EM Clerkship

You are working at Clerkship General when you are called to see a 70 yo male who is presenting with shortness of breath.

Initial Vitals

* Temp 98.0* HR 36* RR 28* BP 80/35* O2 82%

Critical Actions

* Interpret ECG Correctly (3rd degree AV block)* Order a troponin* Perform and Describe transcutaneous pacing* Perform and Describe transvenous pacing* Treat NStemi (ASA, Heparin gtt, nitro if BP improved after pacing)

Further Reading

Complete Heart Block – EMDocs

Bradycardia – EMCrit

DOPES

D-Displacement – endotracheal tube dislodges from trachea, or falls into right mainstem bronchus

O-Obstruction – Mucous plugging, bronchospasm, patient biting tube

P –Pneumothorax – Look out for pneumothorax, it can be subtle

E – Equipment – Disconnected/unpowered equipment, ensure everything is powered on and connected appropriately

S – Stacking – common in asthma/COPD due to inadequate expiration resulting in air trapping between breaths

Further Reading

LITFL – Post-Intubation Hypoxia

CanadiEM – Approach to the Alarming Vent

Brainstorming ideas – how to make it personal

* What makes me unique?

2. What are some specific experiences I’ve had in my life that have either made me want to do EM or given me the skills that will prepare me well for training in EM?

3. If a family member or a friend were to describe me to a stranger, what would they talk about first?

Brainstorming ideas – how to make a statement

* What do I bring to the table?

2. What am I looking for in a training program?

3. Where do I see myself in 5-10 years?

Further Reading:

Personal Statement Library

Welcome to EM Clerkship Maddie Watts!

The personal statement should be *personal* and should *make a statement*.

* Start early* Use solid organizational structure* Address the big three questions – who? what? why?* Check for grammar mistakes* Explain any red flags

Further Reading:

EMRA / CORD Advising Guide

NRMP Program Director Survey

ALiEM Match Advice Series

You are working at Clerkship General when you are called to the resuscitation bay for a 55yo M presenting in respiratory distress.

Initial Vitals

* Temp 99.9* HR 110* RR 22* BP 122/82* O2 82% on BiPAP 10/5 100%FiO2

Critical Actions

* Correctly interpret CXR #1 (multifocal PNA)* Correctly interpret CXR #2 (bilateral PNTX)* Treat with Oseltamivir* Troubleshoot vent alarm#1 (increase sedation)* Troubleshoot vent alarm#2 (place bilateral chest tubes)

Further Reading:

Acute Exacerbation of COPD – EMCrit

COPD – EM@3AM

Cardiac Glycoside containing plants : Foxglove, Lilly of the Valley, Oleander, Squill

* Contain cardiac glycosides, which act as a negative chronotrope as well as a positive inotrope.* Patients present with nausea, vomiting, visual changes, bradycardia/arrhythmia, and may develop hyperkalemia – a poor prognostic factor* Treatment is Digibind/DigiFAB – look out for the side effects of hypokalemia as well as anaphylaxis.

Anticholinergic Alkaloid containing plants: Jimson Weed, Angels Trumpet, Deadly Nightshade

* Contain alkaloids that act as anticholinergics ; often used recreationally* Patients present with delirium/hallucinations, pupillary dilation, anhydrosis, hyperthermia, skin flushing, urinary retention* Treatment is support care, with physostigmine for severe cases – remember to go low and slow!

Toxic Mushrooms

* Important to distinguish between acute onset symptoms (<6hours) or delayed onset (6-24 hours)* Inocybe : acute onset ; cholinergic crisis; treat with atropine* Amanita Muscarina: acute onset; CNS toxicity – delrium, myoclonus, seizures ; supportive care and benzos as needed* Amanita Phalloides: delayed onset ; treat with NAC and maybe Silibinin* Phase 1: 6-24 hrs after ingestion, nausea vomiting diarrhea* Phase 2: transient recovery, 24-60 hours after ingestion* Phase 3: Hepatic / multisystem organ failure* Gyromitra: delayed onset; causes acute B6 deficiency leading to refractory seizures, treat with pyridoxine (vitamin B6) as well as usual seizure care.

Further Reading:

Stone Heart Syndrome – LITFL

Gyromitra – Indiana Poison Center

Anticholinergic Intoxication – EMCrit

You are working at Clerkship General when you see your next patient : a 3 year old male accompanied by his father with chief complaint of vomiting. 

Initial Vitals

* Temp 98.6* HR 50* RR 20* BP 95/55* O2 100%

Critical Actions

* Identify the history of ingestion* Check a blood glucose* Call Poison Control* Treat with DigiBind* Treat subsequent anaphylaxis

Further Reading:

EMCrit – Digoxin Toxicity

The Tox and the Hound – Digoxin: to bind or not to bind

* Opioid overdose is the number one leading cause of death in adults under the age of 50. * Many ED Physicians fail to recognize that offering MAT (medication assisted therapy) to victims of opiate overdose is one of the most effective interventions we can offer in medicine.* 1 in 2 using high-dose buprenorphine (≥ 16 mg) had retention in treatment – meaning NNT of 2!

Further Reading:

TheNNT – Opioid Use Disorder

Critical Actions:

* Administer Naloxone* Minimize Unnecessary Testing* Discuss options for Rehab* Offer opioid replacement therapy* Provide Social Support

Further Reading:

Buprenorphine – EMDocs

Naloxone – EMDocs

Initiating Opioid Treatment in the ED – ACEP

AFib with Rapid Ventricular Rate (RVR) – Rate >110

Primary AFib – Patients symptoms or their hemodynamic instability is due to the AFib itself. Treatment is by rate or rhythm control.

Secondary AFib – Patients AFib rate or their hemodynamic instability is due to an underlying secondary process (eg thyrotoxicosis, PE, sepsis, drugs, etc). Treatment is by treating the underlying process.

Unstable Primary AFib – The presence of hypotension, altered mental status, or pulmonary edema. Treatment is immediate cardioversion, second line agents include digoxin or amiodarone.

Stable Primary AFib (<48 hours duration ) – Treatment is by cardioversion in the ED

Stable Primary AFib ( >48hours or unknown duration) – Treatment is by rate control by CCB (diltiazem or verapimil), or by BB (metoprolol or esmolol)

Anticoagulation – Calculate CHADS2VASC and HASBLED score. Weigh risk of stroke versus risk of major bleeding prior to starting anticoagulation

Further Reading:

Atrial Fibrillation (EMCrit)

Atrial Fibrillation (ACEP Guidelines)

CHADS2VASC Score (MD Calc)

HASBLED Score (MD Calc)