EM Clerkship

The pregnancy test is the most important test in females of reproductive age! Five Important Tests in 1st Trimester Vaginal Bleeding * CBC* Hemoglobin/Hematocrit* Mild anemia in pregnancy is physiologic and normal* Thrombocytopenia* Type and Screen* Required for blood transfusion* Determines if patient needs RhoGAM* Rho(D) immune globulin* Binds fetal Rh antigens from a fetus so that mother doesn’...

Common Causes of Constipation * Lifestyle* Low fiber diet* Minimal water intake* Poor exercise* Medications* Especially opiates* Endocrine/electrolytes* Hypothyroidism* Hypercalcemia* Bowel obstruction* Delayed colonoscopy* Unintentional weight loss* Previous abdominal surgeries* Rectal problems* Anal fissures* Fecal impaction* Masses How to Treat Constipation * Fiber (ex. Metamucil, Citrucel)* Ad...

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!! Signs and Symptoms * Vomiting* Abdominal pain* Polydipsia* Polyuria Step 1: Test for DIABETIC-KETO-ACIDOSIS * Diabetes* Blood sugar* Typically notably elevated (>250 mg/dL)* Can be normal in certain circumstances* Ketones* Easiest test is a urinalysis* Serum ketones also can be obtained* Acidosis* Blood gas (arteri...

Step 1: Pain Control * Local anesthesia* Most common agent is lidocaine (frequently already in laceration repair kits)* Inject through wound edges (not through epidermis)* This decreases pain* Alternative is digital/regional nerve block Step 2: Irrigation * Laceration repair is not a sterile procedure* Copious irrigation is the best method to decrease chance of wound infection* Faucet/sink vs sali...

Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!! To Close or Not To Close? * Closing a wound with sutures, etc = Healing by “primary intention”* INCREASES risk of infection but DECREASES scar* Leaving a wound open = Healing by “secondary intention”* DECREASES risk of infection but INCREASES scar Step 1: History * Does patient have comorbidi...

You must know the FOUR emergent causes of sore throat! Step 1: Apply the Centor Criteria * Determines if patients is at risk for Group A strep (“strep throat”)* 4 Criteria* Fever* No cough* Tonsiller exudates* Lymphadenopathy* Interpretation* If patient has ALL of the criteria* Treat for strep throat* If patient has NONE of the criteria* Don’t even test for strep throat* If patient has SOME of the...

Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses * Aortic Dissection and Abdominal Aortic Aneurysm (AAA)* Age >50* Hypertension* “Ripping” or “Tearing” pain* Absent pulses in lower extremities* Spinal Infections* Fever* Immunocompromized* HIV* Diabetes mellitus* Transplant patients* Spinal cord compression (especially cauda equina)* Urinary retention* Consider obtaining post-void residu...

Minor complaint. Huge SLOE points! Step 1: Identify Which Tooth is Causing Pain * Bonus points if you number teeth correctly!* Number 1-32* Tooth #1 is top right* Tooth #32 is bottom right* Refer to dental chart for reference Step 2: Correct Terminology When Making Diagnosis * Pulpitis* Pain in the tooth itself* Reversible* Triggered by hot/cold etc (then goes away)* Irreversible* Does not resolve...

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:...

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 I...

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...

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...

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 up...

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 thora...

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 ult...

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/He...

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-S...

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* “Blow...

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 thi...

Get your attending! Step 1: Obtain Last Known Well * Stroke treatments including tPA and thrombectomy both require last known well*

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* I...

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 –...

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...

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

3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE. Step 1: Is This a BRUE? * Brief* 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* F...