EM Clerkship

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Head Trauma Sep 11, 2016

Show notes

CT scan without contrast is your test of choice.
Step 1: Consider Your Differential Diagnoses
* Five high-yield head trauma diagnoses* Skull fracture* External skull fracture* Basilar skull fracture* Epidural hematoma* Subdural hematoma* Traumatic subarachnoid hemorrhage (SAH)* Concussion
Step 2: Important Add-ons When Taking History
* Specific mechanism of injury* Loss of consciousness* Blood thinners/antiplatelet agents
Step 3: Important Add-ons To Your Physical Exam
* GCS Score (MDCalc)* Pupils* Basilar Skull Findings* Raccoon eyes* Battle sign* CSF rhinorrhea* Hemotympanum
Step 4: Calculate Canadian Head CT Rule
* Only apply to patients with…* Loss of consciousness* Amnesia to event* Witnessed disorientation* Exclude patients with* Blood thinners* Seizure(s)* Age 65* “Moderate” risk criteria* Retrograde amnesia >30 minutes* Dangerous mechanism* Fall >3 ft* Motor vs pedestrian* Ejected from MVA
Additional Reading
* Canadian CT Head Injury/Trauma Rule (MDCalc)* Evaluation and Management of Concussion in Sports (AAN)

Stroke Aug 21, 2016

Show notes

Get your attending!
Step 1: Obtain Last Known Well
* Stroke treatments including tPA and thrombectomy both require last known well*
Step 2: Finger Stick Blood Glucose
* Hypoglycemia is classic mimic of CVA* Results can be obtained immediately
Step 3: STAT Head CT Without Contrast
* Poor sensitivity for ischemic stroke* Primary use is identification of hemorrhagic stroke* Required prior to administration of tPA!
Step 4: Perform NIHSS
* Use calculator (MDCalc)
Step 5: Give tPA (If No Contraindications)
* Follow department protocol and contraindications* Frequently being updated
Additional Reading
* tPA Basics (EM Clerkship)* 2013 AHA Stroke Guidelines (AHA)* NIH Stroke Scale/Score (MDCalc)

Syncope Aug 07, 2016

Show notes

6 EKG Findings. 6 Risk Factors. 6 Mimics.
Step 1: Get an EKG
* This is the only “required” test for a patient with syncope* Other common tests* CBC* Evaluate for anemia* hCG* If patient might be pregnant
Step 2: Look For 6 High Risk EKG Patterns
* Mnemonic: QT-BRIDE* QT prolongation* Especially QTc >500* Brugada pattern* Right heart strain* Tachycardia* S1Q3T3* Inverted T waves precordial leads* Ischemic changes* ST segment elevation/depression* T wave inversion* Delta waves* Seen in Wolf-Parkinson White (WPW)* Epsilon waves* Seen in arrhythmogenic right ventricular dysplasia (ARVD)
Step 3: Ask the 6 High Risk Historical Questions
* Mnemonic: CHESS +1* Cardiac history* CHF* Structural heart disease* Hematocrit
Step 4: Consider 6 Deadly Syncope Mimics
* 15% of the following diseases reportedly present as “syncope”* AKA “Rule of 15s”* Subarachnoid hemorrhage* Myocardial infarction* Pulmonary embolism* Aortic dissection* Abdominal aortic aneurysm* Perforated GI* Ulcers* Ectopics
Additional Reading
* QT Intervals (LITFL)* Brugada Syndrome (LITFL)* Right Heart Strain (LITFL)* Delta Wave (LITFL)* Epsilon Wave (LITFL)

Common Pain Medications Jul 24, 2016

Show notes

Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone.
Oral Acetaminophen (Tylenol)
* Give every 4-6 hours* Regular strength – 325mg* Extra strength – 500mg* Maximum Daily Dose – 3000mg
Oral Ibuprofen (Advil)
* NSAID* Give every 4-6 hours* Regular strength – 200mg* Therapeutic Ceiling – 400mg
Oral Hydrocodone-Acetaminophen (Vicodin, Norco)
* Give ever 4-6 hours* Common doses – 5-325mg, 7.5-325mg, and 10-325mg
IV/IM Ketorolac (Toradol)
* NSAID* Common dosing – 15-30mg* Therapeutic ceiling – 10mg
IV/IM morphine
* Classic dose (0.1mg/kg)* This would be 7-10mg in adults!* More COMMON dosing is 4mg* Repeat as needed
IV/IM Hydromorphone (Dilaudid)
* COMMON dosing – 0.5-1mg * This drug is notorious for bringing you to peer-review/MM conference* Be careful!
Contraindications to NSAIDS
* Pregnant patients* Elderly patients* Renal disease patients* Cardiac patients* GI/ulcer patients
Side Effects of Opiates
* Sedation* No driving* Do not mix with alcohol* Do not mix with other sedatives* Constipation* Opiate dependency/addiction
Additional Reading
* Pain Management In the Emergency Department: A Review (PubMed)* Myths in EM: The Anti-Inflammatory Properties of NSAIDS (ACEP Now)

STEMI Jul 17, 2016

Show notes

You have 90 minutes to restore blood flow.
Step 1: Obtain EKG and Call STEMI Alert
* This activates ED resources as well as cath lab, interventional cardiology, etc
Step 2: Stop the Platelets
* Dual anti-platelet therapy* Aspirin 325mg chewed (or PR)* Plavix 600mg (not usually given in ED)* Complicates management if patient needs CABG
Step 3: Stop the Coagulation Cascade
* Heparin 60 units/kg (MAX 4000 units)
Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now
* If you DON’T have cath lab* Option 1: 30 minutes to give thrombolytics* Option 2: 120 minutes to get them to a different hospital with cath lab
Sgarbossa Criteria
* Left bundle branch block (LBBB)* PLUS* Concordant ST elevation (>1mm) in leads with positive QRS* OR* Concordant ST depression (>1mm) in leads with negative QRS* Typically V1-V3* OR* Severely discordant ST elevation (>5mm) in leads with negative QRS
“MONA”
* Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain* Oxygen has been shown to worsen outcomes if given indiscriminately* Not ideal to be giving supplemental O2 when SaO2 is 100%* Nitroglycerine* Nitroglycerine 0.4 mg SL q5min* OR* Nitroglycerin 10mcg/min drip (will need to be titrated UP)* For comparison… * 0.4 mg SL nitroglycerine releases approximately 80mcg/min* Contraindications* Inferior/Right heart infarction* Patients usually preload dependent* Nitro drops preload* Sildenafil (Viagra)* Can cause sudden/severe drop in blood pressure* Hypotension
Additional Reading
* Round 3 – Chest Pain (EM Clerkship)* The Death of MONA in ACS: Part 1 – Morphine (REBEL EM)* The Death of MONA in ACS: Part 2 – Oxygen (REBEL EM)* The Death of MONA in ACS: Part 3 – Nitroglycerine (REBEL EM)* The Death of MONA in ACS: Part 4 – Aspirin (REBEL EM)

Toxicology Jul 04, 2016

Show notes

Poison Control Hotline: 1-800-222-1222
Step 1: Evaluate the Airway
* General principles* “If they can’t speak, they can’t control their airway”* “If GCS is
Step 2: Toxicology History
* What did they take? * How much did they take?* Why did they take it?* When did they take it?
Step 3: Toxicology Exam
* Vital signs* Pupils* Skin
Step 4: Medication List
* Make note of all bottles with patient* Make EXTRA note if any pills seem to be missing* Bonus points if you bring your attending a med list
Step 5: Common Toxicology Tests
* Assessing for damage* Electrolytes* Liver function test* EKG* Pregnancy* Assessing for co-ingestion* Serum acetaminophen* Serum salicylate* Serum alcohol* Urine drug screen
The “Big 5” Toxidromes
* Anticholinergic* Increased vitals* Big pupils* Dry skin* Treatment – Physostigmine (rarely given)* Cholinergic* Decreased vitals* Small pupils* Moist skin* Treatment – Atropine* Opioid* Decreased vitals* Small pupils* Dry skin* Treatment – Naloxone* Sedative/Hypnotic* Decreased vitals* Normal pupils* Dry skin* Treatment – Flumazenil (rarely given)* Sympathomimetics* Increased vitals* Big pupils* Moist skin* Treatment – Benzodiazepines
Additional Reading
* NBME Shelf Review – Ophthalmology and Toxicology (EM Clerkship)* Toxidromes (Admin EM)

BRUE (Pediatrics) Jun 20, 2016

Show notes

3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE.
Step 1: Is This a BRUE?
* Brief*
Step 2: Is This Low Risk BRUE?
* Five low risk criteria* Age >2 months* Born at >32 weeks gestational age* First and only episode* No CPR by medical providers* No “Red Flags”
Step 3: Do They Have Red Flags?
* For abuse* History of SIDS/BRUE in sibling* Mental illness at home* Drug use at home* For dysrhythmia* Family history of sudden unexplained death* For infection* Fevers* Unimmunized* Sick contacts* Rash
Step 4: Examine for Non-Accidental Trauma
* Bulging fontanelle* Petechia* Torn frenulum* Blood
Step 5: Place Patient Into One of Three Categories
* NOT a BRUE* Treat as you normally would* HIGH risk BRUE* Admit* LOW risk BRUE* Discharge without testing* May consider EKG and pertussis
Additional Reading
* Brief Resolved Unexplained Events (AAP)

Trauma Jun 06, 2016

Show notes

Airway/C-spine. Breathing. Circulation. Disability. Exposure. Secondary Survey.
Airway and C-Spine
* General airway principles* “If they can’t speak, they can’t control their airway”* “If GCS is
Breathing
* If patient has tachypnea, hypoxemia, or respiratory distress* Give O2* Examine for tension pneumothorax* Deviated trachea* Asymmetric breath sounds* If concerned perform needle decompression* THEN* Tube thoracostomy
Circulation
* If patient has tachycardia, hypotension, or obvious blood loss* Stop the bleed* Emergent transfusion* Consider early OR if unstable* In the real world, CT is frequently obtained pre-op regardless of stability
Disability
* Pupils* GCS* If concerned for head injury* Obtain CT head without contrast
Exposure
* Fully undress the patient* Warm blankets
Secondary Survey
* Visualize everything* Palpate everything* Bedside chest/pelvic x-ray and FAST scan
Common Labs
* Type and screen* CBC* Electrolytes* Urinalysis* EKG* Blood alcohol level* Lactic acid (if concerned for shock)
Common Imaging
* CT head without contrast* CT maxillofacial without contrast* CT cervical spine without contrast* CTA neck* CT abdomen/pelvis WITH contrast* Retrograde urethrogram* Additional x-rays
Common Treatments
* Blood products* Tetanus immunization* Analgesics
Additional Reading
* Advanced Trauma Life Support (Wikipedia)* Round 5 – Geriatric Fall (EM Clerkship)

Priapism May 30, 2016

Show notes

The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock.
Two Types of Priapism
* High flow (non-ischemic)* Common causes* Trauma* AV malformations* Tumors* Priapism from too much blood coming IN* Not painful* Consult urology* Low flow (ischemic)* Common causes* Sickle cell disease* Drug side-effects* Priapism from blood being unable to flow OUT* Patient requires emergent detumescence* 50% chance of erectile dysfunction
Step 1: Prepare (4c approach)
* Collect* 19G needle* 21G needle* Variety of syringes* Gauze* Sterile drape* Betadine* Normal saline* Consent* 50% chance of erectile dysfunction even with successful procedure* Clean* Set up supplies and sterile field* Control pain* Penile nerve block (YouTube)
Step 2: Drain
* Nerve/Artery/Vein on top (12 o’clock)* Urethra on bottom (6 o’clock)* Insert 19G needle at either 3 or 9 o’clock and aspirate* UPDATE: Recommended insertion at either 2 or 10 o’clock* 30% chance of detumescence at this step alone
Step 3: Send Venous Blood Gas
* Confirms high-flow (non-ischemic) from low-flow (ischemic) priapism
Step 4: Irrigate
* Inject normal saline through the needle and then aspirate
Step 5: Phenylepherine
* Dilute 1ml (10 mg/ml) in 9 ml NS (results in 1mg/ml solution)* Inject 0.25 ml of 1 mg/ml solution and repeat q10 minutes* Alpha agonist effect constricts smooth muscle and facilitates venous outflow
Additional Reading
* Dorsal Penile Nerve Block (YouTube)* Drainage of Ischemic Priapism (SinaiEM)

Preeclampsia (Critical Diagnosis) May 23, 2016

Show notes

Never ignore a pregnant woman’s blood pressure.
Introduction
* Pre-Eclampsia* Pathophysiology unknown* Pregnancy induced multi-organ dysfunction* Definition* Pregnancy* PLUS* BP 135/85* PLUS* Proteinuria* Eclampsia* Preeclampsia* PLUS* Seizures* HELLP Syndrome* Preeclampsia* PLUS* Hemolysis* PLUS* Elevated liver enzymes* PLUS* Low platelets
Step 1: Evaluate For Four Big Symptoms
* Swelling/edema* Headache* Visual changes* Abdominal pain
Step 2: Testing
* Urinalysis* Proteinuria* CBC* Hemolysis* Thrombocytopenia* Electrolytes* Liver function tests
Step 3: Start Magnesium
* Hypomagnesemia = Hyporeflexia
Step 4: Control the Blood Pressure
* Hydralazine* Labetalol
Step 5: Admit
* OB emergency* All patients need fetal monitoring
Additional Reading
* Round 2 – Seizure (EM Clerkship)* Preeclampsia and High Blood Pressure During Pregnancy (ACOG)

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