treat with metronidazole* Partners should be checked and treated too
Ovarian Torsion
Severe and sudden pain
* Can be intermittent* Diagnose with Pelvic ultrasound with Doppler* PITFALL: Frequently has normal arterial flow (dual blood supply to ovary)
Additional Reading
* Approach to Non-Pregnant Vaginal Bleeding (EM Clerkship)* Approach to 1st Trimester Vaginal Bleeding (EM Clerkship)

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

Show notes

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 of Stroke in Young People
* Cervical artery dissection* Vasospasm* Vasculitis* Sickle Cell Disease
Meningitis
* Treatment* Vancomycin, Ceftriaxone* Add ampicillin (covers listeria) in very young/old* Rifampin prophylaxis for close contacts (if patient has petechial rash)* Neisseria Meningitidis
HSV Encephalitis
* Classic symptoms* Fevers* Headache* Altered Mental Status* Seizures* Treat with acyclovir
Altered Mental Status
* The two most common causes on your test* Hypoglycemia* Infections (Especially in elderly)* Aka Delirium
Fat embolism
* Trauma PLUS petechial rash * Common with long bone fracture
Schaphoid Fracture
* Exam shows tenderness over anatomic “snuffbox”* Notorious for being missed on X-ray * High risk of osteonecrosis* If suspicious, place patient in thumb spica splint regardless of X-ray findings* Outpatient followup 1-2 weeks for repeat xray
Pericarditis
* Patient complains of chest pain that is… * Sharp* Positional* Worse when laying flat* Friction rub on exam* EKG Findings* Diffuse ST segment elevation* Diffuse PR depression* Treat with NSAIDS
Kawasaki’s Disease
* Mnemonic: CRASH and Burn* Conjunctivitis* Rash* Adenopathy* Strawberry Tongue* Hands/Feet Swelling* Burn = Fever for 5 days* Treat with aspirin
Burns
* Parkland formula* Weight (kg) x BSA (%) x 4 = Volume of fluid needed in first 24 hours* Give half over first 8 hours* Rule of 9s* Estimates % Body surface area burned
Vascular Injury
* Hard Signs * If present patient needs OR* Mnemonic: ABCDE* Active pulsatile hemorrhage* Bruit* Cerebral ischemia* Diminished Distal pulses* Expanding Hematoma
Infectious Disease Pearls
* Gram positive cocci in CLUSTERS* Staphylococcus Aureus* Gram positive cocci in CHAINS* Streptococcus Pneumoniae
Additional Reading
* Basic approach to altered mental status (EM Clerkship)* Basic approach to neck trauma (EM Clerkship)

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

Show notes

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* If severe contrast allergy or other contraindication* Ventilation/Perfusion (V/Q) Scan
Inferior STEMI
* EKG shows ST elevation in 2, 3, aVF* Can involve AV node (bradycardia)* Avoid beta blockers* Treat with atropine* Can involve RV (preload dependent)* Avoid nitroglycerine* Treat with fluids
Common to Nitroglycerine
* Hypotension* Current sildenafil usage
Aortic Dissection
* Type A (ascending) Dissection* Surgical emergency* Type B (descending) Dissection* Medical management* Testing* CTA of the chest* Chest X-Ray SOMETIMES shows a widened mediastinum* Treatment* Esmolol (decrease heart rate)* Labetelol (decrease blood pressure)* PEARL: Aortic dissection can cause STEMI
Heart Failure
* Treatment* Diuresis* Nitroglycerin* BiPAP* If patient needs fluids* Decrease size of fluid bolus
COPD
* Treatments* Albuterol/Ipratropium* Antibiotics* Steroids* BiPAP
Pneumonia
* If alcoholic/homeless/dementia/parkinson’s* Treat for aspiration (anaerobes)* If recent hospitalization/ventilator* Treat for pseudomonas and MRSA* If pneumonia PLUS atypical symptoms* Treat for legionella* If recent influenza* Treat for MRSA
Additional Reading
* Pulmonary Embolism Basics (EM Clerkship)* Pulmonary Embolism Severity (PubMed)

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

Show notes

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 bleeding* History/Exam* Fever* Left lower quadrant pain/tenderness* Testing/Treatment* CT abdomen with IV contrast* Liquid diet* Antibiotics* Complications* Abscess* Stricture* Fistula* Perforation* Obstructions
Abdominal Aortic Aneurysm
* If suspected, perform bedside ultrasound of the abdomen* Aortic diameter >3 cm
Spontaneous Bacterial Peritonitis
* Diagnose by performing a paracentesis* Look for >250 white blood cells* Treat with ceftriaxone
Kidney Stones
* CT without contrast* If the stone is 5mm* Consult urology
Common Indications for Emergency Dialysis
* Mnemonic: AEIOU * Acidosis (pH 6.5)* Intoxication* Lithium* Ethylene Glycol* Methanol* Aspirin* Overload of volume resistant to diuresis* Uremia that is symptomatic* Altered mental status* Pericarditis
Ectopic Pregnancy
* Testing* BhCG QUANTITATIVE* Type and screen for Rh Status* Pelvic ultrasound* IUP = Gestational sac PLUS a Yolk sac* Beware “heterotopic” pregnancy in fertility treatment patients (IVF)* Treatment* If no IUP visualized, ectopic pregnancy is a possibility, and management depends on hCG* If 1500* Ectopic until proven otherwise, consult OBGYN* Rh- needs RhoGAM* Prevents complications in future pregnancies
Additional Reading
* Ectopic Pregnancy (EM Clerkship)* Abdominal Aortic Aneurysm (EM Clerkship)

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

Show notes

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 liver disease (hepatitis, alcoholics)* Treatment* Fluid bolus if hypotensive* Octreotide* Ceftriaxone* Transfuse blood as needed* If hemoglobin
Hepatic Encephalopathy
* Common findings* Altered mental status* Asterixis* Elevated ammonia level * Treat with lactulose or rifamixin
Peptic Ulcer Disease
* History* Hematemesis or Melena* Epigastric abdominal pain* Chronic NSAIDS or steroids* Treatment* PPI (such as pantoprazole)* Works better than an H2 blocker
Cholecystitis
* RUQ ultrasound* Thickened gallbladder wall* Distended gallbladder* Pericholecystic fluid* Obvious impacted stone* HIDA scan* Inject radioactive material* Absorbed by hepatocytes* Secreted into biliary tree into small intestine* If gallbladder not visualized* Cystic duct obstruction* If common bile duct cannot be visualized* Choledocolithiasis
Ascending Cholangitis
* Charcots Triad* Fever* RUQ Pain* Jaundice* Patient requires ERCP (gastroenterology consult)* Give antibiotics
Acute Pancreatitis
* Diagnosis* Classic description* Epigastric pain radiating to back* Severe vomiting* Lipase* >3x upper limit of normal is diagnostic* CT scan to look for complications of pancreatitis
Additional Reading
* RUQ Abdominal Pain (EM Clerkship)* Biliary Diseases and Pancreatitis (EM Clerkship)

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

Show notes

“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 effect of multiple medications* Antipsychotics* Methadone* Ondansetron* Give Magnesium Sulfate
High yield EKG patterns
* Long QTc* Wolf Parkinson White (WPW)* Brugada Pattern
Atrial Fibrillation
* Stable* Patient presents immediately after onset (
Bradycardia
* AV Blocks* 1st Degree* 2nd degree (type 1)* 2nd degree (type 2)* 3rd degree* If symptomatic and stable…* Atropine* If they become unstable… * Transcutaneous or transvenous pacing
Additional Reading
* Life in the Fast Lane EKG Library (LITFL)* Tachycardias (EM Clerkship)* Bradycardias (EM Clerkship)

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

Show notes

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
* Common features* Severe headache* Tenderness of the Temporal Arteries * Jaw claudication* Elevated ESR (“sed rate”)* Treat with steroids
Anterior Uveitis
* Painful red eye* Cell and flair on slit lamp examination
UV Keratitis (“snow blindness”)
* Common in skiers/snowboarders* Diagnose with fluorescein and use woods lamp* Punctate lesions on the cornea
Common Poisons/Antidotes
* Digoxin toxicity* Digibind* Acetaminophen toxicity* N-Acetylcysteine (NAC)* Ethylene glycol or methanol toxicity* Fomepizole* Jimson weed (anticholinergic toxicity)* Physostigmine* Organophosphate toxicity* Atropine* Treat until airway secretions have stopped* Pralidoxime * Opiate toxicity* Naloxone* Benzodiazepine * Flumazenil (falling out of favor)* Cocaine toxicity* DON’T give beta blockers* Unopposed alpha effect* Very little data to support this but commonly believed* Iron toxicity* Deferoxamine* Salicylate overdose* Sodium bicarbonate* Dialysis* Tricyclic antidepressent* Sodium bicarbonate* Beta blocker overdose* Glucagon* Calcium channel blocker overdose* Glucagon* IV Calcium* High dose euglycemic insulin therapy* Sulfonylurea overdose* Octreotide* Dextrose* Heparin reversal* Protamine sulfate* Cyanide toxicity (common in house fires)* Hydroxocobalamin * Sodium Nitrite* Carbon monoxide toxicity* Oxygen oxygen oxygen* Hyperbaric oxygen* BEWARE: pulse oximetry will be normal* Valproic acid toxicity* L-carnitine
Additional Reading
* Approach to Eye Complaints (EM Clerkship)* Acetaminophen Overdose (EM Clerkship)* Salicylate Overdose (EM Clerkship)

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

Show notes

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 can’t be monitored* Bite by domestic animal that develops symptoms during observation
Black widow spider
* Painful bite* Symptoms* Abdominal pain* Diaphoresis* Myalgias* Muscle spasms/cramping* Supportive care
Pit Viper Bite
* Causes Coagulopathy/DIC* Swelling around bite site* Treat with CroFab antivenin
Brown Recluse Bite
* Painless bite* Ulceration/necrosis around bite site
Altitude Illnesses
* Acute Mountain Sickness (AMS)* Headache* Nausea and vomiting* Treat with acetazolamide or decent* High Altitude Pulmonary Edema (HAPE)* Shortness of breath* Treat with supplemental oxygen and immediate decent* Consider nifedipine or sildefenil* High Altitude Cerebral Edema* Ataxia* Confusion* Cushings reflex* Bradycardia* Hypertension* Cheyne-Stokes respirations* Treat with supplemental oxygen and immediate decent* Consider dexamethasone
Digit Amputation
* Wrap in saline soaked gauze* Put in plastic bag* Place on ice* Send to surgeon
Tooth avulsion
* Reimplant tooth in socket* Place in glass of milk
Frostbite
* Remove wet clothing* Rewarm at body temperature
Additional Reading
* Rabies Prophylaxis (EM Clerkship)

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

Show notes

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 seizure* Consider full workup including lumbar puncture
Pediatric Abdominal Pain
* Intussusception* Classic history* Severe emesis* INTERMITTENT severe abdominal pain* Common causes* Meckles diverticulum* Henoch-Schonlein purpura* Diagnose with abdominal ultrasound* Look for target sign* Treat with air enema* Malrotation with Volvulus* Classic symptoms* Bilious emesis* Projectile* CONSTANT severe abdominal pain* Peritonitic abdominal exam* Common tests (if stable)* Upper GI Series* Corkscrew sign* Coffee-bean sign* Necrotizing Enterocolitis* Classic symptoms* Premature neonate* Bloody stool* X-Ray shows pneumotosis intestinalis* (Air in the bowel wall)* Hirschsprungs Disease* Delayed passage of meconium* Diagnosis* Contrast enema (not typically done in ED)* Look for distal transition point* Rectal suction biopsy (DEFINITELY not done in the ED)* Gold standard for diagnosis
Bronchiolitis
* Commonly caused by RSV* Initial fever and URI* Progresses to respiratory distress
Croup (laryngotrachealbronchitis)
* Commonly caused by parainfluenza* Initial fever and URI* Progresses to stridor* Barky cough* Neck xray will show “steeple sign” (subglottic narrowing)* Treatment* Steroids* Nebulized epinephrine
Epiglottitis
* Commonly caused by Haemophilus influenzae * Classic symptoms* Fever* Sore throat* Drooling* Muffled voice* Treatment* Keep the child calm* Intubation in a controlled environment* Antibiotics
Additional Reading
* Pediatric Abdominal Pain (EM Clerkship)* Peds O – Oxygen, Airway, and Respiratory Disorders (EM Clerkship)

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

Show notes

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* Perform FAST exam* If the patient is stable* CT scan of the abdomen/pelvis with contrast
Basilar Skull Fracture
* Bilateral post-auricular ecchymosis (Battle’s Sign)* Raccoon eyes* Hemotympanum* Otorrhea/Rhinorrhea
Tension Pneumothorax
* Classic findings* Hypotension* Obstructive shock* Absent breath sounds* Jugular vein distension (JVD)* Treatment* Needle decompression* 2nd intercostal space* Mid-clavicular line* Tube thoracostomy
Hemothorax
* Hypotension* Hemorrhagic shock* Absent breath sounds* NO jugular vein distension
Cardiac Tamponade
* Beck’s Triad* Hypotension* Obstructive shock* Jugular vein distension* Muffled heart sounds* Perform bedside ultrasound* Diastolic collapse of right ventricle (RV)* EKG* Electrical alterans
Traumatic Aortic Rupture
* Rapid deceleration injuries* Tears at ligamentum arteriosum* Widened mediastinum on chest X-Ray
Pulmonary Contusion
* Blunt chest trauma* Respiratory distress* NO paradoxical chest movement with breathing* Chest X-Ray* Shows non-lobar infiltrates* Located near location of injury
Additional Reading
* Abdominal Trauma (EM Clerkship)* Head Trauma (EM Clerkship)* Thoracic Trauma (EM Clerkship)

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