EM Clerkship

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Subarachnoid Hemorrhage May 20, 2018

Show notes

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 difficult to interpret after a traumatic lumbar puncture* Xanthochromia
Treatment Plan
* Prevent rebleeding* Keep SBP
Additional Reading
* Ottawa Subarachnoid Hemorrhage (MDCalc)

Blood in the Diaper May 13, 2018

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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
* Step 1: Check if guaiac positive* If negative, it’s not blood* Urinary crystals, food coloring, etc* Step 2: Consider vaginal bleeding* Step 3: Perform apt test* Diagnoses maternal blood* Step 4: Check for anal fissure* Self resolve* Step 5: Expand the differential diagnosis* Necrotizing enterocolitis* Intussusception* Cow’s milk allergy* Colitis* Red Food Dye
Additional Reading
* Neonate With Bloody Stool (Pediatric EM Morsels)

Nutritional Emergencies May 06, 2018

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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* Treatment* High dose thiamine
Niacin (B3) Deficiency
* “Pellagra”* Clinical Triad* Diarrhea* Dementia* Dermatitis* Scaly rash* Neck* Dorsum of hands* Treatment* Vitamin B3
Folate (B9) Deficiency
* Megaloblastic anemia* Treatment* Folate
B12 Deficiency
* Classically occurs in vegans (in addition to the previous high risk groups)* Manifestations* Megaloblastic anemia* PLUS* Neurologic complaints* Subacute combined (posterior and lateral column) degeneration of spinal cord* Posterior columns* Impaired vibratory sensation and propioception* Lateral columns* Sensory loss* Motor weakness
Additional Reading
* Thiamine Deficiency: Pearls and Pitfalls (emDOCs)

Complications of Myocardial Infarction Apr 29, 2018

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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 heart sounds* Hypotension* Diagnosed with bedside ultrasound* Treatment is pericardiocentesis
Heart Failure
* Occurs in approximately 1/3 post-MI patients* Leads to cardiogenic shock* Treatment* Fluid bolus* Vasopressors (esp. norepinephrine)* Inotropes (milrinone, dobutimine)* Left ventricular assist devices* Intra-aortic balloon pumps
Valve Failure/Rupture
* Rapid decompensation (similar to ventricular wall rupture)* PLUS* New heart murmur* Surgical emergency
Aneurysm
* A classic STEMI mimic* Large Q waves with ST segment elevation (IN ASYMPTOMATIC PATIENT)
Dresslers Syndrome/Pericarditis
* Rule out cardiac tamponade* Treatment* NSAIDS/colchicine
Embolism
* Occur in damaged ventricles and in cardiac aneurysms* Require anticoagulation
Recurrence
* Emphasize lifestyle management
Additional Reading
* Approach to STEMI (EM Clerkship)

tPA Basics Apr 15, 2018

Show notes

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 of the core treatments for acute ischemic stroke* The history of tPA is filled with controversy* Mechanism* Activates plasminogen to plasmin* Plasmin breaks down fibrin
Contraindications to tPA
* Objective contraindications* Hypoglycemia* Blood pressure (>185/110)* Hemorrhagic CVA seen on head CT* Other common contraindications* Mnemonic: ABCDE* A– History of Aneurysm, AVMs (or other intracranial structural problems)* B– Actively Bleeding* C– IntraCranial injuries (trauma, surgery, or strokes) within last 3 months* D– Bleeding Diasthesis (blood thinners, abnormal coagulation panels, clotting disorders)* E– Endocarditis* Relative Contraindications (Discuss with neurology)* Minimal or resolving symptoms* Recent surgery or major trauma* Seizure* Recent lumbar puncture* Pregnancy* Active pericarditis* 3-4.5 Hour Contraindication Addons* A- Age >80* B- Bad Stroke (NIH >25)* C- CT shows multilobar stroke* D- Bleeding diasthesis (even if coagulation studies normal)* E- Ever had old stroke or diabetes
Additional Reading
* tPA Contraindications for Ischemic Stoke (MDCalc)* 2018 Stroke Management Guidelines (AHA/ASA)

Sepsis Apr 01, 2018

Show notes

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 qSOFA instead of SIRS criteria* qSOFA criteria* Altered mental status* Tachypnea* Hypotension* SIRS criteria* Tachycardia* Tachypnea* Leukocytosis* Hyper/hypothermia* qSOFA criteria miss cases of sepsis (too specific)* SIRS calls everything “sepsis” even if the patient is fine (too sensitive)* Change definition of “Sepsis” (no more SIRS plus source)* New definition* Source of infection* PLUS* Organ disfunction* Determined by SOFA score (different purpose than qSOFA)* Eliminate the term “severe sepsis” completely* Redefine “septic shock”* Persistent hypotension* OR * Lactic acid >4
Current Approach to Sepsis
* Step 1- If the patient has SIRS plus source* Get labs including a lactic acid* Step 2- If the patient has organ dysfunction* Diagnose sepsis* Step 3- If the patient has sepsis* Order broad spectrum antibiotics* Order blood cultures* Needs to be completed in 4* Diagnose septic shock* Step 5- If they have septic shock* Give 30ml/kg crystalloid bolus* Start vasopressers if hypotension doesn’t improve with bolus
Additional Reading
* CMS Sepsis Core Measures (ACEP)* Sepsis-3 Recommendations (EMJ)* Surviving Sepsis Campaign (SCCM)

Neonatal Jaundice Mar 25, 2018

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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 Syndromes* Breast milk jaundice* Breast milk inhibits conjugation of bilirubin* Decreased excretion* Bowel obstruction* Breast feeding failure (dehydration)* Decreased stool output results in reabsorbed bilirubin
Kernicterus
* Brain damage from severe hyperbilirubinemia (>25 mg/dL)* Compare measured bilirubin to established nomogram* Treatment is phototherapy* (Worst case scenarios require exchange transfusion)
Additional Reading
* Approach to Neonatal Jaundice (emDOCs)

Thrombocytopenia Mar 11, 2018

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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 (HUS)* Clinical presentation* Pediatric patient with bloody diarrhea* Renal dysfunction* Thrombocytopenia* Treatment* Supportive care* Heparin Induced Thrombocytopenia (HIT)* Clinical presentation* Recent heparin administration* Acute thrombocytopenia (
Additional Reading
* Thrombocytopenia: An ED Approach (emDOCs)

Nausea and Vomiting Mar 04, 2018

Show notes

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 patients* Other tests to consider* CBC* LFTs/Lipase* Urinalysis
Step 3: Give a Treatment Plan
* IV fluids (1L normal saline)* Antiemetics* Ondansetron (Zofran)* Promethazine (Phenergan)* Prochlorperazine (Compazine)
Step 4: PO Challenge
* Prior to discharge patient needs to keep fluids down* Bonus points if you update your attending on this
Step 5: Repeat Abdominal Exam
* Perform this prior to discharging patient
Additional Reading
* Antiemetic Pearls (EM Cases)

Complications of Cirrhosis Feb 25, 2018

Show notes

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 Hypertension Complications
* Gastric/esophageal varices* Symptoms* Altered mental status* Hepatic encephalopathy triggered by reabsorbed GI blood* Melena* Black stools from digested GI blood* Treatment* Proton pump inhibitor (PPI)* Pantoprazole* Octreotide* Antibiotics* Classic procedure* Blakemore tube (balloon tamponade)* Ascites with spontaneous bacterial peritonitis (SBP)* Symptoms* Abdominal pain/tenderness* Ascites* Fever* Testing plan* Diagnostic paracentesis* >250 neutrophils* High protein* Low glucose* Treatment* Antibiotics* Albumin
Liver Failure Complications
* Coagulopathy* Diagnose with abnormal coagulation studies* PT with INR* Patients can be BOTH hyper and hypocoagulable
Additional Reading
* How to Perform Paracentesis (Medscape)

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