
CAUTION: THESE NOTES CONTAIN SPOILERS!!!



Case Introduction



You are called to the resuscitation bay for a poorly responsive patient that has been brought in by EMS. 



Initial Vitals



* Temp 98.8* HR 78* RR 4* BP 124/78* O2 98%



Critical Actions



* Obtain Early Blood Glucose* Administer Dextrose* Obtain Salicylate and Acetaminophen Levels* Admit for Further Observation* Psychiatry Consult



Final Diagnosis



Intentional Sulfonylurea Overdose



Tips and Tricks



All unresponsive patients should receive a blood glucose level early in the case



Additional Reading



* Sulfonylurea Toxicity Overview (LITFL)* Approach to Altered Mental Status (EM Clerkship)

Round 1 (Altered Mental Status)

The purpose of this podcast is to help medical students crush their emergency medicine clerkship and get top 1/3 on their SLOE. The content is organized in an approach to format and covers different chief complaints, critical diagnoses, and skills important for your clerkship.

Education

Training

Language Courses

Higher Education

K-12

Educational Technology

Medicine

Science & Medicine

Health & Fitness

Courses


You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen. 



Initial Vitals:



HR: 101



BP: 138/85



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Diagnose Retrobulbar Hematoma



* Diagnose Subdural Hematoma



* Reverse Anticoagulation



* Perform a Lateral Canthotomy Procedure



* Administer Tetanus Shot



* Elevate the Head of Bed


Round 21 (MW) Geriatric Fall


Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.   



The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags.  



Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’s paralysis.  



Management/treatment – thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (<185/110 if treating, <220/120 if no treatment).  



Remember that time is brain, so move fast! 



  AAEM tPA Infographic



AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

Ischemic Stroke (Deep Dive MW R20)


You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.” 



Initial Vitals:



HR: 51



BP: 201/98



Temp: 98.0F



RR: 18



O2: 99% (Room Air)



Critical Actions:




* Check a Blood Glucose



* Activate a Stroke Alert



* Assess Contraindications to tPA



* Consent for tPA



* Transfer via Air for Thrombectomy


Round 20 (MW) Stroke Symptoms



* Common during the first year of life as well as during puberty



* Presents with nausea/vomiting, abdominal pain, and/or testicular pain



* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)



* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex   



* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound



* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US



* Attempt manual detorsion if there will be a significant delay to surgery


Testicular Torsion (Deep Dive MW R19)


You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting



Initial Vitals:



HR: 119



BP: 104/63



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Finger Stick Blood Glucose



* Treat Patient’s Pain



* Diagnose Testicular Torsion



* Immediate Urology Consult



* Perform Manual Detorsion




References:



Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

Round 1 (Altered Mental Status)

Download our free app to listen on your phone