EM Clerkship

tPA usage is controversial. Listen to find out why. Read more to form your own opinions. Episode Sources: After Re-Analysis, No Trials Show Efficacy of tPA in Acute Ischemic Stroke Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department Why we can’t trust clinical guidelines – BMJ Alteplase for Stroke: Money and Optim...

Initial Assessment: * Obtain Vitals and blood glucose level* Time of onset (important for tPA/TNK vs thrombectomy)* Neurologic and Cardiac Examination / NIHSS* do not delay head CT to complete NIHSS, can always finish after CT* Assess contraindications for tPA Workup: * Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck* CXR and UA (infections can cause recrudescence of prior cva)* ECG looki...

ATLS – Advanced Traumatic Life Support Primary Survey * Airway* Breathing* Circulation* Disability* Exposure Secondary Survey * Head to Toe Examination* Look for injury patterns and important injuries, such as* Battle Sign (post auricular ecchymosis)* Raccoon Eyes (infraorbital ecchymosis)* Hemotympanum* Nasal Septal Hematoma* Urethral Injuries* Circumferential Burns* Obtain a basic medical histor...

You are working a shift at ABEM General when you receive a call from EMS over the radio for a patient involved in a house fire. Initial Vitals * Temp 99.0* HR 150* RR 40* BP 90/50* O2 95% Critical Actions * Administer 8L IVF in first 8 hours* Administer supplemental oxygen for CO poisoning* Administer TDAP* Give hydroxycobalamine for cyanide toxicity* Obtain head CT to diagnose SDH Further Reading...

* 50% of cases of Pelvic Inflammatory Disease (PID) is caused by common STIs (Gonorrhea, Chlamydia ) but up to 50% is caused by native vaginal flora/other organisms* No SINGLE historic, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID* Women with PID may be asymptomatic!!* Presumptive treatment of PID should be initiated for sexually active women if the...

You are working a shift at ABEM General when three patients check in simultaneously at the start of your shift at 6AM. Initial Vitals#1 (Ms. Taylor, 65F with Back Pain) * Temp 98.8* HR 120* RR 22* BP 210/110* O2 97% Critical Actions#1 (Ms. Taylor, 65F withBack Pain) * Obtain Medication/Social Hx (Ciprofloxacin use, Cocaine use)* Diagnose Aortic Dissection (Type B)* Treat HR Appropriately (Esmolol...

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...