EM Clerkship

Latest Episodes:

Cardiac Arrest (ACLS) Aug 20, 2017

Show notes

Hard, fast, unrelenting chest compressions are the core of ACLS!!!
Step 1: Check the Patient’s Pulse
* If the patient does not have a pulse, start CPR* Hard, fast, unrelenting compressions* Intubated patients* Continuous Compressions* Non-intubated adults* 30 compressions then 2 breaths… Repeat* Non-intubated pediatrics* 15 compressions then 2 breaths… Repeat
Step 2: Determine if the Rhythm is Shockable or Non-shockable
* Shockable rhythms* Ventricular Fibrillation (VF)* Ventricular Tachycardia (VT)* Non-shockable rhythms* Pulseless electrical activity (PEA)* Asystole
Step 3: Start a Timer For 2 Minutes
* Do a rhythm/pulse check every 2 minutes
Step 4: Is the Patient in a Shockable Rhythm?
* Repeat/coordinate shocks with every 2-minute pulse check* Give 1mg IV/IO epinephrine every 3-5 minutes* Give amiodarone* 300mg with first dose* 150mg with a repeat dose
Step 5: Is the Patient in a Non-Shockable Rhythm?
* Give epinephrine every 4 minutes (every other cycle)
Quick Facts
* Shockable rhythms (VT/VF) have best prognosis* Frequently related to myocardial infarction* Asystole has the worst prognosis* PEA has mixed prognosis (depends on diagnosis)* Two types (wide and narrow)* “Wide” PEA frequently caused by metabolic abnormalities* Consider bicarb and calcium chloride* “Narrow” PEA frequently caused by shock state* Perform bedside ultrasound in attempt to determine cause* “The H’s and T’s”* Hypoxemia* Hypovolemia* Hydrogen Ions* Hyper/hypokalemia* Tension pneumothorax* Tamponade* Toxins* Thrombosis (MI/PE)
Additional Reading
* When to Stop CPR (EM Clerkship)

RUQ Abdominal Pain Aug 13, 2017

Show notes

There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain.
Cholelithiasis and Biliary Colic
* Cholelithiasis = Gallstones in the gallbladder* Frequently seen on CT scan or RUQ ultrasound* Present in 15% of the population* Biliary colic = Intermittent episodes of pain if stone passes* Classically colicky/crampy/spasmy pain in RUQ* Frequently radiates to right shoulder/flank* Pain is intermittent and resolves after a few hours* Patients need pain control and outpatient follow up with general surgery
Cholecystitis (Inflammation of the Gallbladder)
* Caused by obstruction of the cystic duct* Increased pressure in the gallbladder results in ischemia/inflammation* Diagnosis* RUQ Ultrasound* Gallbladder wall thickening* Pericholecystic fluid* Cholelithiasis* CT of the abdomen and pelvis also has decent sensitivity/specificity* Admit for cholecystectomy
Choledocolithiasis (Common Bile Duct Obstruction)
* Terminology* Cholecystitis = Stone in CYSTIC DUCT* Choledocolithiasis = Stone in COMMON BILE DUCT* Symptoms similar to cholecystitis* Testing* LFTs will be elevated* Results from blockage of bile outflow from liver* RUQ Ultrasound* Shows dilation of the common bile duct* Treatment* GI Consult* Endoscopic Retrograde Cholangiopancreatography (ERCP)
Cholangitis (Infection of Bile Duct/Liver)
* Common complication of choledocolithiasis* Charcots triad* RUQ pain* Fever* Jaundice* Reynolds pentad* RUQ pain* Fever* Jaundice* Altered mental status* Shock/hypotension* Treatment* Fluids* IV antibiotics* ERCP
Gallstone Pancreatitis
* Gallstone obstructs PANCREATIC DUCT* Testing* Lipase will be elevated* LFTs will be elevated* RUQ will show dilation of the CBD* Treatment* Fluids* Pain medicine* ERCP
Additional Reading
* Biliary Diseases and Pancreatitis (EM Clerkship)* Biliary Anatomy (TeachMeAnatomy)

Gunshot Wounds (Arms and Legs) Jul 30, 2017

Show notes

Evaluate 5 important structures when evaluating gunshot wounds in an extremity.
Blood Vessel Injuries
* 3 Categories* Hard-Signers* Mnemonic: HARD Bruit* Hypotension* Arterial/pulsatile bleeding* Rapidly expanding hematoma* Deficits (pulse)* Audible BRUIT/thrill* These patients likely need OR* Soft-Signers* Significant vascular oozing/bleeding* Large hematoma* These patients need to be screened with ABI (ankle brachial index)* ABI
Nerve Injuries
* Relatively rare* Document neuro exam in the extremity* Consult if abnormal
Bone Injuries
* Relatively common* Diagnosed by x-ray* Consult orthopedics for fracture
Soft Tissue Injury
* Be sure to count/document number of holes* Typically do not need laceration repair unless cosmetic area* Don’t miss compartment syndrome* Mnemonic: “P’s”* Pain out of Proportion* Pain with Passive range of motion* Paresthesias* Pallor* Paralysis* Poikilothermia
The Bullet: What To Do With It?
* The bullet is almost never removed, unless…* Very superficial/cosmetic and easy to remove* In a joint
Additional Reading
* NBME Shelf Review Part 2- Trauma (EM Clerkship)

Asthma and COPD Jul 23, 2017

Show notes

5 core treatments and 5 MORE treatments
5 Core Treatments
* Albuterol* Beta agonist* Bronchodilator* Core treatment for asthma* Ipratropium* Anti-muscarinic* Relax muscles around the airways* Works synergistically with albuterol* Steroids* Decrease inflammation in the airways* Prednisone (PO)* Methylprednisone (IV)* BiPAP (COPD)* Decreases work of breathing* Decreases rates of intubation* Decreases mortality* Antibiotics (COPD)* Infection common cause of inflammation
5 More Treatments
* Magnesium sulfate* Ketamine* Epinephrine (systemic beta agonist)* Heliox* LAST RESORT – Intubation* Decrease rate and volume* Increase expiratory time and inspiratory flow
Additional Reading
* Antibiotics in COPD (AAFP)* The Crashing Asthmatic (REBEL EM)

GI Bleed Jul 16, 2017

Show notes

Basic Categories
* Upper GI Bleed* Symptoms* Coffee ground emesis* Melena* Black tarry stool* Digested blood* Common causes* Peptic ulcer disease* Varices* Lower GI Bleed* Symptoms* Bright red blood per rectum (BRBPR)* Maroon/bloody stools* Common causes* Diverticulosis* Colon cancer* Angiodysplasia* AV Malformations
History
* Ask about risk factors for upper GI bleed* Peptic ulcer risk factors* NSAIDS* Steroids* History of ulcers* Varices risk factors* Heavy alcohol use* History of liver disease
Exam
* Abdominal exam* Usually minimal tenderness* If patient has severe tenderness/peritoneal signs consider alternative diagnosis* Perforation* Rectal exam* Identify stool color* Guaiac testing* Hemorrhoids* Are they bleeding* Anal fissures
Testing Plan
* CBC* Looking for anemia* Electrolytes* Elevated BUN* Commonly present in upper GI bleed* Coagulation panel* Type and screen
Treatment Plan
* Proton pump inhibitor (upper GI bleeds)* “-prazoles” such as pantoprazole* Octreotide/Antibiotics if varies suspected
Disposition
* Most upper GI bleeds get admitted* Lower GI bleeds depend on risk factors* Comorbidities* Clinical findings/stability* Vital signs* Hemoglobin/Hematocrit
Additional Reading
* GI Bleed Emergencies (EM Cases)* GI Bleed (emDOCs)

Pulmonary Embolism Jul 02, 2017

Show notes

Introduction
Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries
Can cause pulmonary infarction (which mimics pneumonia on chest x-ray)
Basic Approach to the Diagnosis of PE
* Step 1: Consider PE in any patient with signs or symptoms consistent with the disease* Common signs/symptoms* Shortness of breath* Chest pain* Syncope* Tachycardia* Hypoxemia* Hypotension* Step 2: Do not do additional testing for PE in patients with a CLEAR alternative diagnosis* Common alternative diagnoses* COPD exacerbation* Acute coronary syndrome* Pneumonia* Keep in mind that these diagnoses are also the most frequent misdiagnoses in cases of missed PE!!! Be careful.* Step 3: Calculate Wells Score and PERC criteria* Wells score* (I personally use Wells’ Criteria for PE by MDCalc)* Define patient as either “Low” “Medium” or “High” risk* PERC criteria* I use the PERC Rule for PE by MDCalc for this as well* If patient is both low risk wells and meets all PERC criteria…* No additional testing needed!!!* Step 4: Get a D-Dimer* IF… * Low risk Wells but fails PERC criteria* Medium risk Wells score* Step 5: Get a CTA* IF…* Wells score is high* Elevated d-dimer* (Update: it is now established that you can safely use AGE ADJUSTED D-DIMER)* ACEP’s clinical policy supporting this can be found HERE
Final Thoughts
* Bilateral lower extremity ultrasounds not sensitive enough to rule out PE* The classic EKG finding is S1Q3T3
Additional Reading
* Emergency Evaluation of PE: Diagnosis (Journal of Emergency Medicine)* Wells Criteria (MDCalc)* PERC Criteria (MDCalc)* Age Adjusted D-Dimer Policy (ACEP)

Hemoptysis Jun 18, 2017

Show notes

There are 3 main “categories” of hemoptysis…
Mild, “Streaky” Hemoptysis
* Most common diagnosis* Bronchitis* Testing plan* Chest xray* Rules out alternative causes of hemoptysis* Pneumonia* Cancer* Pulmonary Embolism* Vasculitis
Scary but Stable Hemoptysis
* Patient is coughing up frank blood* Testing plan* CTA of the chest* CBC* PTT/PT/INR* Electrolytes* Need renal function if giving IV contrast
Oh-My-God-That’s-A-Lot-Of-Blood!!!
* Intubate the patient* Consult cardiothoracic surgery/interventional radiology
Additional Reading
* Hemoptysis: An EM Primer (emDOCs)

Salicylate Overdose Jun 11, 2017

Show notes

Salicylate toxicity is the great toxicologic mimicker!!!
Step 1: When to Suspect Salicylate Overdose
* Signs of CNS stimulation* Tachypnea* Hyperthermia* Altered mental status* Signs of GI irritation* Nausea/Vomiting* Abdominal pain* Common “mimicker”* Sepsis* Acute abdomen
Step 2: Testing Plan
* Electrolyte panel* Anion gap metabolic acidosis* Sodium – Chloride – Bicarb* Normal anion gap (AG) is
Step 3: Obtain Serum Salicylate Level
Step 4: Treatment Plan
* Mild salicylate toxicity* Alkalinize urine with sodium bicarbonate (NaHCO3) drip* Severe salicylate toxicity* Dialysis
Additional Reading
* Salicylate Poisoning (LITFL)

Acetaminophen Overdose Jun 04, 2017

Show notes

Acetaminophen is the most important overdose in toxicology
Step 1: Check a Serum Acetaminophen Level
* Common situations where testing is ordered* Suicidal ideation* Severe depression* Overdose
Step 2: Consult the Rumack-Matthew nomogram
* Only works for acute/single ingestions of acetaminophen* Loses reliability if patient is on drugs that affect bowel motility* If the time of ingestion is KNOWN* Measure acetaminophen level 4 hours post-ingestion* Plot on nomogram and treat if above line* If time of ingestion is UNKNOWN* Determine earliest possible time of ingestion* Plot on nomogram and treat if above line
Step 3: Order hepatic labs (LFTs)
* AST* ALT* Alk Phos* PTT/PT/INR
Step 4: Identify Phase of Toxicity
* Phase 1/Day 1* High acetaminophen levels* Normal LFTs* Minimal symptoms* Phase 2/Day 2* Acetaminophen level starts decreasing* LFTs level starts increasing* Mild GI symptoms develop* Abdominal pain* Nausea/vomiting* Phase 3/Day 3* Acetaminophen levels are normalized* LFTs are peaking* Phase 4* Recovery
Step 5: Give N-Acetylcysteine (NAC)
* If patient meets criteria on Rumack-Matthew nomogram* If patient is in phase 1, 2, or 3
Additional Reading
* Acetaminophen Overdose and NAC Dosing (MDCalc)

Non-Pregnant Vaginal Bleeding May 14, 2017

Show notes

Common Causes
* Structural* Cancer* Post-menopausal bleeding is cancer until proven otherwise* Fibroids* Adenomyosis* Polyps* Coagulopathy* Present in approximately 20% of non-pregnant vaginal bleeding* Most common = Von Willebrand Disease* Hormonal causes* Dysfunctional uterine bleeding
Basic Approach to Non-Pregnant Vaginal Bleeding
* Step 1: Pelvic exam* The utility of this is debated* It is best to sound thorough on your clerkship* Have a chaperone present and document this (include the chaperones name)* Step 2: Obtain Labs* CBC* Anemia?* Thrombocytopenia?* Coags* aPTT is prolonged in 50% of patients with Von Willebrand Disease!* Thyroid (TSH)* Can be obtained outpatient* Common cause of hormonal related vaginal bleeding* Step 3: Pelvic ultrasound* Evaluates for ANATOMIC causes of vaginal bleeding* Step 4: NSAIDS* This treats both abdominal pain/cramping* Also improves bleeding* Step 5: Oral contraceptive pills* Can be started on an outpatient basis* Useful in patients with hormonal/dysfunctional uterine bleeding* Stabilizes endometrial lining
Additional Reading
* NBME Shelf Review: OBGYN (EM Clerkship)* Non-Pregnant Vaginal Bleeding (WikiEM)

Our TOPPODCAST Picks

Follow Us

Stay Connected

Related Podcasts

Links

Stay Connected