EM Clerkship

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Pediatrics History Nov 19, 2017

Show notes

Always ask about pediatric patient’s ‘P-I-S-S’ status!!!
Core Function Questions (P-I-S-S Status)
* Peeing* Evaluates for dehydration* Number of wet diapers per day?* Same number as usual?* Intake* Rule of 3s* Estimates how much milk/formula an average infant should be taking* 3oz of milk or formula every 3 hours* Sleeping* Is the patient sleeping MORE than usual?* LESS than usual?* Stooling* Normal stool* Changes from dark meconium to tans/yellows
Pediatric Medical History
* Prebirth* Did the patient have prenatal care?* Any issues with the pregnancy?* Was mom GBS positive?* Peribirth* What gestational age was patient born at?* Vaginal delivery or c-section?* How long did baby have to stay in hospital after delivery?* Postbirth* Diagnosed medical/surgical problems* Immunization status
Additional Reading
* The Truth About Baby Poop (WebMD)

Fever in a Returning Traveler Nov 12, 2017

Show notes

If a returning traveler has a fever, think malaria malaria malaria!!!
Step 1: Ask your patient if they have traveled within the last year
* If yes… You should at least CONSIDER malaria
Step 2: If patient says yes, take a travel history
* When did they go* Where did they stay* Where they exposed to anything concerning* Mosquitos* Animals* Weird foods* Sexual partners* Sick people* Where they in developed/tourist areas or “off the trail”
Step 3: Ask about prophylaxis
* Did they see a doctor before leaving?* Did they take any immunizations or medicines prior to departure?* Did they continue prophylaxis as instructed?
Step 4: Go to the CDC website
* Look up the country of concern* Will help establish your differential
Step 5: Test for malaria
* If you are concerned that patient has malaria…* Order thick and thin blood smear
Additional Reading
* CDC Yellow Book (CDC Website)

Diarrhea Nov 05, 2017

Show notes

If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!!
3 Big (Non-Viral) Causes of Diarrhea
* The Icky ‘I’s* Ischemia* Frequently require surgery consult* Infection* Frequently require antibiotics* Inflammatory bowel disease* Frequently require GI consult, steroids, or salicylates
5 Red Flags
* Is it bloody? * Consider performing a guaiac test* Bloody diarrhea usually isn’t “just a virus”* Is it severely painful? * (Viral gastroenteritis may cause gas cramping but shouldn’t be tender or severely painful)* Bonus red flag!!!* POST-PRANDIAL pain* Consider mesenteric ischemia* Recent antibiotics or hospitalization?* Consider C. difficile* Treat with PO vancomycin* Recent travel? * ~80% travelers diarrhea is bacterial* Treat with ciprofloxacin* Note: See FDA black box for fluoroquinolones prior to prescribing* Do you have history of atrial fibrillation? * Increases risk for mesenteric ischemia and ischemic colitis
Consider Testing if Patient is Ill or has Red Flags
* CBC* Electrolytes* Stool studies* Stool WBCs* Stool culture* C-diff* Ova/Parasite* CT abdomen/pelvis with IV contrast
Common Antidiarrheals
* Loperamide (Imodium)* Bismuth (Pepto-Bismol)* Dphenoxylate (Lomotile)
Additional Reading
* Fluoroquinolone Black Box Update (FDA)

Appendicitis Oct 22, 2017

Show notes

Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!!
Three Stages of Appendicitis
* Stage 1: ~12 hours of “gastroenteritis” like symptoms* Stage 2: Direct somatic irritation* This is when pain over McBurney’s develops!* Stage 3: Perforation* Patient is now sick and septic
Approach to Appendicitis
* Step 1: Consider getting labs* Always remember “The white blood cell count is the last refuge of the intellectually destitute”* The WBC count has both low sensitivity and low specificity for acute appendicitis* Step 2: Get a detailed history* When did the pain start? * How many HOURS into their syndrome are they (remember stages of appendicitis)* Is the pain migrating?* Objective fever?* Did the pain start before the vomiting started?* Does the patient have decreased appetite?* Step 3: Perform a physical exam* Pain over McBurney’s point* Right lower quadrant* 1/3 the distance from the ASIS to the umbilicus* Peritoneal signs (Rigidity, Rebound, Guarding)* Psoas sign* Lie patient on left side with legs extended* Extend their hip behind them* Pain = Suspected retroperitoneal inflammation* Obturator sign* Have patient lie on back with hip/knee flexed at 90 degrees* Internally rotate hip (move ankle away from body)* Pain = Suspected obturator internus inflammation* Step 4: Imaging* Most adults* CT scan +/- IV contrast* Pregnant women* MRI abdomen* Pediatric patients* RLQ ultrasound* Step 5: Disposition* Perform a repeat abdominal exam* Even if CT is negative, consider followup in ED in 12-24 hours
Additional Reading
* McBurney’s Point (Wikipedia)* Psoas Sign (Wikipedia)* Obturator Sign (Wikipedia)

Eye Complaints Oct 15, 2017

Show notes

Common Complaints
* Red Eye* Decreased Vision* Trauma to the Eye
Approach to a Vision Complaint
* Step 1: Assess visual acuity* Visual acuity is the “vital sign of the eye”* Snellen eye chart is best* If patient unable to see chart…* Count fingers?* Able to see light?* Step 2: Examine the conjunctiva/cornea with fluorescein* How to apply fluorescein* Recline patient 45 degrees* Pull down on lower eyelid to create pocket* Place anesthetic eye drops in pocket (ex. tetracaine) * Wet the fluorescein strip with eye drops and apply to pocket* Have the patient blink to distribute the dye* Look under woods lamp for bright “uptake” areas that don’t move with blinking* These represent abrasions, ulcers, etc* This step is also a good opportunity to evert the eyelids and examine for foreign bodies if appropriate* Step 3: Examine the anterior chamber with slit lamp * “Cell and flare” (example HERE)* Representative of iritis, uveitis* This is also a good opportunity to examine any other abnormal areas of the eye under magnification!!! * Step 4: Check intraocular pressure* Pressure >20mmHg (especially when unequal) is concerning for acute angle closure glaucoma* Multiple tools to measure pressure on market, ask somebody to show you how to use* Step 5: If appropriate, use ultrasound to evaluate posterior eye* Multiple things can be diagnosed with ultrasound of the eye* Retinal detachment* Optic neuritis* Papilledema* Foreign bodies
Additional Reading
* Introduction to Slit Lamp (YouTube)* Cell and Flair (TimRoot.com)

Bradycardia Oct 08, 2017

Show notes

Differential Diagnosis
* Mnemonic: HE DIES* Hypothyroidism* Elevated intracranial pressure (ICP)* Cushings reflex* Bradycardia* Increased blood pressure* Irregular breathing* Drugs* Beta blockers* Calcium channel blockers* Digoxin* Ischemia* Electrolytes* Especially potassium!!!* Sick Sinus Syndrome
Approach to Bradycardia
* Step 1: Get an EKG* Ischemia?* Heart block?* 1st degree = PR interval >200ms (5 small boxes)* 2nd degree type 1 = PR gradually prolongs until dropped beat* 2nd degree type 2 = Intermittent dropped beats* 3rd degree = None of the atrial beats result in a ventricular beat* Evidence of hyperkalemia?* Step 2: Determine if patient is SYMPTOMATIC* Hypotension* Chest Pain* Syncope* Lightheadedness* Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications* Step 3: If patient is having symptoms… Give atropine!* Typical dose is 0.5mg IV atropine* Step 4: If patient still having symptoms… Give epinephrine!* Step 5: If patient still having symptoms… Cardiac pacing!* If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology* Transcutaneous pacing* Sometimes difficult to get mechanical capture* Transvenous pacing* Place through the right internal jugular vein
Additional Reading
* How to Read an EKG (EM Clerkship)* Transcutaneous Pacing Procedure (EM Clerkship)

Anaphylaxis Oct 01, 2017

Show notes

Airway and Epi! Airway and Epi! Airway and Epi!
Introduction
* Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen”* The antigen causes extensive mast cell and basophil cross-linking/activation* Common antigens* Foods* Drugs* Insect venoms
Basic Approach
* Step 1: Diagnose anaphylaxis* Consider anaphylaxis if the patient has TWO body systems involved* Dermatologic symptoms* Flushing* Rash* Urticaria* Pulmonary symptoms* Shortness of breath* Wheezing* Cardiovascular symptoms* Hypotension* Lightheadedness* Gastrointestinal symptoms* Nausea/Vomiting* Diarrhea* Step 2: Give epinepherine* A major pitfall in the treatment of anaphylaxis is delay of epinephrine!!!* Normal adult “EpiPen” contains 0.3mg epinephrine* Normal dosing of IM epinephrine is 0.01mg/kg* Step 3: Consider intubation* The second biggest pitfall in the treatment of anaphylaxis is delaying intubation until it’s extremely difficult to intubate!!!* Step 4: Give adjunct medications* H1 blocker* Diphenhydramine* H2 blocker* Ranitidine* Steroids* Prednisone, dexamethasone, etc* Step 5: Send the patient home with an EpiPen prescription* Education them on this* Articulate this part of the plan to your attending* Bonus* Refractory anaphylaxis* Beta-blockers? * Treat with glucagon
Additional Reading
* Round 10 – Allergic Reaction (EM Clerkship)* How to Use an EpiPen (YouTube)

Tachycardia Sep 10, 2017

Show notes

Basic Approach
* Step 1: Is this SINUS tachycardia? * P before every QRS? * Treat the underlying condition* Step 2: Is this a NARROW and REGULAR rhythm?* SVT* Treat with vagal maneuvers or adenosine* Another new trend is treating with calcium channel blockers!! * ORTHOdromic Wolf Parkinson White* Treat with adenosine* Atrial flutter with fixed block* Treat with AV blockers (diltiazem)* Slows the heart rate* Step 3: Is this a NARROW and IRREGULAR tachycardia?* Almost always atrial fibrillation* Treat with AV blockers (diltiazem)* Other (less common) diagnoses* Atrial flutter with variable block* Multifocal atrial tachycardia* Step 4: Is this a WIDE and REGULAR tachycardia?* Assume ventricular tachycardia until proven otherwise* Treatment is immediate cardioversion if unstable* May try chemical cardioversion if stable* Procainamide* Amiodarone* Lidocaine* Other diagnoses* ANTIdromic Wolf Parkinson White* Narrow complex tachycardias PLUS aberrancy* Step 5: Is this a WIDE and IRREGULAR tachycardia?* Atrial fibrillation with bundle branch block* Extremely fast and bizarre in appearance? * Consider atrial fibrillation with Wolf Parkinson White
Additional Reading
* Calcium Channel Blockers for Stable SVT (ALiEM)* Atrial Fibrillation in WPW – Pearls and Pitfalls (County EM)

Status Epilepticus Sep 03, 2017

Show notes

Introduction
* Simple seizure* Seizure ends in 5 minutes OR* Patient has a 2nd seizure before waking up from 1st* Initiate status epilepticus pathway
Approach to Status Epilepticus
* Step 1: Give a benzodiazepine* Lorazepam (IV)* Diazepam (IV or PR)* Midazolam (IV or IM)* Step 2: Give an anti epileptic* Levetiracetam (Keppra)* Fosphenytoin* Valproic Acid* Step 3: Continue attempting agents for 30 minutes* If seizure continues, you must move onto step 4… * Step 4: Sedate and intubate the patient* Propofol* Phenobarbital* Step 5: Start patient on continuous EEG* Detects non-convulsive status epilepticus* Usually started once patient is in ICU
Additional Reading
* Round 9 – Seizure (EM Clerkship)* Emergency Management of Status Epilepticus (EM Cases)

Seizure Aug 27, 2017

Show notes

Basic Approach
* Step 1: Describe the seizure* Did patient have an aura? * Was there loss of consciousness?* What did the movements look like?* Did they have postictal phase? * Did they have a trauma as well?* Step 2: Ask about TIME (mnemonic)* Tongue biting* Usually occurs on the lateral sides of tongue* Incontinence* Medication changes/adjustments* Ethanol use* Step 3: Do a FULL neurologic examination* Mental Status* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Reflexes* Gait* Step 4: Testing plan* Glucose* Pregnancy Test* CBC* Electrolyte panel* Urine drug screen* Drug levels of anti-epileptic agents* Step 5: Simple seizures (
Additional Reading
* Approach to Status Epilepticus (EM Clerkship)

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