EM Clerkship

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You are working at Clerkship General when you hear a woman screaming from triage… It’s baby time! Initial Vitals: HR: 120 RR: Shallow O2: 58% Critical Actions: * Place neonate in warmer * Administer positive pressure ventilation * Obtain pre-ductal pulse ox * Check blood glucose * Place umbilical vein catheter * Administer dextrose

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You are working at Clerkship General when the nurse comes up to you and says, “Hey doc, EMS dropped off this guy named Randy from the memory care unit at the nursing home down the street. He’s in the hall bed outside of room 7. EMS says he’s here for confusion, we will get him in a room once we can get one clean. Initial Vitals: HR: 118 BP: 109/55 Temp: 102.5 F RR: 22 O2: 99% Room Air Critical Act...

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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 a 3 year old female with complaints of altered mental status. We are pulling in now.” Initial Vitals: HR: 129 BP: 98/66 Temp: 99.7F RR: 35 O2: 99% Room Air Critical Actions: * Check blood glucose * Check ingestion labs * Start bicarbonate drip * Call nephrology * Check venous blood...

Guillain-Barre Syndrome (GBS) – Autoimmune polyneuropathy that results in widespread demylination of peripheral nerves Typically occur 1 week after a triggering infection Paresthesias/Neuropathic Pain -> Ascending symmetric paralysis -> Respiratory Failure Major Diagnostic Criteria * Progressive limb weakness in multiple limbs that is relatively symmetric * Diminished/Absent deep tendon reflexes i...

Critical Actions: * Treat the Patient’s Pain * Perform a detailed neurologic exam (including reflexes) * Perform LP * Administer IVIG * Check NIF or FVC and intubate prior to transfer

Orbital Compartment Syndrome – needs to be diagnosed CLINICALLY On exam, LOOK for: Proptosis, Ophthalmoplegia, Afferent Pupillary Defect, Vision Loss On exam, FEEL for: Rock hard globe, tense eyelids, resistance to retropulsion IOP > 40 means immediate canthotomy is indicated! Don’t perform if open globe is present Lateral Canthotomy Procedure: Anesthetize, Devascularize, Canthotomy, Cantholysis (...

You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen. Initial Vitals: HR: 101 BP: 138/85 Temp: 98.0F RR: 20 O2: 99% (Room Air) Critical Actions: * Diagnose Retrobulbar Hematoma * Diagnose Subdural Hematoma * Reverse Anticoagulation * Perform a Lateral Canthotomy Procedure * Administer Tetanus Shot * Elevate the Head of Bed

Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.   The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags.  Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’...

You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.” Initial Vitals: HR: 51 BP: 201/98 Temp: 98.0F RR: 18 O2: 99% (Room Air) Critical Actions: * Check a Blood Glucose * Activate a Stroke Alert * Assess Contraindications to tPA * Consent for tPA * Transfer via Air for Thrombectomy

* Common during the first year of life as well as during puberty * Presents with nausea/vomiting, abdominal pain, and/or testicular pain * ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain) * Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex * Consult Urolog...

You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting Initial Vitals: HR: 119 BP: 104/63 Temp: 98.0F RR: 20 O2: 99% (Room Air) Critical Actions: * Finger Stick Blood Glucose * Treat Patient’s Pain * Diagnose Testicular Torsion * Immediate Urology Consult * Perform Manual Detorsion References: Mellick LB, Sinex JE, Gibson RW, Mears...

Phase One: CNS * Ataxia, Slurred Speech, Confusion, N/V, Seizures Phase Two: Cardiopulmonary * CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS Phase Three: Renal * Flank pain, Hematuria, Oliguria, Renal Failure Diagnosis: * HIGH INDEX OF SUSPICION * Ethylene Glycol Serum Level * Elevated Osmolar Gap * Serial Anion Gap Measurements Treatment: * Fomepizole or Ethanol to prevent breakdown t...

You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again Initial Vitals: HR: 116 BP: 150/70 Temp: 98.8 RR: 26 O2: 85% (Room Air) Critical Actions: * Recognize Hypoxemia * Diagnose Toxic Alcohol Ingestion * Consult Nephrology Emergent Dialysis * Administer Fomepizole * Workup Anion Gap Metabolic Acidosis

Hypertensive Emergencies of Pregnancy PreEclampsia, Eclampsia, HELLP syndrome Diagnosis: BP >140/90 plus end organ dysfunction * Acute Kidney Injury * Proteinuria * Thrombocytopenia * Transaminitis * Hemolysis * Pulmonary Edema * Cerebral Edema / Hemorrhage * Headache refractory to tylenol * Visual Changes * RUQ Pain not attributable to another diagnosis Treatment * Loading Dose: IV Magnesium 4-6g...

You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache. Initial Vitals: HR: 56 BP: 172/93 Temp: 98.8F RR: 18 O2: 97% Critical Actions: * Check a Blood Glucose * Diagnose Preecclampsia/Ecclampsia * Administer Magnesium * Treat the Hypertension * Discuss with OBGYN and Admit

Diagnosing PE: Step 1: Consciously consider the diagnosis Step 2: Risk Stratify into low, intermediate, and high risk Step 3: Choose appropriate testing based on pre-test probability Classification of PE * High Risk/Massive PE: Hemodynamic Instability * Intermediate Risk/Submassive PE: Right Heart Strain without instability ; or PESI Class 3+ * Low Risk/Non-Massive PE: Everything else (no instabil...

You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.” Initial Vitals: HR: 122 BP: 75/40 Temp: 100.1 RR: 24 O2: 74% Critical Actions: * Obtain full set of vital signs * Treat the patient’s pain * Diagnose...

Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion * Hypovolemic Shock * Hemorrhage * Volume Loss (vomiting/diarrhea, dehydration) * Cardiogenic Shock * ACS, Myocarditis, CHF, Valve failure, Endocarditis, etc * Obstructive Shock * Massive PE, Tension Pneumothorax, Cardiac Tamponade * Distributive Shock * SIRS (Septic Shock, Pancreatitis, Severe Burns) * Anap...

You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision” Initial Vitals: HR: 65 BP: 88/50 Temp: 97.0F RR: 20 O2: 96% Room Air Critical Actions: * Apply Cervical Collar * Treat the Patient’s Pain * Give Antibiotics for Open Fracture * Identify...

* Differential * Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter * Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors * Work-up * XRay * Labs to evaluate for septic arthritis – CBC BMP ESR CRP * Kocher Criteria * Non-weight bearing * Fever >38.5C * ESR >40 * W...

You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury. Initial Vitals: HR: 112 BP: 97/67 Temp: 99.2F RR: 20 O2: 97% Room Air Critical Actions: * Consider Non-Accidental Trauma * Evaluate for Septic Arthritis * Treat the Childs Pain * Diagnose Lyme Disease * Prescribe Antibiotics (Avoid Doxycycline)

* Focused Physical Exam * Tachypnea and Hypoxemia * Able to speak in complete sentences * Accessory muscle use/retractions * Moving air or quiet on auscultation * Basic Treatment Algorithm * Albuterol Inhaler * Albuterol/Ipratropium Nebulized (Duoneb) * Steroids * IV Magnesium * Non Invasive Ventilation (CPAP or BiPAP) * Decreases Work of Breathing * Epinepherine * Less Common Treatments * Benzodi...