EM Clerkship

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...

Applying oxygen is one of the first steps in treating any crashing child!!! Airway Emergencies * Foreign body (FB)* Patient presentation* Stridor* Choking episode* Testing* CXR* May directly show foreign body* May show secondary effects of a foreign body* Hyperinflated/collapsed lobes of the lung* Patient needs bronchoscopy if suspicion is high* Peritonsillar abscess* Visible in the pharynx* Bacte...

When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!! Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies * Foreign body* Peritonsillar abscess* Bacterial tracheitis* Epiglottitis* Retropharyngeal Abscess* Bronchiolitis* Asthma* Croup* Pneumonia* Cystic Fibrosis Hyper/Hypoglycemia- Check Blood Glucose * Hypoglycemia* DKA Sepsis- Consider S...

These are most important in trauma patients!!! Platelet Disorders * Symptoms of SUPERFICIAL bleeding* Mucosal bleeding* GI bleeding* Recurrent epistaxis* Thrombocytopenia* When the platelets ARE LOW* Refer to THIS episode* Von-Willebrand disease* When the platelets CAN’T BIND* Treatment * Desmopressin (DDAVP)* Causes increase in amount of von-willebrand factor (vWF) available* Also causes free wat...

Always remember…1, 2, 3, get an old EKG!!! Step 1: Identify the Rate and Rhythm * Is it sinus rhythm?* P wave before every QRS* Is it one of the tachycardias? (Refer to THIS episode)* Is it one of the bradycardias? (Refer to THIS episode) Step 2: Look for Signs of Ischemia * Most consistent way is to examine by anatomic region of the heart* II, III, and aVF are “inferior” leads* I, aVL, V5, V6 are...

Mnemonic: ABCDEF Appearance * The ‘A’ in the pediatric assessment triangle* Interactive vs distant* Good tone vs floppy* Calm and happy vs inconsolable Breathing * The ‘B’ in the pediatric assessment triangle* Signs of respiratory distress* Nasal flaring* Retractions* Abnormal respiratory sounds Color/Circulation * The ‘C’ in the pediatric assessment triangle* Pink = good* Abnormalities* Pallor* C...

Always ask about pediatric patient’s ‘P-I-S-S’ status!!! Core Function Questions (P-I-S-S Status) * Peeing* Evaluates for dehydration* Number of wet diapers per day?* Same number as usual?* Intake* Rule of 3s* Estimates how much milk/formula an average infant should be taking* 3oz of milk or formula every 3 hours* Sleeping* Is the patient sleeping MORE than usual?* LESS than usual?* Stooling* Norm...