EM Clerkship

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Hyperkalemia Jan 01, 2017

Show notes

Hyperkalemia = EKG… EKG changes = Calcium…
Step 1: Recheck the Potassium
* Most common cause of hyperkalemia is PSEUDOhyperkalemia* Caused by too aggressive/fast of a blood draw* Causes RBCs to break open and falsely increase serum potassium
Step 2: Get an EKG
* Earliest EKG change* Peaked T waves* Late EKG changes* Flattened P wave* Prolonged QRS* Critical/Emergent EKG changes* Sine wave
Step 3: Protect the Heart
* EKG Changes = Give Calcium* Calcium gluconate (can be given IV)* Stabilizes the myocardium against dysrhythmia
Step 4: Shift Potassium Into Cells
* Insulin (plus D50)* Albuterol
Step 5: Remove Potassium from Body
* Kayexalate* Notorious for causing intestinal necrosis* Falling out of favor* Furosemide
Additional Reading
* Round 8 – Fall (EM Clerkship)* Emergency Management of Hyperkalemia (EM Cases)

How to Interpret a Chest X-Ray Dec 11, 2016

Show notes

A-B-C-D-E-F-G
Two Types of X-Rays
* Anterior-Posterior (“AP”)* Classic “portable” xray* The beam shoots from in front of the patient (anterior)* TO* The plate sitting behind the patient (posterior)* Posterior-Anterior (“PA”)* Requires trip to radiology* Results in a better picture* The beam shoots from behind the patient (posterior)* TO* The plate sitting in front of the patient (anterior)
Three Indicators of a High Quality Chest X-Ray
* Well inflated lungs* Visualize spine through cardiac silhouette* Medial aspect of both clavicles lined up* Evaluates for rotation
Chest X-Ray Interpretation Mnemonic
* A-B-C-D-E-F-G* A = Airway* Trachea midline (rule out tension pneumothorax)* B = Bones* Rib/Clavicle/Shoulder fractures* C = Cardiac silhouette* Should be no bigger than 50% of distance from chest wall to chest wall* Larger than this may represent cardiomyopathy* D = Diaphragm* Costophrenic angles should be sharp* Blunted in pleural effusion* E = Equipment* Central lines* Endotracheal tubes* Chest tubes* F = Lung Fields* The most important step* Look at lung markings/tissue to evaluate for…* Pneumothorax* Consolidation* Nodules* Pulmonary Edema* G = Great vessels* Look for mediastinal widening (> 8cm)* Can be a sign of aortic injury* Looks falsely widened on AP/portable chest x-ray
Additional Reading
* How to Read a Chest X-Ray (Medgeeks)* Learn to Read a Chest X-Ray in 5 Minutes (YouTube)

Trauma in Pregnancy Dec 06, 2016

Show notes

Mom is Scared. You are Scared. Don’t Be Scared.
General Principles
* Evaluate for intimate partner violence in all poorly explained traumas during pregnancy* Get the scans you would order in a non-pregnant patient, even CTs!* Shield the uterus if necessary
Basic Approach to Trauma in Pregnancy
* Step 1: Place mother in left lateral decubitus position* This removes the weight of the uterus OFF the inferior vena cava (IVC)* Can significantly improve patient’s hemodynamics* Step 2: Palpate the fundus* If fundus is palpable at umbilicus, fetus is approximately 20 weeks* Add 1 week of pregnancy for every 1cm above umbilicus* Step 3: Pelvic ultrasound* Primary utility is to reassure mother that baby is OK* Calculate fetal heart rate* Also identifies SOME placental abruptions and pelvic free fluid* Step 4: Obtain type and screen* If mother is Rh NEGATIVE…* Give RhoGAM* Prevents Rh isoimmunization in mothers with Rh positive babies* Step 5: Consult OBGYN for fetal heart monitoring (tocodynamometry)* Best test to rule out placental abruption and uterine irritability* Only necessary if patient is >20 weeks gestational age
Additional Reading
* Trauma Basics (EM Clerkship)* Trauma in Pregnancy (AAFP)

Genitourinary Trauma Nov 13, 2016

Show notes

Four important injuries. Four different imaging studies to obtain.
Step 1: Obtain Pelvic X-Ray
* Commonly performed at bedside as part of initial trauma evaluation* A pelvic injury significantly increases risk of GU injury
Step 2: Examine the Perineum
* Common signs of GU injury* Blood at urethral meatus* Bruising of the perineum
Step 3: Obtain Urinalysis
* Gross hematuria is the red flag* Can be identified at bedside* Importance of microscopic hematuria uncertain* If you decided to send a formal urinalysis…* Patient needs follow up on the hematuria until resolved
Step 4: Consider the FOUR Genitourinary Injuries
* Kidney injury* Evaluate with CT scan abdomen/pelvis with IV contrast* Occur in approximately 10% abdominal trauma* Flank pain* Lower rib trauma* Ureteral injury* Evaluate with delayed CT scan abdomen/pelvis with IV contrast* Call radiology to help choose right imaging protocol* RARE injury* Sometimes seen with penetrating trauma or surgical injury* Frequently needs surgical repair* Bladder injury* Evaluate with retrograde cystogram* Occurs when patient with distended bladder has direct impact to low abdomen* Urethral injury* Evaluate with retrograde urethrogram (RUG)* TWO subtypes* Posterior injury* Occur with pelvic fractures* Anterior injury* Occur with straddle-type injuries
Additional Reading
* The Importance of the RUG (Taming the SRU)* Genitourinary Trauma (emDOCs)

Abdominal Trauma Nov 06, 2016

Show notes

Step 1: Does This Patient Need Surgery NOW?
* Obvious penetrating injury to abdomen* Peritonitis* Hypotensive
Step 2: FAST Scan
* Performed with bedside ultrasound machine* Blood/intra-peritoneal fluid is hypoechoic (black) in appearance* Four views required* Right upper quadrant* Probe marker points towards patient’s head* “Morrisons Pouch”* Potential space between liver and right kidney* Left upper quadrant* Probe marker towards patient’s head* Most difficult view to obtain* Potential space around spleen and between spleen and left kidney* Suprapubic* Probe marker towards patient’s head* Looking for thin rim of fluid between bladder wall and bowel wall* Subxiphoid* Hold probe flat and aim through liver towards heart* Looking for fluid around heart and evidence of cardiac tamponade
Step 3: Consider the Mechanism
* Low risk* Low speed MVAs* Falling down only a few steps* High risk* Falling off ladder/roof* High velocity MVA/impact
Step 4: Perform Careful Abdominal Exam
* Pain* Bruising/Seatbelt sign* Distension* Peritonitis* Rigidity* Rebound* Guarding
Step 5: Obtain Imaging if High Risk Mechanism or Abnormal Exam
* CT Abdomen/Pelvis with IV contrast* If normal CT scan but you still have clinical concern- ADMIT* Serial abdominal exams* CT notorious for missing small bowel and diaphragmatic injuries
Additional Reading
* Trauma Basics (EM Clerkship)* FAST Examination (SAEM)

Cardiac Trauma Oct 30, 2016

Show notes

Cardiac tamponade. Aortic Dissection. Blunt cardiac injury.
Cardiac Tamponade
* Blood fills pericardial sac* Increasing pressure on myocardium -> Decreased preload* Decreased preload -> Hypotension -> Death* Clinical exam shows Beck’s Triad* Hypotension* Muffled heart sounds* Jugular venous distension (JVD)* Diagnosed during FAST exam (subxiphoid view)* Treat with pericardiocentesis* Bedside thoracotomy if patient loses pulse
Aortic Dissection/Rupture/Tear
* Common with rapid deceleration injuries* Most commonly occurs at ligamentum arteriosum* Small ligament that attaches arch of aorta to pulmonary artery* Remnant of the ductus arteriosus* Obtain CTA of the chest if…* Widened mediastinum on chest x-ray* Unequal pulses* Concerning mechanism of injury* Requires emergent repair
Blunt Cardiac Injury
* Contusion to the myocardium can cause arrhythmia/death* Place patient on cardiac monitor* Consider EKG/troponin* Commotio Cordis* Blunt impact to chest resulting in ventricular fibrillation
Additional Reading
* Blunt Cardiac Injury (American Association for the Surgery of Trauma)* FAST Exam (SAEM)

Thoracic Trauma Oct 16, 2016

Show notes

Step 1: Perform ATLS Primary Survey (B- Breathing)
* Signs of respiratory distress/injury* Shortness of breath* Hypoxemia* Tracheal deviation* Diminished breath sounds
Step 2: Consider Performing Bedside Tube Thoracostomy
* Insert at 5th intercostal space just anterior to mid-axillary line
Step 3: Imaging
* Start with portable bedside chest x-ray* Pneumothorax can also be diagnosed by thoracic ultrasound
Step 4: Consider the 3 Critical Diagnoses
* Tension pneumothorax* Pressure builds up between chest wall and lung* Eventually decreases cardiac preload -> Hypotension/Death* Treatment* Needle decompression* Tube thoracostomy* Open pneumothorax* Lung unable to expand during inspiration* Treatment* 3-sided occlusive dressing over open (“sucking”) chest wound* Tube thoracostomy* Hemothorax* Chest cavity fills with blood* Eventual decreases cardiac preload -> Hypotension/Death* Treat with tube thoracostomy
Step 5: Consider the 3 Other Common Diagnoses
* Rib fractures* Diagnose with chest x-ray* Treatment* Pain control* Incentive spirometry* Small pneumothorax* Worsens with positive pressure ventilation (intubation, BiPAP)* Treatment* Supplemental oxygen* Supportive care* Pulmonary contusion* Supportive care
Additional Reading
* Round 12 – Difficulty Breathing (EM Clerkship)* Chest Tube Thoracotomy Demonstration (YouTube)

Neck Trauma Oct 09, 2016

Show notes

The hardest question… Should you get a CTA?
Blunt Trauma of Neck
* Obtain CTA if…* Patient has neurologic deficit* Numbness* Weakness* Visual changes* Patient sustained forceful impact to the neck* Patient has fracture* Basilar skull* Facial bones* Cervical spine
Penetrating Trauma of the Neck
* Go to OR if patient is unstable* Go to OR if patient has HARD signs* HARD Bruit Mnemonic* Hemoptysis/Hematemesis/Hypotension* Arterial bleeding* Rapidly expanding hematoma* Deficit (neurologic/pulse)* Bruit* Otherwise obtain CTA of the neck
Additional Reading
* Neck Trauma: A Practice Update (emDOCs)

C-Spine Trauma Oct 02, 2016

Show notes

Step 1: Protect the Spine
* Apply cervical collar
Step 2: Apply NEXUS Criteria
* Use the “SPINE” mnemonic* Spinal midline tenderness* Painful distracting injury* Intoxication* Neurologic deficit* Encephalopathy
Step 3: If Patient Has None of the NEXUS Criteria… You Are Done!
Step 4: If Patient Has Positive NEXUS Criteria…
* Obtain CT scan of the cervical scan without contrast
Step 5: Clear the C-Spine
* If CT scan negative -> Have patient turn head 45 degrees to right and left* If patient has no limitation and no paresthesias or neurologic deficit…* Remove collar* If still concerned for spinal injury despite normal CT* Keep collar on and have patient follow up in clinic for reexam
Unstable Cervical Spine Fractures
* Mnemonic: Jefferson Bit Off a Hangmans Tit* Jefferson fracture* Bilateral facet dislocation* Odontoid fracture* Atlantooccipital dislocation* Hangman’s fracture* Teardrop fracture
Additional Reading
* NEXUS Criterial for C-Spine Imaging (MDCalc)* Unstable Spine Fractures (WikEM)

Facial Trauma Sep 25, 2016

Show notes

There are 6 major areas/injuries to the face.
Basic Approach to Facial Injury
* Step 1: Airway* Indications for intubation after trauma* Burns to the airway* Rapidly expanding hematoma* GCS Ophthalmology* ENT trauma -> ENT* Oral/Dental trauma -> Oral/maxillofacial surgery or dentistry
Six Key Facial Injuries
* Frontal bone* Fractures of the INTERNAL frontal sinus wall = BAD* Eyes and orbits* “Blowout” fractures with entrapment of the extra-occular muscles = BAD* Nose* Septal hematoma = BAD* Zygoma (Cheekbone)* Zygomaticomaxillary complex fracture (aka Tripod fracture) = BAD* Maxilla (Upper jaw)* Le Fort fractures = BAD* Mandible (Lower jaw)* Open fractures (intraoral laceration) = BAD
Additional Reading
* Trauma Basics (EM Clerkship)* CORE EM: Facial Fractures (emDOCs)

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