EM Clerkship

Latest Episodes:

Deep Dive MW R11 Jul 15, 2023

Show notes

The 6 STEMI Equivalents:
* Posterior MI
* ST Depression V2/V3 (or STE in V7-V9)
* Right Ventricular MI
* STE V1 associated with inferior MI ; or STE V4R-V6R
* Wellens Syndrome
* Type A: Biphasic T-waves V2/3
* Type B: Deep Symmetric T-wave Inversion V2/V3
* De Winter’s T Wave
* ST Depression with a large, symmetric, upright T wave
* STE avR with diffuse ST-Depression
* Usually a strain pattern due to underlying pathology, in correct clinical context can represent a left main or proximal LAD coronary occlusion
* Modified Sgarbossa Criteria in LBBB
* Concordant STE in any lead
* Concordant ST Depression in V1-V3
* Excessive Discordance (ST/S ratio >0.25)
Other atypical ischemic EKG findings:
* Isolated TWI in avL – early sign of inferior MI
* Hyperacute TWave
* NTTV1 (New Tall T-wave in V1)
Further Reading (see photos in the article):
ECG Diagnosis of Life-Threatening STEMI Equivalent’s: Journal of the American College of Cardiology

Round 11 (MW) Chest Pain Jul 02, 2023

Show notes

You are working at Clerkship Rural when the nurse hands you your next chart to see. It’s a 59 year old farmer with chest pain.
Initial Vitals:
BP: 156/97
HR: 110
RR: 22
O2: 98% (Room Air)
Temp: 98.8F
Critical Actions:
* Give Aspirin, Nitroglycerin, and Heparin
* Identify Posterior STEMI
* Assess for Thrombolytic Contraindications and Consent
* Transfer for PCI
* Diagnose Accelerated Idioventricular Rhythm (AIVR)

Deep Dive MW R10 Jun 17, 2023

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* The MILDLY agitated patient : verbal de-escalation or PO benzo/antipsychotic
* The MODERATELY agitated patient : IM benzo/antipsychotic
* The SEVERELY agitated patient : IM Ketamine 5mg/kg
Consider removing the terminology “Agitated Delirium” from your vocabulary, as there is significant racial bias behind this term.

Round 10 (MW) Agitation Jun 01, 2023

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You are working at Clerkship General when you hear an EMS call on the radio…
“CLERKSHIP GENERAL – We are bringing you an agitated and combative 30 year old male, we’ll see you in 5 minutes.”
Initial Vitals:
BP: 192/105
HR: 134
RR: 22
O2: 99% (Room Air)
Temp: 98.8 F
Critical Actions:
* Administer Sedation for Patient/Staff Safety
* Intubate the Patient and Obtain Chest Xray
* Diagnose Intracranial Hemorrhage
* Treat Patients Hypertension
* Diagnose Rhabdomyolysis and Give Fluids
Dangerous Actions:
* Giving Succinylcholine
* Giving B-Blocker (Controversial)
Check Out:
Procrastinators Guide to Emergency Medicine

Deep Dive MW R9 May 16, 2023

Show notes

Indications for LP: CNS infection, SAH, Guillian Barree, IIH
Contraindications for LP: Space occupying lesion with mass effect ; severe thrombocytopenia and coagulopathy; cellulitis over LP site or concern for epidural abscess ; traumatic injury to spine
Complications for LP: Post LP Headache, spinal hematoma, brainstem herniation
Technique for LP: Positioning is everything. Use US if necessary. Check for CSF early and often.
When to CT before LP?: AMS; focal neuro deficit; new onset seizures, known CNS lesions; immunosuppression; papilledema

Round 9 (MW) Altered Mental Status May 01, 2023

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You are working at Clerkship General when the charge nurse comes and grabs you… “Hey doc, we need you in room 2, this kid looks sick…”
Initial Vitals:
BP: 68/40
HR: 128
RR: 22
O2: 99% (Room Air)
Temp: 103.5F
Critical Actions:
* Diagnose Meningitis and Perform Lumbar Puncture
* Give Empiric Antibiotics
* Treat Septic Shock
* Give Steroids
* Give Prophylaxis to Close Contacts
Check Out:
Pearson Ravitz Webinar – “Disability Insurance 101 for Residents”
https://us06web.zoom.us/webinar/register/1416806357023/WN_ziYRNc0kT8yAyOOJZ-Xk2g

Deep Dive MW R8 Apr 16, 2023

Show notes

* Two Types of Priapism
* Low Flow “Ischemic” (Most Common >95% of Cases)
* Urologic Emergency
* Results in Erectile Dysfunction
* Painful
* Common Etiologies
* Idiopathic
* Erectile Dysfunction Drugs (ex. sildenafil)
* Sickle Cell Disease
* Trazodone (“TrazoBONE”)
* Cocaine/Meth
* High Flow
* Caused by Trauma and AV Fistulas
* Management
* Analgesia
* Dorsal Penile Nerve Block
* Aspiration
* Can intermittently irrigate with normal saline to dilute the clot
* Injection
* Phenylepherine
* Recommend cardiac monitor

Round 8 (MW) Groin Pain Apr 01, 2023

Show notes

You are working at Clerkship General on an overnight shift when the next chart is handed to you. It’s a 35 year old male with a chief complaint of groin pain.
Initial Vitals:
BP: 150/90
HR: 107
RR: 20
O2: 99% (Room Air)
Temp: 98.0F
Critical Actions:
* Diagnose Ischemic/Low Flow Priapism
* Perform Penile Nerve Block
* Aspirate Blood and Irrigate with Saline
* Inject Intracavernous Phenylepherine
* Diagnose and Treat Ventricular Tachycardia

Deep Dive MW R7 Mar 16, 2023

Show notes

Obtain IV Access – get two large bore IVs (18g or larger)
Resuscitate – un-crossmatched blood at first, don’t forget type and screen!
Medicate – Give Pantoprazole always, Octreotide and Ceftriaxone if hx liver disease, reverse anticoagulation if indicated
Imaging – Upright CXR to assess for perforation, CTA if concerned for lower GIB
Consult – GI if unstable / if variceal bleeding
Disposition – based on amount of bleeding and hemodynamic stability

Round 7 (MW) – Vomiting Blood Mar 01, 2023

Show notes

You are working at Clerkship General when the charge nurse grabs you – “hey we got a real sick one, a 57yo Male who I just put in the resuscitation bay, he is vomiting blood”.
Initial Vitals:BP: 77/34
HR: 135
RR: 24
O2%: 95%
Temp: 98.8F
Critical Actions:
* Place two large bore IVs
* Transfuse emergency uncross matched blood
* Administer IV Pantoprazole
* Administer IV Ceftriaxone and IV Octreotide
* Consult GI
Further Reading: EMDocs – GI Bleed

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