EM Clerkship

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1st Trimester Vaginal Bleeding Apr 30, 2017

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The pregnancy test is the most important test in females of reproductive age!
Five Important Tests in 1st Trimester Vaginal Bleeding
* CBC* Hemoglobin/Hematocrit* Mild anemia in pregnancy is physiologic and normal* Thrombocytopenia* Type and Screen* Required for blood transfusion* Determines if patient needs RhoGAM* Rho(D) immune globulin* Binds fetal Rh antigens from a fetus so that mother doesn’t develop antibodies against future Rh positive children* Prevents hemolytic disease of the newborn* Give to Rh negative mothers to protect future Rh positive children* Quantitative hCG* hCG >1500* “Cutoff” where definitive pregnancy should be seen on ultrasound* If no pregnancy is seen, highly concerning for ectopic pregnancy* hCG
Additional Reading
* Ectopic Pregnancy (EM Clerkship)

Constipation Apr 23, 2017

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Common Causes of Constipation
* Lifestyle* Low fiber diet* Minimal water intake* Poor exercise* Medications* Especially opiates* Endocrine/electrolytes* Hypothyroidism* Hypercalcemia* Bowel obstruction* Delayed colonoscopy* Unintentional weight loss* Previous abdominal surgeries* Rectal problems* Anal fissures* Fecal impaction* Masses
How to Treat Constipation
* Fiber (ex. Metamucil, Citrucel)* Adds structure to the stool* Water (polyethylene glycol/miralax)* Hydrates the stool* Fat (colace)* Softens the stool* Stimulants (Senna)* Increases intestinal activity* Decreases transit time* Suppositories (Glycerine, Dulcolax, Fleet)* Stimulate rectum and cause reflexive bowel movements
Additional Reading
* Constipation Treatment and Management (Medscape)

Diabetic Ketoacidosis (DKA) Apr 02, 2017

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The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!!
Signs and Symptoms
* Vomiting* Abdominal pain* Polydipsia* Polyuria
Step 1: Test for DIABETIC-KETO-ACIDOSIS
* Diabetes* Blood sugar* Typically notably elevated (>250 mg/dL)* Can be normal in certain circumstances* Ketones* Easiest test is a urinalysis* Serum ketones also can be obtained* Acidosis* Blood gas (arterial or venous)* pH
Step 2: Check Potassium Level
* Patients frequently depleted of whole body potassium* Insulin administration will causes further drops in serum potassium level
Step 3: Replace Potassium
* If potassium 3.3 but
Step 4: Give Fluids
* Adult patients are frequently 3-6 LITERS depleted* 20 ml/kg NS during first hour
Step 5: Start an Insulin Drip
* This accomplishes 2 things…* It decreases blood sugar* It also decreases acid production
Additional Reading
* Peds H- Hyperglycemia and Hypoglycemia (EM Clerkship)* DKA Myths (REBEL EM)

Laceration Repair Mar 12, 2017

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Step 1: Pain Control
* Local anesthesia* Most common agent is lidocaine (frequently already in laceration repair kits)* Inject through wound edges (not through epidermis)* This decreases pain* Alternative is digital/regional nerve block
Step 2: Irrigation
* Laceration repair is not a sterile procedure* Copious irrigation is the best method to decrease chance of wound infection* Faucet/sink vs saline
Step 3: Alternative Wound Closure Techniques
* Dermabond/Tissue Adhesive* Works best on easily approximated wound edges and little tension* Commonly used in pediatrics and geriatrics* Staples* Sometimes leaves a poor cosmetic outcome* Commonly used for scalp wounds* Rapidly stops bleeding* Quickest and easiest closure method to perform
Step 4: Choose a Suture Type
* Absorbable (Gut, Monocryl) * Pros: Patient doesn’t need to return for removal* Cons: Loses tensile strength* Non-Absorbable (Prolene)* Pros: Good cosmetic outcomes, easy to see (bright blue)* Cons: Patient must have them removed
Step 5: Repair the Wound
* Gently approximate wound edges* You are not trying to “seal” the wound closed* Primary goal is to improve cosmetic outcome* Keep it simple* Simple interrupted sutures* Instrument tie
Additional Reading
* Laceration Evaluation (EM Clerkship)* Wound Closure for the Emergency Practitioner (LacerationRepair)

Laceration Evaluation Mar 05, 2017

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Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!!
To Close or Not To Close?
* Closing a wound with sutures, etc = Healing by “primary intention”* INCREASES risk of infection but DECREASES scar* Leaving a wound open = Healing by “secondary intention”* DECREASES risk of infection but INCREASES scar
Step 1: History
* Does patient have comorbidities that increase risk of infection/poor healing?* Diabetes* Renal Failure* Obesity* Smoking* Immunosuppression* How long since injury happened?* Any concern for foreign body?
Step 2: Identify Tetanus Status
* Has patient EVER been immunized against tetanus?* Has it been >5 years since last tetanus shot?
Step 3: Tetanus Prophylaxis
* Give tetanus booster (Tdap) if >5 years since last tetanus shot* Give tetanus immunoglobulin (IG) if patient has never had tetanus immunization
Step 4: Give Specific, Objective Description of Laceration
* EXACT length* Must use a ruler* Most important BILLING categories* 2.5 cm or less* 2.6 cm to 7.5 cm* 7.6 cm to 12.5 cm* Description* Shape* Linear* Stellate* Flap* Depth* Superficial* Muscle* Bone* Neurovascular exam* Sensation* Motor* Cap refill
Step 5: Rule Out Foreign Body
* Consider X-Ray* Not all foreign bodies will show up on x-ray* Especially organic material, clothing, etc* Consider bedside ultrasound* (You are not expected to know how to do this, only to consider this)
Additional Reading
* Laceration Repair (EM Clerkship)* Wound Closure for the Emergency Practitioner (LacerationRepair)

Sore Throat Feb 26, 2017

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You must know the FOUR emergent causes of sore throat!
Step 1: Apply the Centor Criteria
* Determines if patients is at risk for Group A strep (“strep throat”)* 4 Criteria* Fever* No cough* Tonsiller exudates* Lymphadenopathy* Interpretation* If patient has ALL of the criteria* Treat for strep throat* If patient has NONE of the criteria* Don’t even test for strep throat* If patient has SOME of the criteria* Consider testing for strep throat
Step 2: Prescribe Antibiotics
* B-lactams work best* Penicillin* Amoxicillin* If patient has allergy, consider alternative agent* Azithromycin* Clindamycin
Step 3: Pain Control
* NSAIDS* Steroids
Step 4: Consider EBV (Epstein-Barr Virus)
* Consider in patients not getting better on antibiotics* Examine for splenomegaly* If present, no contact sports
Step 5: Consider the FOUR Emergent Causes of Sore Throat
* Ludwigs angina* Airway emergency* Infection UNDER the tongue* Peritonsillar abscess (PTA)* Complication of bacterial pharyngitis* Causes “trismus” (difficulty opening mouth)* Frequently need to be drained* Retropharyngeal abscess* Airway emergency* Difficult to diagnose by exam alone* Infection is BEHIND airway* Seen on lateral neck xray* Epiglottitis* Airway Emergency* “The Triad”* Drooling* Dysphagia* Distress (respiratory)* Lateral neck xray shows “thumbprint sign”
Additional Reading
* Peds O- Oxygen, Airway, and Respiratory Disorders (EM Clerkship)* Airway Infectious Disease Emergencies (UNM)

Procedural Sedation Feb 19, 2017

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Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship
Common Scenarios
* Cardioversion* Orthopedic reductions* Painful procedures
Three Step Approach to Procedural Sedation
* Step 1: Risk stratify the patient* Mallampati score (aka “How visible is the uvula?”)* Level 1: Can visualize THE WHOLE uvula* Level 2: Can visualize MOST of the uvula* Level 3: Can visualize SOME of the uvula* Level 4: Can NOT visualize the uvula* ASA (aka “How healthy are they?”)* Level 1: Healthy* Level 2: Mild illness* Hypertension* Hyperlipidemia* Anemia* Level 3: Major illness* Diabetes* Coronary disease* COPD* Chronic renal disease* Level 4: Extremely unhealthy* Dialysis patient* Severe heart failure* Chronically debilitated* Level 5: Dying* Patient needs operation to live* Intracranial hemorrhage with midline shift* Ruptured aortic aneurysm* Ruptured papillary muscle with cariogenic shock* Dissecting aortic aneurysm* Step 2: Informed consent* Patients sign a GENERAL CONSENT to treat when registering to the department* Many emergency scenarios require physician to operate with IMPLIED CONSENT* Many patients have an ADVANCED DIRECTIVE* In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required* Varies by hospital* Typically required for procedural sedation in stable patients* Step 3: Gather supplies* Nurse and nursing supplies* IV* Cardiac monitor* Respiratory therapy and respiratory supplies* Capnography* Bag-valve mask* Airway box
Top 5 Procedural Sedation Medications
* Midazolam (“Versed”) – 0.02 mg/kg IV* Reduces anxiety prior to procedure* Provides no analgesia* Fentanyl – 1 mcg/kg IV* Reduces pain* Useful for painful procedures* Incision and drainage* Simple reductions* Propofol – 0.5-1mg/kg IV* General anesthetic* Best given “low and slow”* Short acting* Causes respiratory depression and hypotension* Etomidate – 0.15 mg/kg IV* General anesthetic* Less hypotension than propofol* Can cause myoclonus* Ketamine – 1-2mg/kg IV* “Dissociative”* Provides both amnesia AND analgesia* Can cause emergence reactions* Can cause laryngospasm and secretions
Additional Reading
* Mallampati Score (Wikipedia)* ASA Physical Status Classification (Wikipedia)

Back Pain Feb 05, 2017

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Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses
* Aortic Dissection and Abdominal Aortic Aneurysm (AAA)* Age >50* Hypertension* “Ripping” or “Tearing” pain* Absent pulses in lower extremities* Spinal Infections* Fever* Immunocompromized* HIV* Diabetes mellitus* Transplant patients* Spinal cord compression (especially cauda equina)* Urinary retention* Consider obtaining post-void residual* Saddle anesthesia* Fecal incontinence/decreased rectal tone* Fracture* Recent trauma* Advanced age* Cancer* History of cancer* Night sweats* Weight loss
Step 2: Testing Plan (If Patient Has Red Flags)
* X-ray or CT scan if concerned for fracture* MRI if concerned for infection, cord compression, or cancer
Step 3: Symptom Management
* NSAIDS* Naproxen* Ibuprofen* “Muscle relaxants” * Cyclobenzaprine* Other agents* Opiates* Topical therapy* Lidocaine patches
Step 4: Counseling
* Remain active* Avoid heavy lifting* Red flags = immediate return to ED
Additional Reading
* Round 6 – Back Pain (EM Clerkship)* Back Pain Red Flags (WikEM)

Dental Pain Jan 15, 2017

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Minor complaint. Huge SLOE points!
Step 1: Identify Which Tooth is Causing Pain
* Bonus points if you number teeth correctly!* Number 1-32* Tooth #1 is top right* Tooth #32 is bottom right* Refer to dental chart for reference
Step 2: Correct Terminology When Making Diagnosis
* Pulpitis* Pain in the tooth itself* Reversible* Triggered by hot/cold etc (then goes away)* Irreversible* Does not resolve* Gingivitis* Pain of the gingiva around the tooth* Periapical abscess* Pain with percussion of tooth
Step 3: Give Pain Medicine
* NSAIDS have been shown to work best* Naproxen* Ibuprofen* Opiates for breakthrough pain* Hydrocodone-acetaminophen (Norco)* Oxycodone-acetaminophen (Percocet)
Step 4: Consider Antibiotics
* Pulpitis does not require antibiotics* Gingivitis/Periapical abscess frequently improve on antibiotics* Penicillin VK
Step 5: Inferior Alveolar Nerve Block
* Watch HERE
Additional Reading
* Inferior Alveolar Nerve Block (YouTube)* Common Dental Emergencies (AFP)

Vertigo Jan 08, 2017

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Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo?
Step 1: How Does Patient Describe the Vertigo?
* Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is)* Central vertigo* Mild* Vague* Peripheral vertigo* Severe* Sudden
Step 2: What Are the Associated Symptoms?
* Central vertigo frequently associated with “The Dangerous D’s”* Diplopia (double vision)* Dysphagia (difficulty swallowing)* Dysmetria (uncoordinated movement)* Dysarthria (difficulty speaking)
Step 3: Does this Patient Have Risk Factors for Central Vertigo?
* History of stroke* Atrial fibrillation* Diabetes* Recent trauma
Step 4: Do a Neuro Exam
* Important exam findings for central vertigo* Abnormal gait* Abnormal finger-to-nose* Nystagmus* Important exam findings for peripheral vertigo* Dix-Hallpike
Step 5: Plan
* If concerned for CENTAL vertigo* MRI head/neck* If concerned for PERIPHERAL vertigo* Treat with meclizine
Additional Reading
* Posterior Circulation Strokes and Dizziness (emDOCs)

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