EM Clerkship

Latest Episodes:

Headache May 16, 2016

Show notes

With this complaint, it’s ALL about doing a good history and exam.
Step 1: Write Out Your Differential Diagnosis
* The KING* Subarachnoid hemorrhage* The QUEEN* Meningitis* 3 Killers in the BRAIN* Stroke* Hematomas* Elevated ICP/Tumors* 3 Killers in the VESSELS* Arterial dissection* Brain DVT (Dural Venous Sinus Thrombosis)* Giant cell/temporal arteritis* 3 MISCELLANEOUS killers* Preeclampsia* Carbon monoxide toxicity* Glaucoma
Step 2: How Does This Compare to Previous Headaches?
* Finding the answer to this question is not always easy!
Step 3: Do a FULL Neuro Exam
* Mental status* Neck stiffness* Extra-ocular movements* Visual fields* Cranial nerves* Speech* Motor* Sensation* Finger to Nose* Gait
Step 4: Order Tests As Necessary
* CT head without contrast* MRI brain* Lumbar puncture* ESR* Carbon monoxide level
Step 5: Give “Headache Cocktail”
* Mix and match based on personal and patient preferences* IV Dopamine antagonist* IV Antihistamine* IV Steroid* IV NSAIDS* IV Fluids* Tylenol* Triptans and opiates rarely indicated
Additional Reading
* Round 7 – Headache (EM Clerkship)* Round 11 – Headache (EM Clerkship)* Approach to Headache (SAEM)

Tummy Ache May 03, 2016

Show notes

Don’t forget to do a thorough GU exam!
Step 1: Write Out Your Differential Diagnosis
* Remember 2-4-2-4* (2) In the upper abdomen* Pyloric stenosis* Pneumonia* (4) In the lower abdomen* Hirschsprung’s disease* Intussusception* Appendicitis* Hernia* (2) Genitourinary* UTI* Testicular/Ovarian torsion* (4) Generalized* Volvulus* Necrotizing enterocolitis* Henoch Schonlein Purpura* Diabetic ketoacidosis
Step 2: Do Pediatric History and Exam
* Pediatric assessment triangle* Appearance* Breathing* Color* Birth history* Gestational age* Complications* Eating/drinking/peeing/pooping* Immunizations* Physical exam* Don’t forget GU exam!
Step 3: Five Important Tests
* Finger stick blood glucose* Urinalysis* Chest x-ray* Abdominal x-ray* Abdominal ultrasound
Step 4: Common Treatments
* Fever/Pain* Acetaminophen* Vomiting* Zofran* Diarrhea* NOTHING* Dehydration* Pedialyte
Additional Reading
* Pediatrics History (EM Clerkship)* Pediatrics Exam (EM Clerkship)

Circulation (Shock) Apr 26, 2016

Show notes

Tank. Clogged Pipes. Broken Pipes. Pump.
Introduction
* “Tank”* Hypovolemic shock* Hemorrhagic shock* “Clogged Pipes”* Cardiac tamponade* Tension pneumothorax* Pulmonary embolism* “Broken Pipes”* Septic Shock* Neurogenic Shock* Anaphylactic Shock* “Pump”* Cardiogenic Shock
Step 1: Fill the Tank
* Establish an IV* IO line alternative in emergent situations
Step 2: Consider Clogs
* Cardiac tamponade* Diagnosis: Ultrasound* Treatment: Pericardiocentesis* Tension pneumothorax* Diagnosis: Clinical/Xray/Ultrasound* Treatment: Needle decompression and tube thoracostomy* Pulmonary embolism* Diagnosis: Clinical/CTA* Treatment: Thrombolytics
Step 3: Squeeze the Pipes
* Administer vasopressors* Most common: Norepinephrine* Alternatives: Epinephrine, Phenylepherine
Step 4: Analyze the Pump
* Get an EKG* Ischemia = Aspirin/Heparin/Cath lab* Dysrhythmia = Electricity
Additional Reading
* Airway Part 1 – Immediate Actions (EM Clerkship)* Breathing (EM Clerkship)* RUSH Exam (EMCrit)

Breathing Apr 19, 2016

Show notes

Hypoxemia fixed by only TWO things: FiO2 and PEEP
Step 1: Add FiO2
* If the patient is breathing…* Nasal cannula* Non-rebreather mask* If the patient is NOT breathing…* Bag-valve mask
Step 2: Add PEEP
* *Cannot be completed in 60 seconds, but equipment can be requested* If patient is breathing…* BiPAP* If the patient is NOT breathing…* Intubation
Additional Reading
* Ventilator Basics (EM Clerkship)* Airway Part 1 – Immediate Actions (EM Clerkship)* Circulation (EM Clerkship)

Airway Apr 11, 2016

Show notes

“Airway” does not necessarily mean “Intubation”
Introduction
* In emergency medicine we are taught “A-B-Cs”* These are actions that can be accomplished in first 60 seconds of patient encounter* Intubation takes several minutes to accomplish* Intubating a crashing patient might even KILL them!* Resuscitate THEN intubate
Step 1: Suction
* Immediately suction if patient is…* Altered and vomiting* Gurgling
Step 2: Move the Tongue
* Bedside maneuvers* Head tilt* Chin lift* Jaw thrust* Adjunct equipment* Oropharyngeal airway* Nasopharyngeal airway
Additional Reading
* Airway Part 2 – BVM Adjuncts (EM Clerkship)* Airway Part 3 – Rapid Sequence Intubation (EM Clerkship)* Airway Part 4 – What to Do If Intubation Fails (EM Clerkship)* Laryngoscope As A Murder Weapon – Hemodynamic Kills (EMCrit)

Epistaxis Apr 03, 2016

Show notes

Don’t forget to wear protective gear. Gown up!
Initial Encounter
* History* Anticoagulants* Easy bleeding/bruising* Lightheadedness* Exam* Pallor* Tachycardia/Hypotension
Step 1: Put on Personal Protective Equipment
* Gown* Gloves* Mask* Eye Protection
Step 2: Clear Nose and Visualize Bleeding
* Have patient blow out/remove any clot and look for source of bleed* Kiesselbachs plexus* “Anterior” epistaxis* Sphenopalatine artery* “Posterior” epistaxis* Most severe/dangerous form
Step 3: Spray In Oxymetazoline (Afrin)
* Hold pressure for 15 minutes after initial application
Step 4: Cauterize With Silver Nitrate
* Avoid bilateral cauterizations* Can cause septal perforation* Anesthetize as necessary* 4% lidocaine on gauze and leave in nose for 10 minutes prior to cauterization
Step 5: Pack the Nose
* Multiple commercial products available for this* The utility of antibiotic prophylaxis at this step is unclear* Patient goes home with packing in place
Additional Reading
* Epistaxis Management (EM:RAP)

Chest Pain Mar 27, 2016

Show notes

There are six cardiopulmonary causes of chest pain that you need to know.
The SIX Causes
* Cardiac* Acute coronary syndrome (ACS)* Pericarditis with tamponade* Pulmonary* Pneumonia* Pneumothorax* Vascular* Pulmonary embolism* Aortic dissection
Step 1: Core Measures
* Aspirin* EKG
Step 2: Look for the “King” (Acute Coronary Syndrome)
* Four high yield symptoms* Radiation to the RIGHT shoulder* Vomiting* Worsens with exertion* Diaphoresis
Step 3: Look for the “Queen” (Pulmonary Embolism)
* Wells score* PERC rule
Step 4: Print a Previous Cath Report
* Major bonus points with attending!* Other useful information* Previous echocardiograms* Previous stress tests* Previous CTAs for PE
Step 5: Basic Testing Plan
* If concerned for cardiac causes* Troponin* If concerned for pulmonary causes* Chest x-ray* If concerned for vascular causes* CTA of the chest
Additional Reading
* STEMI (EM Clerkship)* Pulmonary Embolism (EM Clerkship)

Patient Presentations Mar 27, 2016

Show notes

Patient presentations are the single most important skill to develop for your Emergency Medicine rotation.
General Principles
* Stay focused, thorough, and organized* Write out the basic 8-step presentation for reference
The 8-Step Patient Presentation
* Summary statement* Demographics* Risk factors/Past medical history* Chief complaint* History* OPQRST* Try to give at least 4 descriptors* This is for billing reasons* Pertinent positives/negatives* Give approximately 5 most pertinent symptoms* Vitals* Physical exam* Give approximately 3 MOST pertinent findings * Differential diagnosis* Briefly argue for/against* Include both most likely and most dangerous* Testing plan* Treatment plan* This is the most commonly forgotten step of presentation
Additional Reading
* Abdominal Pain Presentation – History (EM Clerkship)* Abdominal Pain Presentation – Exam, Plan, and Disposition (EM Clerkship)* Patient Presentations in Emergency Medicine (EMRA)

Introduction Mar 20, 2016

Show notes

To Do Well On WRITTEN Exam
* Study the “Core 4” body systems* Neurology* Headache* Strokes* Meningitis* Cardiology* Chest pain* ACS* EKG interpretation* Pulmonary* Shortness of breath* PE* GI* Abdominal pain* Nausea/vomiting* Appendicitis
To Do Well In the DEPARTMENT
* Study the “other stuff”* Epistaxis* Foley catheter issues* Rectal bleeding* Laceration repair* Rashes* Geriatric falls* Suicidal ideation* The list goes on and on…
Additional Reading
* Emergency Medicine Advanced Clinical Subject Exam Content Breakdown (NBME Website)

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