EM Clerkship

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 concerning* Mosquitos* Animals* Weird foods* Sexual partners* Sick people* Where they in dev...

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 performing...

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* Alway...

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 apply fluorescein* Recline patient 45 degrees* Pull down on lower...

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 >20...

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* Derm...

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 AV blockers (diltiazem)* Slows the h...

Introduction * Simple seizure* Seizure ends in 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 (IV or IM)* Step 2: Give an anti epileptic* Levetiracetam (Keppra)* Fosphenytoin* Valproic Acid* Step 3: Continue attempting agents for 30...

Basic Approach * Step 1: Describe the seizure* Did patient have an aura? * Was there loss of consciousness?* What did the movements look like?* Did they have postictal phase? * Did they have a trauma as well?* Step 2: Ask about TIME (mnemonic)* Tongue biting* Usually occurs on the lateral sides of tongue* Incontinence* Medication changes/adjustments* Ethanol use* Step 3: Do a FULL neurologic exami...

Hard, fast, unrelenting chest compressions are the core of ACLS!!! Step 1: Check the Patient’s Pulse * If the patient does not have a pulse, start CPR* Hard, fast, unrelenting compressions* Intubated patients* Continuous Compressions* Non-intubated adults* 30 compressions then 2 breaths… Repeat* Non-intubated pediatrics* 15 compressions then 2 breaths… Repeat Step 2: Determine if the Rhythm is Sho...

There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain. Cholelithiasis and Biliary Colic * Cholelithiasis = Gallstones in the gallbladder* Frequently seen on CT scan or RUQ ultrasound* Present in 15% of the population* Biliary colic = Intermittent episodes of pain if stone passes* Classically colicky/crampy/spasmy pain in RUQ* Frequently radiates to right s...

Evaluate 5 important structures when evaluating gunshot wounds in an extremity. Blood Vessel Injuries * 3 Categories* Hard-Signers* Mnemonic: HARD Bruit* Hypotension* Arterial/pulsatile bleeding* Rapidly expanding hematoma* Deficits (pulse)* Audible BRUIT/thrill* These patients likely need OR* Soft-Signers* Significant vascular oozing/bleeding* Large hematoma* These patients need to be screened wi...

5 core treatments and 5 MORE treatments 5 Core Treatments * Albuterol* Beta agonist* Bronchodilator* Core treatment for asthma* Ipratropium* Anti-muscarinic* Relax muscles around the airways* Works synergistically with albuterol* Steroids* Decrease inflammation in the airways* Prednisone (PO)* Methylprednisone (IV)* BiPAP (COPD)* Decreases work of breathing* Decreases rates of intubation* Decrease...

Basic Categories * Upper GI Bleed* Symptoms* Coffee ground emesis* Melena* Black tarry stool* Digested blood* Common causes* Peptic ulcer disease* Varices* Lower GI Bleed* Symptoms* Bright red blood per rectum (BRBPR)* Maroon/bloody stools* Common causes* Diverticulosis* Colon cancer* Angiodysplasia* AV Malformations History * Ask about risk factors for upper GI bleed* Peptic ulcer risk factors* N...

Introduction Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries Can cause pulmonary infarction (which mimics pneumonia on chest x-ray) Basic Approach to the Diagnosis of PE * Step 1: Consider PE in any patient with signs or symptoms consistent with the disease* Common signs/symptoms* Shortness of...

There are 3 main “categories” of hemoptysis… Mild, “Streaky” Hemoptysis * Most common diagnosis* Bronchitis* Testing plan* Chest xray* Rules out alternative causes of hemoptysis* Pneumonia* Cancer* Pulmonary Embolism* Vasculitis Scary but Stable Hemoptysis * Patient is coughing up frank blood* Testing plan* CTA of the chest* CBC* PTT/PT/INR* Electrolytes* Need renal function if giving IV contrast...

Salicylate toxicity is the great toxicologic mimicker!!! Step 1: When to Suspect Salicylate Overdose * Signs of CNS stimulation* Tachypnea* Hyperthermia* Altered mental status* Signs of GI irritation* Nausea/Vomiting* Abdominal pain* Common “mimicker”* Sepsis* Acute abdomen Step 2: Testing Plan * Electrolyte panel* Anion gap metabolic acidosis* Sodium – Chloride – Bicarb* Normal anion gap (AG) is

Acetaminophen is the most important overdose in toxicology Step 1: Check a Serum Acetaminophen Level * Common situations where testing is ordered* Suicidal ideation* Severe depression* Overdose Step 2: Consult the Rumack-Matthew nomogram * Only works for acute/single ingestions of acetaminophen* Loses reliability if patient is on drugs that affect bowel motility* If the time of ingestion is KNOWN*...

Common Causes * Structural* Cancer* Post-menopausal bleeding is cancer until proven otherwise* Fibroids* Adenomyosis* Polyps* Coagulopathy* Present in approximately 20% of non-pregnant vaginal bleeding* Most common = Von Willebrand Disease* Hormonal causes* Dysfunctional uterine bleeding Basic Approach to Non-Pregnant Vaginal Bleeding * Step 1: Pelvic exam* The utility of this is debated* It is be...

The pregnancy test is the most important test in females of reproductive age! Five Important Tests in 1st Trimester Vaginal Bleeding * CBC* Hemoglobin/Hematocrit* Mild anemia in pregnancy is physiologic and normal* Thrombocytopenia* Type and Screen* Required for blood transfusion* Determines if patient needs RhoGAM* Rho(D) immune globulin* Binds fetal Rh antigens from a fetus so that mother doesn’...

Common Causes of Constipation * Lifestyle* Low fiber diet* Minimal water intake* Poor exercise* Medications* Especially opiates* Endocrine/electrolytes* Hypothyroidism* Hypercalcemia* Bowel obstruction* Delayed colonoscopy* Unintentional weight loss* Previous abdominal surgeries* Rectal problems* Anal fissures* Fecal impaction* Masses How to Treat Constipation * Fiber (ex. Metamucil, Citrucel)* Ad...

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!! Signs and Symptoms * Vomiting* Abdominal pain* Polydipsia* Polyuria Step 1: Test for DIABETIC-KETO-ACIDOSIS * Diabetes* Blood sugar* Typically notably elevated (>250 mg/dL)* Can be normal in certain circumstances* Ketones* Easiest test is a urinalysis* Serum ketones also can be obtained* Acidosis* Blood gas (arteri...

Step 1: Pain Control * Local anesthesia* Most common agent is lidocaine (frequently already in laceration repair kits)* Inject through wound edges (not through epidermis)* This decreases pain* Alternative is digital/regional nerve block Step 2: Irrigation * Laceration repair is not a sterile procedure* Copious irrigation is the best method to decrease chance of wound infection* Faucet/sink vs sali...

Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!! To Close or Not To Close? * Closing a wound with sutures, etc = Healing by “primary intention”* INCREASES risk of infection but DECREASES scar* Leaving a wound open = Healing by “secondary intention”* DECREASES risk of infection but INCREASES scar Step 1: History * Does patient have comorbidi...

You must know the FOUR emergent causes of sore throat! Step 1: Apply the Centor Criteria * Determines if patients is at risk for Group A strep (“strep throat”)* 4 Criteria* Fever* No cough* Tonsiller exudates* Lymphadenopathy* Interpretation* If patient has ALL of the criteria* Treat for strep throat* If patient has NONE of the criteria* Don’t even test for strep throat* If patient has SOME of the...