EM Clerkship

General Approach to a Test Question * Read the last sentence of the question* Read the answer choices* THEN read the vignette Common Scenarios with Quick Answers * Hypotensive patients* Give a fluid bolus* Altered mental status* Check a blood glucose* Hypoglycemia* Orange juice if can swallow safely* D50 if patient cannot swallow and mildly altered* IM glucagon if unresponsive* Patient with altere...

Why is this Important? * It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal. * Hospitals need to steward their resources to distribute equitable care between its patients When is it Appropriate to Stop CPR on a Pulseless Patient? * Patient shows signs of irreversible death* Rigor mortis* Decapitation* Rotting/decaying* Patient has dismal prognosi...

Kidney Stones are a Diagnosis of Exclusion!!! History * Risk factors* Age >60* Tobacco use* Classic presentations* Stable with sudden flank/back/abdominal pain or syncope* Unstable with pallor, hypotension, and ill appearance Exam * Pulsatile abdominal mass* Unstable vitals Testing Plan * Labs* TYPE AND SCREEN* CBC* Electrolytes* Coagulation studies* Lactic acid* Imaging* Bedside ultrasound (optim...

Kidney Stones are a Diagnosis of Exclusion!!! Introduction * Testicular torsion is a time sensitive diagnosis (risk of infertility, etc)* Commonly mimics kidney stones History * Sudden onset pain* Epididymitis tends to be slower in onset* Flank/lower abdomen/scrotal pain* Frequently causes vomiting* Uncommon in geriatric patients Exam * Perform a GU exam and look for* Unequal/horizontal “lie”* Tes...

Kidney Stones are a Diagnosis of Exclusion!!! Step 1: Consider the Differential Diagnosis for Flank Pain * Appendicitis* Abdominal Aortic Aneurysm* Ectopic Pregnancy* Testicular/Ovarian Torsion* Kidney Stone Step 2: Diagnose the Kidney Stone * Option 1- Renal Ultrasound* Findings consistent with kidney stone diagnosis* Hydronephrosis* Lack of ureteral jets (in bladder)* Kidney stones (poor sensiti...

Step 1: Start Patient on Volume Assist-Control Ventilation * The most basic mode of ventilation* Provides a FIXED VOLUME at a FIXED RATE* If the patient over-breaths…* The ventilator will give another FULL breath* Can cause breath stacking and be uncomfortable in patients who are poorly sedated* This is not a problem in the ED because patients are typically deeply sedated Step 2: Know your oxygena...

Introduction * What is rabies?* A very rare and aggressive encephalitis* Global impact with exception of UK/Australia* Animals whose bites/scratches may require prophylaxis* Bats* Dogs, Cats, Ferrits* Other carnivorous animals* Foxes, Coyotes, Skunks, Raccoons* Post exposure prophylaxis* Both Rabies vaccine and immunoglobulin When Do You Give Rabies Prophylaxis? * Step 1: Bitten or scratched by do...

The only chief complaint that you are guaranteed to eventually have to manage in a colleague Respiratory Exposures * Meningococcus​ (meningococcemia, meningitis, etc)* Give prophylaxis (ceftriaxone) if…* Intubated a pt without a mask* Suctioned a pt without a mask* Performed mouth to mouth resuscitation* Tuberculosis​ * CDC recommends testing if exposed* Treat if positive* CDC recommends prophylax...

All breast complaints are cancer until proven otherwise!!! History * Increased risk of breast cancer* Family history of breast cancer (especially 1st degree)* Delayed childbearing (no children until after 30)* Age >50* Associated with menstrual cycle Exam * Asymmetric appearance of breasts* Palpable mass* Red Flags* Non-mobile* Overlying skin changes* Lymphadenopathy* Located in upper/outer quadra...

The 3 Worst Causes of Neonatal Conjunctivitis * Gonorrhea* Causes corneal ulcers and sepsis* Red flags* 1st week of life* Copious purulent drainage* Diagnose with cultures* Treatment* Cefotaxime (3rd generation cephalosporin)* Admit* Chlamydia* Occurs in 1st month of life* Treat with PO erythromycin* HSV* Can disseminate to the brain* Red flags* Mother tested positive (or had active lesions)* Vesi...

History * Sudden and maximal in onset* Compared to previous headaches* Family history of aneurysm* Associated Symptoms* Photophobia* Visual Changes* Neck Stiffness Exam * Full neuro examination* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Gait Testing Plan * Non-contrast head CT* Excellent sensitivity 100 RBCs in tube 4* Can be difficult to interpret after a...

The 4 Most Common Causes of Blood in Diaper * Urinary crystals* Will be guaiac negative* Common in first few weeks of life* Vaginal bleeding* Common in newborn females as they withdraw from maternal estrogen* Maternal blood* Swallowed during birthing process* Breastfeeding with cracked/bleeding nipples* Anal fissures* Common and will improve on its own Basic Approach * Step 1: Check if guaiac posi...

Consider In High Risk Patients * Alcoholics* GI disorders* Eating disorders* Starvation/poor diet* Extremes of age Thiamine (B1) deficiency * Causes damage to neurons and cardiac myocytes* Manifestations* Dry beriberi* Neuropathy* Paresthesias* Wernicke’s encephalopathy* Ophthalmoplegia* Ataxia* Altered mental status* Korsakoff syndrome* Ophthalmoplegia, ataxia, altered mental status* PLUS* Confab...

Mnemonic: DARTH VADER Death Arrhythmia * ACS patients need to be placed on cardiac monitor* Frequently degenerate into non-perfusing rhythms Rupture of Ventricle * Occur within a few days of myocardial infarction* Rapid decompensation* Bedside ultrasound will show pericardial effusion and tamponade Tamponade * Multiple etiologies* Rupture of ventricle (see above)* Pericarditis* Becks Triad* Jugula...

My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated. Introduction * tPA is one of the core treatments for a...

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information. Introduction * Sepsis is bad and needs to be treated aggressively* Confusion around multiple conflicting guidelines and requirements* Surviving Sepsis Campaign recommendations* CMS requirements* Sepsis-3* SOFA/SIRS/qSOFA* Institutional protocols Sepsis-3...

Physiology * RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin* Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin* Conjugated (direct) bilirubin -> Eliminated in stool Causes of Hyperbilirubinemia * Increased RBC turnover* Sepsis* Rh incompatibility* RBC disorders* Maternal diabetes* Scalp hematoma* Decreased/slow conjugation by the liver* Peaks around day 5 o...

Clinical Presentation * Incidental finding on routing CBC* Petechiae/purpura* Mucosal bleeding* Epistaxis* Gingival bleeding* Hematuria* Vaginal bleeding 5 Major Causes of Thrombocytopenia * Thrombotic Thrombocytopenic Purpura (TTP)* Clinical presentation (pentad)* Thrombocytopenia* Fever* Microangiopathic hemolytic anemia* “schistocytes”* Neurologic abnormalities* Renal dysfunction* Physiology* L...

The hardest part about this chief complaint is expanding your differential beyond gastritis!!! Step 1: Expand Your Differential Diagnosis * Early appendicitis* Bowel obstructions* Myocardial infarction* Elevated ICP* Diabetic Ketoacidosis Step 2: Give a Testing Plan * High yield tests to consider* EKG – older adults* Pregnancy test – women of child bearing age* Electrolytes – most patients* Other...

Organ Failure Complications * Hepatorenal syndrome (renal failure)* Decreased urine output* Labs show elevated creatinine* Admit to hospital (high mortality)* Hepatic encephalopathy (brain failure)* Introduction* Liver clears ammonia from body* In advanced liver failure, ammonia increases* Symptoms* Altered mental status/confusion* Asterixis* Treatment* Lactulose* Binds ammonia and is excreted* Ri...

Non-Accidental Trauma * Estimated 10% of pediatric patients are victims of abuse* Sexual abuse* Physical abuse* Neglect* Common red flags* Changing story* Story that doesn’t make since* Delays in seeking care* Unusual bruising locations* Torso* Ears* Neck* Common tests if non-accidental trauma suspected* Skeletal survey x-rays* Head CT* Especially if altered mental status* Abdominal CT* Especially...

Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!! Inborn Errors of Metabolism (IEM) * Almost always result in one of the following three clinical abnormalities* Buildup of toxins* Ammonia* To test for this, obtain an ammonia level* Buildup of acids* Methylmalonic acidemia* To test for this, obtain electrolyte panel and look for de...

Common Chief Complaints * Cyanosis* Difficulty feeding* Failure to thrive Cyanotic Heart Lesions * Truncus arteriosus* Aorta and pulmonary artery are fused* Single vessel comes from both ventricles* Transposition of great vessels* Aorta comes off RIGHT ventricle* Pulmonary artery comes off LEFT ventricle* Tricuspid atresia* Blood unable to get from right atrium to right ventricle* Tetrology of fal...

Pediatric “Sepsis” * Consider in any toxic appearing child/neonate* Especially with fever (or hypothermia)* Treatment* Early antibiotics* Fluid bolus “Serious Bacterial Infections” (SBI) * Consider in any baby with fever* Three classic categories* Age

Introduction * In pediatric patients, have a low threshold to check blood sugar* Undiagnosed diabetics commonly identified in ED during first episode of DKA* HYPOglycemia is very common in multiple conditions, especially in ill children Hyperglycemia * DKA is different in kids* They get cerebral edema* Increased intracranial pressure with rapid fluid administration* Common symptoms* Headache* Alte...