EM Clerkship

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

Show notes

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 glucagon if unresponsive* Patient with altered mental status and possible drug overdose* Give empiric naloxone * Female patients of childbearing age* Get a pregnancy test* If you need to give contrast for a CT scan (example CTA for pulmonary embolism)* Need renal function
Hyperkalemia
* Common scenarios* Crush injury* Severe burns* End stage renal disease* Especially if missed dialysis* Leukemia on chemotherapy* Remember: Don’t give succinylcholine to a patient with hyperkalemia* Common EKG findings on test* Hyperacute T waves* Sinusoidal waves* Treatment* Stabilizes cardiac cell membranes* Calcium* Shifts potassium into the cells* Insulin/Glucose* Albuterol* Sodium Bicarbonate* Removes potassium* Furosemide* Dialysis* Kayexalate
Hypokalemia
* EKG findings* Flattened T waves* QTC prolongation* U waves* At risk for ventricular arrhythmias* Treatment* Oral potassium replacement* IV potassium replacement* Consider magnesium replacement
Hyponatremia
* Hypertonic saline IF* Comatose* Actively seizing* Otherwise treat with normal saline* Pseuohyponatremia * Correct the sodium if patient has severe hyperglycemia* Add 1.6 to sodium for every 100 glucose above normal limit
Hypercalcemia
* Symptoms* “Stones, bones, groans, psychiatric overtones”* Treatment* IV fluids (promotes excretion) FIRST* Then calcitonin/bisphosphates
Torsade de Pointes
* Common in patients with prolonged QTc* Hypokalemia* Hypocalcemia* Treat with magnesium
Additional Reading
* Hyperkalemia (EM Clerkship)

When to Stop CPR Sep 09, 2018

Show notes

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* Patient has dismal prognosis (3 studies discuss this)* Implementation of the universal BLS termination of resuscitation rule in a rural EMS system* Non-EMS witnessed arrest* No return of spontaneous circulation prior to transport* Only non-shockable rhythms present* Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation* Non-EM witnessed arrest* Non-shockable INITIAL rhythm* No ROSC despite 3 doses of epinepherine* Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study* Less than 1% chance of recovery after 46 minutes of resuscitation
Additional Reading
* Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.* Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.* Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

Abdominal Aortic Aneurysm Sep 02, 2018

Show notes

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 for aorta >3cm* RUSH protocol* Mnemonic: HI-MAP* Heart* IVC* Morrisons Pouch (RUQ)* Aorta* Pulmonary* CT scan with IV contrast (less optimal)
Treatment Plan
* 2 Large bore IVs (16G)* Massive transfusion protocol* PRBCs* Platelets* Fresh Frozen Plasma* Blood pressure management* Goal Systolic ~100* Goal MAP ~60-65
Clerkship Pearls
* Put AAA in your differential during your presentation for all older patients with back/flank pain* Attempt to perform a bedside ultrasound of the aorta OR find recent CT of the abdomen with normal sized aorta
Additional Reading
* Abdominal Aortic Aneurysm Review (Medscape)

Testicular Torsion Aug 26, 2018

Show notes

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 tenderness* Swelling* Absent cremasteric reflex
Testing Plan
* Testicular/Scrotal Ultrasound* Urinalysis
Treatment Plan
* Consult urology when suspected (even if ultrasound hasn’t returned yet)* Manual detorsion* “Open the Book”* Twist medial to lateral* Switch directions if no pain relief
Additional Reading
* Flank Pain Practice Case (EM Clerkship)* Pediatric Abdominal Pain (EM Clerkship)

Flank Pain and Kidney Stones Aug 19, 2018

Show notes

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)* Benefits* Can be performed at bedside* No radiation* Option 2- Non-contrast CT scan* Great for identifying alternative diagnoses
Step 3: Rule Out Infection
* Fevers* Urinalysis with nitrites or bacteria* If present, patient needs antibiotics
Step 4: Control Symptoms
* Analgesics* NSAIDS (such as ketorolac)* Opiates* Antiemetics* Zofran
Step 5: Rule Out Kidney Injury
* Elevated creatinine* Solitary kidney
Admission Criteria for Kidney Stones
* Coexisting Urinary Tract Infection* Unable to Control Symptoms* Renal Injury/Solitary Kidney
Additional Reading
* How to Interpret a Urinalysis (EM Clerkship)

Ventilator Basics Jul 08, 2018

Show notes

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 patients are typically deeply sedated
Step 2: Know your oxygenation and ventilation goals
* Oxygenation (getting oxygen in)* Try to keep O2 saturation >92%* Ventilation (getting CO2 out)* Try to keep pCO2
Step 3: Know the 4 Most Important Settings on a Ventilator
* FiO2* The concentration of oxygen* Room air is 21% oxygen (or 0.21 on the vent)* Maximum is 100% oxygen (or 1.0 on the vent)* PEEP* The pressure applied during exhalation* Typical starting point is 5 (but can be increased significantly)* “Recruits” and opens alveoli* Tidal Volume* The volume of air moved during each cycle of the vent* Respiratory Rate* How fast the ventilator cycles/breaths for the patient
Step 4: Improving the patient’s OXYGENATION
* FiO2* Increases the amount of oxygen present for exchange in non-damaged alveoli * PEEP* Increases the number of alveoli available to exchange oxygen
Step 5: Improving the patient’s VENTILATION
* FORMULA: Minute Ventilation (MV) = Tidal Volume (Vt) x Respiratory Rate (RR)* Increasing either of these will improve ventilation
BONUS
* Patients with COPD/asthma* Have tendency to not get full breath out (“breath stacking”)* “Plateau pressures” will increase above 30* Can damage alveoli* Can cause pneumothorax* Treat by increasing the I:E ratio* Quick inhalation* Longggggggggggggg exhalation
Additional Reading
* Breathing (EM Clerkship)* Dominating the Vent Part 1 (EMCrit)* Dominating the Vent Part 2 (EMCrit)

Rabies Prophylaxis Jun 24, 2018

Show notes

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?* Immunization status of pet does not matter* Animal must be monitored* Give prophylaxis if animal develops encephalitis* Step 2: Bitten or scratched by wild animal? * If animal is captured it can be sacrificed and tested* Give prophylaxis the animal is not captured and is a potential carrier* Step 3: Possible bat scratch/bite?* Give prophylaxis if the patient (or baby) cannot confidently say “NO, I DID NOT GET BITTEN OR SCRATCHED BY THE BAT”* Step 4: Do NOT give prophylaxis if the animal is not a carrier of rabies (check local guidance)* Reptiles* Birds* Small rodents* Rabbits/Hares* Livestock* Step 5: How to give prophylaxis* Only contraindication is severe egg allergy* Can be given to babies/pregnant women/etc* Rabies immunoglobulin* Give ONCE in the department* Inject as much as possible around wound* Rabies vaccine* Give first day* Have patient come back for more doses on day 3, 7, 14 (and SOMETIMES 28)
Pearls
* It doesn’t matter if the bite/scratch was provoked or unprovoked* It doesn’t matter where on the body the patient received the bite/scratch* It’s a universally fatal disease* No rabies in small rodents, reptiles, birds, squirrels, hamsters, rats, or rabits* The NNT is >300,000 (but we still do it)
Additional Reading
* Rabies Guidelines (CDC)

Occupational Exposures Jun 17, 2018

Show notes

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..* Little children, HIV positive, immunosuppressed
Cutaneous Exposures (Broken Skin, Mucous Membranes, Needle Stick)
* Hepatitis B* Test source patient* If positive, 1-30% risk of transmission with needle stick exposure* (Mucous membrane/broken skin exposures are much lower risk)* Test exposed colleague for anti-HepB surface antibody level* If source patient is positive and coworker is not fully immunized…* Treatment * Hep B Vaccine* Hep B Immunoglobulin* Hepatitis C* Test source patient* If positive, 2% risk of transmission with needle stick exposure * (Mucous membrane/broken skin exposures are much lower risk)* Get baseline hepatic function labs (LFTs) in coworker* Follow-up on outpatient basis, no prophylaxis available* HIV* Test source patient with rapid HIV test* If positive, 1/300 risk of transmission with needle stick exposure* Transmission risk increases if: bloody exposure, large needle bore* (Mucous membrane/broken skin exposures are much lower risk)* Generally recommend prophylaxis if source is positive* Prophylaxis is potentially curative if given at exposure* Counsel on safe sex practices* Counsel on common treatment side effects* GI symptoms, headaches, fatigue
Additional Reading HIV Occupational Exposure Guidelines (US Public Health Service)

Breast Complaints Jun 10, 2018

Show notes

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
Differential Diagnoses
* Red/inflamed/painful breast* Postpartum engorgement* Treat with warm compresses, continue breastfeeding/pumping, massage* Infection (“Mastitis”)* Treat with antibiotics and continue breastfeeding* Abscess* Treat with needle aspiration* Refer to breast surgeon* Non-inflamed breast pain* Fibrocystic changes* Associated with menses* Treat with supportive bra* Breast mass* Fibroadenoma* Slippery/mobile* Fibrocystic changes* Nipple discharge* Red flags* Unilateral discharge* Bloody discharge
Additional Reading
* Breast Cancer Screening Guidelines (CDC)

Neonatal Conjunctivitis Jun 03, 2018

Show notes

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 active lesions)* Vesicles on baby* Treatment* IV acyclovir* Admit
Other Causes of Conjunctivitis
* Viral/other bacterial* Treat with erythromycin ointment* Chemical conjunctivitis* Caused by eye drops given after birth* Dacryostenosis (closed eye ducts)* Watery eyes from tears not draining
Additional Reading
* Neonatal Conjunctivitis (CDC)

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