The EM Clerkship Podcast

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Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated.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 […]

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 Propose...

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 of...

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 Low ADAMTS13 results...

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 […]

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 Rifaximin Eliminat...

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 […]

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 […]

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 <30 days Introduction Weak immune system No immunizations Very high risk for serious bacterial infections Require a significant amount of testing Urinalysi...

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 Altered […]

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 […]

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 Sepsis and Seri...

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 water retention Tr...

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 […]

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 Cyanosis Mottling...

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 […]

If a returning traveler has a fever, think malaria malaria malaria!!! Step 1: Ask your patient if they have traveled within the last year If yes… You should at least CONSIDER malaria Step 2: If patient says yes, take a travel history When did they go Where did they stay Where they exposed to anything […]

If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!! 3 Big (Non-Viral) Causes of Diarrhea The Icky ‘I’s Ischemia Frequently require surgery consult Infection Frequently require antibiotics Inflammatory bowel disease Frequently require GI consult, steroids, or salicylates 5 Red Flags Is it bloody? Consider […]

Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!! Three Stages of Appendicitis Stage 1: ~12 hours of “gastroenteritis” like symptoms Stage 2: Direct somatic irritation This is when pain over McBurney’s develops! Stage 3: Perforation Patient is now sick and septic Approach to Appendicitis Step 1: Consider getting labs […]

Common Complaints Red Eye Decreased Vision Trauma to the Eye Approach to a Vision Complaint Step 1: Assess visual acuity Visual acuity is the “vital sign of the eye” Snellen eye chart is best If patient unable to see chart… Count fingers? Able to see light? Step 2: Examine the conjunctiva/cornea with fluorescein How to […]

Differential Diagnosis Mnemonic: HE DIES Hypothyroidism Elevated intracranial pressure (ICP) Cushings reflex Bradycardia Increased blood pressure Irregular breathing Drugs Beta blockers Calcium channel blockers Digoxin Ischemia Electrolytes Especially potassium!!! Sick Sinus Syndrome Approach to Bradycardia Step 1: Get an EKG Ischemia? Heart block? 1st degree = PR interval >200ms (5 small boxes...

Airway and Epi! Airway and Epi! Airway and Epi! Introduction Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen” The antigen causes extensive mast cell and basophil cross-linking/activation Common antigens Foods Drugs Insect venoms Basic Approach Step 1: Diagnose anaphylaxis Consider anaphylaxis if the patient has TWO body systems involved Dermatologic […...

Basic Approach Step 1: Is this SINUS tachycardia? P before every QRS? Treat the underlying condition Step 2: Is this a NARROW and REGULAR rhythm? SVT Treat with vagal maneuvers or adenosine Another new trend is treating with calcium channel blockers!! ORTHOdromic Wolf Parkinson White Treat with adenosine Atrial flutter with fixed block Treat with […]

Introduction Simple seizure Seizure ends in <5 minutes AND Patient wakes up before next seizure No meds required Status epilepticus Seizure lasts >5 minutes OR Patient has a 2nd seizure before waking up from 1st Initiate status epilepticus pathway Approach to Status Epilepticus Step 1: Give a benzodiazepine Lorazepam (IV) Diazepam (IV or PR) Midazolam […]