EM Clerkship

Cardiac Tamponade Cardiac Tamponade – A physiological state caused by a pericardial effusion in which the pressure in the pericardial sac is higher than the pressure inside the right sided chambers of the heart, leading to impaired filling, decreased cardiac output, and hemodynamic collapse. Pericardial Effusions – Can be caused by infections, rheumatologic diseases, malignancy, uremia, hypothyroi...

Case Introduction You are working a shift at your local free-standing emergency room when a family of three checks in to be seen (a father and his two sons). Initial Vitals#1 (Chris, 18mo with stridor) * Temp 100.4F* HR 120* RR 40* O2 93% Critical Actions#1 (Chris, 18mo with stridor) * Check pulse oximetry (hidden)* Administer PO Steroids* Administer Racemic Epinephrine* Reassess patient after the...

Hyponatremia in the ED Four questions to ask yourself: * Is the patient symptomatic from their hyponatremia (confusion, nausea/vomiting, ams, seizures, etc)?* If not, outpatient followup (unless super low)* Is the patient having severe neurologic symptoms from their hyponatremia? (seizures, AMS)* If yes, treat with hypertonic saline (3%)* Is the patient going to be admitted from their hyponatremia...

CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you are called to the waiting room by the charge nurse for a seizing patient. Initial Vitals * Temp 99.0F* HR 97* RR 16* BP 120/80* O2 90% Critical Actions * Perform airway maneuvers to clear obstruction* Administer IV Benzodiazepines * Administer Hypertonic Saline* Diagnose Anterior Shou...

Acetaminophen Overdose & Toxicology Pearls * History: Figure out how much was taken, what time the ingestion occurred, and if any other toxins were ingested* Physical Exam: Perform a regular physical exam, and in addition, perform the toxicologic physical exam!* Check pupil size* Assess neuromuscular status for rigidity/clonus* Perform the “toxicologist handshake”* Listen to bowel sounds* Workup:*...

CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you receive a radio call from EMS who are bringing in a young female who was found unresponsive. Initial Vitals * Temp 98.0F* HR 97* RR 16* BP 120/80* O2 98% Critical Actions * Obtain collateral history from EMS/friends* Administer Naloxone as needed for respiratory depression* Obtain 0-h...

Asymptomatic Hypertension * Make SURE the patient isn’t having symptoms of end organ dysfunction, which could make this hypertensive emergency (confusion, severe headache, blurry vision, weakness, chest pain, shortness of breath, seizures during pregnancy, etc). * ACEP clinical policy states, that in the patient with true asymptomatic hypertension who presents to the emergency department, no routi...

CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you are handed the next chart, a 60 year old male presenting with high blood pressure. Initial Vitals * Temp 98.0F* HR 90* RR 18* BP 220/120* O2 98% Critical Actions * Perform thorough neurological exam (and find papilledema)* Diagnose Hypertensive Emergency* Start anti-hypertensive drip...

Neonatal Resuscitation *THIS IS A BASIC FRAMEWORK AND IS NOT COMPREHENSIVE* * EVALUATE* Is the newborn crying/breathing spontaneously? Does the newborn have good tone? Is the newborn a term infant?* If YES, hand baby to mom for direct skin-to-skin.* If NO, proceed to step 2.* INTERVENE* STIMULATE – dry vigorously* WARM – place cap on head, place in warmer* OPEN AIRWAY – sniffing position, oral/nas...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkship General when the triage nurse runs and grabs both you and your attending for a patient in triage who has active CPR in progress. Initial Vitals * Temp 98.0F* HR 0* RR 0* BP unmeasurable* O2 70% Critical Actions * Identify pregnancy by exam, POCUS, or history* Place patient in left lateral decubitus*...

Torsades de Pointes (TdP) A type of polymorphic ventricular tachycardia that is inherently unstable and often quickly degrades into ventricular fibrillation. It usually occurs in the setting of a prolonged QT interval, which can either be genetic or acquired. Treatment * Defibrillation – per ACLS, ventricular tachycardia with a pulse should receive synchronized cardioversion. But in real life, the...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkship General when EMS calls you on the radio… “Hey doc we’re bringing a young female who drowned in a pool ETA 1 minute”. Initial Vitals * Temp 95.0F* HR 55* RR 5-6* BP 110/82* O2 90% Critical Actions * Evaluate for traumatic injury (and/or place C-Collar)* Intubate the patient* Identify Long QT Syndrome...

Kawasaki Disease A small vessel vasculitis that affects children, usually

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when the next chart is handed to you – a four year old male named Tommy with chief complaint of dehydration. Initial Vitals * Temp 100.4F* HR 132* RR 22* BP 98/64* O2 98% Critical Actions * Identify key historical findings (fever >= 5 days)* Identify abnormal physical exam findings (Conjunct...

“The Brady Bunch” – Beta-Blockers, Calcium Channel Blockers, Digoxin, Clonidine Treatment of Beta Blocker OD * Activated Charcoal – Only if ingestion time was

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when you are called to the resuscitation bay to see an elderly patient with unstable vitals brought in by EMS. Initial Vitals * Temp 98.0F* HR 43* RR 18* BP 60/40* O2 98% Critical Actions * Diagnose the etiology for the bradycardia (BB overdose)* Administer Atropine* Administer Glucagon* Adm...

Four definitions you must know: * SIRS – Must have at least 2 of 4 SIRS criteria (listed below):* Fever (>38C) or Hypothermia ( 12k or 10%* Tachycardia > 90* Tachypnea > 20* SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc)* SEVERE SEPSIS – Must have Sepsis + ONE of the following criteria indicative of end organ dysfunction:* Hypotension (MA...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a 20yo female accompanied by her mother checks into the ER with chief complaint of fatigue. Initial Vitals * Temp 101.2F* HR 122* RR 22* BP 110/90* O2 98% Critical Actions * Obtain travel history in patient presenting with fever of unknown source* Perform sepsis workup and treatment in...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a sepsis alert is paged overhead for a young female  who appears diaphoretic and confused. Initial Vitals * Temp 102.7F* HR 145* RR 32* BP 141/85* O2 93% Critical Actions * Workup and treat for sepsis upfront (Cultures, Lactate, IVF, Abx)* Order TSH with Free T4* Administer non-selectiv...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise beautiful Friday afternoon when a mother brings her 16 year old son to the ED with chief complaint of allergic reaction.   Initial Vitals * Temp 98.7* HR 155* RR 28* BP 125/85* O2 99% Critical Actions * Interpret ECG * Interview patient alone (and identify trigger)* Perform vagal maneuver* A...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at Clerkship General when a 51 year old female is brought in after a syncopal episode. Initial Vitals * Temp 100.2* HR 132* RR 28* BP 105/69* O2 85% Critical Actions * Give supplemental Oxygen* Diagnose Pulmonary Embolism* Administer Heparin* Assess contraindications for tPA* Administer tPA Final Diagnosis Massive P...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise quiet night when a young male is brought into your ED in obvious respiratory distress. Initial Vitals * Temp 98.6* HR 99* RR 34* BP 105/69* O2 95% Critical Actions * Give Albuterol + Ipratropium + Steroids* Obtain Chest Xray* Give Magnesium* Place patient on BiPAP* Give IV Beta Agonist (Epin...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working at your local hospital when the next chart gets put in your rack. You groan. The chief complaint is dizziness.. Initial Vitals * Temp 98.6* HR 109* RR 20* BP 105/69* O2 100% Critical Actions * Diagnose Upper GI Bleed* Initiate IV Proton Pump Inhibitor* Obtain Type and Screen* Admit Patient to the Hospital* Identify Medicati...

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CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A young gentlemen runs out to triage yelling “I can’t breath!” and collapses to the floor in front of the nurse… Initial Vitals * Temp 98.8* HR 145* RR 45* BP 60/30* O2 85% Critical Actions * Give Supplemental Oxygen* Identify Pneumothorax Prior to Imaging* Correctly Perform Needle Thoracostomy* Correctly Perform Tube Thoracostomy Final Di...