EM Clerkship

Tip #16 Recheck the patient’s heart rate and respiratory rate (and put in your presentation that you did so) * Heart rate frequently falsely elevated when being triaged* Respiratory rate frequently falsely normal when being triaged Tip #17 Fully examine the specific complaint. Some common misses include… * Neurologic complaints (headache, paresthesias, dizziness, asymptomatic hypertension, seizure...

Tip #11 Give 4 descriptors/adjectives for each complaint * Location* Quality* Duration* Modifying Factors* Severity* Context* Timing* Associated Symptoms Tip #12 Get the ACTUAL story. Why did the patient come NOW? * Did something change or worsen?* Did family force them to come?* Do they have a family history of something similar? Tip #13 Present the pertinent RED FLAGS for each complaint (some ex...

Tip #6 Make your patient remember your name. * Introduce yourself clearly* Show the patient your badge* Use a nickname if your name is difficult for people to remember/understand* Repeat your name again and again Tip #7 Keep the patient informed about… * Diagnosis* Anticipated ED course/timeline* Delays Tip #8 Keep your patient comfortable. * Get them blankets* Show them how to use the remote/call...

Tip #1 Introduce yourself. * Attending? “Hello, my name is Zack, I’m one of the medical students” * Resident? “Hello, my name is Zack, I’m one of the medical students”* Nurse? “Hello, my name is Zack, I’m one of the medical students”* Janitor? “Hello, my name is Zack, I’m one of the medical students” Tip #2 Be humble but confident. * Humility- Students know very little about the practice of medici...

Verbalize the out loud prior to performing rapid sequence intubation. The Bougie * Ideal for situations when you’re view is suboptimal* Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique). Video Laryngoscopy (Glidescope) * Laryngoscope with a camera at the tip which displays on...

The most important thing to do when preparing for RSI is to PREOXYGENATE the patient. Step 1: Choose Your Equipment * Miller or Mac blade? * Miller blade is straight (like the ‘L’ in miller)* Frequently used in kids* Mac blade is curved (like the ‘c’ in mac)* (Generally, this is the best choice to use on your clerkship and most common in the ED)* Tube Size?* 7.5 cuffed tube for a small adult* 8.0...

How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful? Pharyngeal Airways * These tools bypass the posterior portion of the tongue to help with BVM ventilation* Nasopharyngeal Airway (NP)* Measure from earlobe to tip of nose* TEST QUESTION: Don’t use in a patient with possible skull fracture* Oropharyngeal Airway...

Most Life Threatening Fungal Infection * Mucormycosis* Black facial discharge* Cranial nerve dysfunction* Facial swelling* Eschar formation When to Suspect a Fungal Infection * Immunocompromised (HIV, Diabetes, Organ Transplants, etc)* Not getting better on typical antibiotics Other Fungal Infections * Aspergillus* Aspergilloma* Bronchopulmonary Aspergillosis* Invasive Aspergillosis* Coccidiomycos...

The Two Objectives During Every Psychiatric-Type Complaint * Medical Clearance* Psychiatric Risk Assessment Medical Clearance * Required by EMTALA to perform a “screening exam” regardless of complaint* Most psychiatric facilities have poor diagnostic/treatment capabilities for non-psychiatric conditions and will want patient to be “medically cleared”* Sometimes they will require specific tests to...

Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age! * It changes the differential diagnosis* It changes the medications you can give* It changes the tests you can order Vaginal Bleeding Pearls * Non-pregnant vaginal bleeding* Order a pelvic ultrasound (for structural causes)* Order a CBC and coagulation panel (for anemia and coagulopathy)* Pregnant vag...

Stroke * Most appropriate initial tests * Blood Glucose* Hypoglycemia is a common stroke mimic* CT Head without contrast* Rules out HEMORRHAGIC strokes Subarachnoid Hemorrhage * Classic description* “Worst headache of life”* “Sudden and maximal in onset”* “Thunderclap”* Testing* CT Head without contrast* (If negative CT) Lumbar puncture* Xanthochromia (yellowish fluid)* Treatment* Nimodipine (Give...

Pulmonary Embolism * Three types of pulmonary embolism* “Massive”* Hypotension or severe bradycardia* Treat with tPA or thrombectomy* “Submassive”* Normotensive but with Right Heart Strain* S1Q3T3 on EKG* Elevated BNP* Elevated troponin* Dilation of RV on ultrasound* Treat with heparin/lovenox and admit* “Low Risk”* Treat with anticoagulation* Outpatient vs inpatient treatment* Testing* CTA of the...

Acute Mesenteric Ischemia * History of atrial fibrillation* “Pain out of proportion to exam” Bowel Obstruction * History* Abdominal pain* Bloating/Distention* Vomiting* Decrease stool/flatus* Exam* Abdominal tenderness and distention* If guarding/rigidity/rebound tenderness (aka peritonitis)* Consider perforated bowel* Testing* Obtain CT abdomen with IV contrast* Treatment* Fluids* NPO* NG Tube Ac...

Hernia * 3 classifications for hernia* Reducible* Able to be reduced (placed back into the abdomen) at bedside* Incarcerated* Cannot be reduced but not severely tender or erythematous* Can occasionally cause bowel obstructions* Strangulated* Cannot be reduced but LOSING BLOOD SUPPLY* Extremely tender and abnormal exam* Needs emergent surgical consult Esophageal Varices * Classic presentation* Hema...

“Unstable” Arrhythmias * Arrhythmias that cause* Hypotension* Pulmonary Edema* Chest Pain* Altered Mental Status Supraventricular Tachycardia (SVT) * Stable* Vagal maneuver* Adenosine* Beta blocker or calcium channel blocker* Unstable* SYNCHRONIZED cardioversion Monomorphic Ventricular Tachycardia (VT) * Stable* Amiodarone* Procainamide* Lidocaine* Unstable* SYNCHRONIZED cardioversion* Pulseless*...

Corneal Abrasion * Stain the eye with fluorescein and use woods lamp* Look for fixed staining (“uptake”) on the cornea Acute Angle Closure Glaucoma * Symptoms* Eye Pain* Headache* Check for intraocular pressure greater than 20* Commonly precipitants* OTC cough/cold medicine (anticholinergic effect)* Dark environment (such as movie theater)* Treatment* Timolol* Pilocarpine* Acetazolamide* Apracloni...

General Bite Wound Management * Irrigate thoroughly* Update tetanus* LOW RISK bites get sutured* High risk bites to cosmetic areas (face) get sutured AND antibiotics* High risk bites to non-cosmetic areas are left open AND get antibiotics Rabies * Give vaccine if… * ANY suspicion for bat bite (bat in room, cave, etc)* Bite by wild animal that can’t be monitored* Bite by domestic animal that develo...

Febrile Seizures * Simple (All features must be present)* Age 6 months – 5 years* Febrile* Lasts less than 15 minutes* Only one seizure in 24 hour period* No focal neuro deficits on exam* Generalized seizure (must have LOC)* Treat with acetaminophen and reassurance* Complex* Does not meet ALL of the criteria for a simple febrile seizure* Consider full workup including lumbar puncture Pediatric Abd...

Penetrating Abdominal Trauma * Anything below the 4th intercostal space (nipple) is potentially an abdominal injury* Gunshot wounds to the abdomen* Needs immediate exploratory laparotomy* Stab wounds to the abdomen* Needs immediate exploratory laparotomy IF…* Hemodynamically unstable* Peritonitis on exam (rebound, rigidity, guarding)* Organs hanging out of abdomen Blunt Abdominal Trauma * If the p...

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...