EM Clerkship

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Case Introduction

You are working a shift at EM Clerkshift General when the next chart is handed to you – a four year old male named Tommy with chief complaint of dehydration.

Initial Vitals

* Temp 100.4F* HR 132* RR 22* BP 98/64* O2 98%

Critical Actions

* Identify key historical findings (fever >= 5 days)* Identify abnormal physical exam findings (Conjunctivitis, Rash, Adenopathy, Strawberry Tongue)* Diagnose Kawasaki Disease Clinically* Administer Aspirin* Administer IVIG

Final Diagnosis

Kawasaki Disease

Tips and Tricks

* Remember the CRASH & BURN mnemonic* Always have a high index of suspicion for this diagnosis* Remember the diagnosis is CLINICAL!

Further Reading

EMDocs – Kawasaki Disease

“The Brady Bunch” – Beta-Blockers, Calcium Channel Blockers, Digoxin, Clonidine

Treatment of Beta Blocker OD

* Activated Charcoal – Only if ingestion time was <1 hour ago, and only if patient is protecting their airway (or intubated).  

2. Glucagon – the best answer for the exam, unlikely to work in real life

3. Epinephrine Drip

4. Calcium 

5. High Dose Insulin Therapy

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Case Introduction

You are working a shift at EM Clerkshift General when you are called to the resuscitation bay to see an elderly patient with unstable vitals brought in by EMS.

Initial Vitals

* Temp 98.0F* HR 43* RR 18* BP 60/40* O2 98%

Critical Actions

* Diagnose the etiology for the bradycardia (BB overdose)* Administer Atropine* Administer Glucagon* Administer Epinephrine drip* Attempt transcutaneous/transvenous pacing* Administer high-dose Insulin therapy

Final Diagnosis

Beta Blocker Overdose

Tips and Tricks

* Keep in mind the broad differential for severe bradycardia – ischemia, ingestion, electrolyte abnormalities, intrinsic arrhythmia/heart block, hypothyroidism, hypothermia, hypoglycemia, hypoxia, increased intracranial pressure, neurogenic shock.

Further Reading

High Dose Insulin Therapy (EMCRIT)

Low and Slow Poisoning (EMCASES)

Four definitions you must know:

* SIRS – Must have at least 2 of 4 SIRS criteria (listed below):* Fever (>38C) or Hypothermia (<36C)* WBC >12k or <4k ; OR Bandemia >10%* Tachycardia > 90* Tachypnea > 20* SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc)* SEVERE SEPSIS – Must have Sepsis + ONE of the following criteria indicative of end organ dysfunction:* Hypotension (MAP<65 or SBP<90)* Creatinine > 2.0 (with normal baseline renal function)* Lactate > 2.0* Platelets < 100k* INR > 1.5* Bilirubin > 2* SEPTIC SHOCK – Must have severe sepsis PLUS one of the following* Hypotension DESPITE adequate fluid resuscitation (usually 30cc/kg bolus)* Lactate > 4.0 DESPITE adequate fluid resuscitation (usually 30cc/kg bolus)

GENERAL GUIDELINES (exact management depends on clinical scenario):

* If patient meets SIRS criteria you work the patient up for sepsis / severe sepsis:* Lactate, Blood Cultures, Urinalysis/Culture, Chest XRay* CBC, BMP, Coags, LFTs* If patient meets SEPSIS criteria, you add in broad spectrum antibiotics +/- intravenous fluids* If patient meets SEVERE SEPSIS criteria, you give a 30cc/kg fluid bolus,* If patient meets SEPTIC SHOCK criteria and is HYPOTENSIVE, you start vasopressors (norepinephrine usually)

MDCalc – Sepsis

Sepsis-2 and Sepsis-3 Guidelines Summarized

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Case Introduction

You are working a shift at EM Clerkshift General when a 20yo female accompanied by her mother checks into the ER with chief complaint of fatigue.

Initial Vitals

* Temp 101.2F* HR 122* RR 22* BP 110/90* O2 98%

Critical Actions

* Obtain travel history in patient presenting with fever of unknown source* Perform sepsis workup and treatment in patient with at least 2 SIRS criteria* Order thick/thin peripheral blood smear* Consult ID* Admit patient

Final Diagnosis

Malaria

Tips and Tricks

* Always obtain detailed history in patient presenting with fever without obvious source (travel history for infectious agents, IV Drug history for endocarditis, etc)* Utilize CDC.org to determine which infections are endemic to each country that your patient traveled in

Further Reading

Malaria (EMDocs)

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Case Introduction

You are working a shift at EM Clerkshift General when a sepsis alert is paged overhead for a young female  who appears diaphoretic and confused.

Initial Vitals

* Temp 102.7F* HR 145* RR 32* BP 141/85* O2 93%

Critical Actions

* Workup and treat for sepsis upfront (Cultures, Lactate, IVF, Abx)* Order TSH with Free T4* Administer non-selective Beta Blocker (Propanolol)* Administer Inhibitor of Thyroid Hormone Synthesis (Methimazole or PTU)* Administer Steroids, +/- Iodine (must be given after inhibitor)

Final Diagnosis

Post Partum Thyroid Storm

Tips and Tricks

* Be aware of common post-partum pathologies (PP depression, hyper/hypothyroidism, cardiomyopathy, infections, eclampsia, etc)* Have a DDX for Fever other than infectious (especially if refractory to acetaminophen)* Administer treatment in correct order (BB first, inhibitor second, Iodine at least 1 hour after inhibitor, steroids)

Further Reading

Thyroid Storm (EMCrit)

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Case Introduction

You are sitting at your computer on an otherwise beautiful Friday afternoon when a mother brings her 16 year old son to the ED with chief complaint of allergic reaction.  

Initial Vitals

* Temp 98.7* HR 155* RR 28* BP 125/85* O2 99%

Critical Actions

* Interpret ECG * Interview patient alone (and identify trigger)* Perform vagal maneuver* Administer Adenosine* Discharge patient

Final Diagnosis

Supraventricular Tachycardia

Tips and Tricks

* Interview pediatric patients without family members in the patient’s room* Escort family out of patient room during invasive procedures* Ask about / rule out potential triggers (caffeine use, drugs, ischemia, electrolyte abnormalities, etc)

Further Reading

The REVERT Trial (RebelEM)

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Case Introduction

You are working a shift at Clerkship General when a 51 year old female is brought in after a syncopal episode.

Initial Vitals

* Temp 100.2* HR 132* RR 28* BP 105/69* O2 85%

Critical Actions

* Give supplemental Oxygen* Diagnose Pulmonary Embolism* Administer Heparin* Assess contraindications for tPA* Administer tPA

Final Diagnosis

Massive Pulmonary Embolism

Tips and Tricks

* Reassess vital signs after interventions* Obtain collateral history from EMS and family* Make sure your diagnosis fits the patient’s symptoms! (EG don’t diagnose pneumonia based on a consolidation on CXR if the patient doesn’t clinically have pneumonia)

Further Reading

Submassive and Massive PE (EMCrit)

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Case Introduction

You are sitting at your computer on an otherwise quiet night when a young male is brought into your ED in obvious respiratory distress.

Initial Vitals

* Temp 98.6* HR 99* RR 34* BP 105/69* O2 95%

Critical Actions

* Give Albuterol + Ipratropium + Steroids* Obtain Chest Xray* Give Magnesium* Place patient on BiPAP* Give IV Beta Agonist (Epinephrine)

Final Diagnosis

Status Asthmaticus

Tips and Tricks

Frequently perform verbal reassessments on patients with the examiner (vitals, patient appearance, pain, etc)

Additional Reading

* The Crashing Asthmatic (REBEL EM)

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Case Introduction

You are working at your local hospital when the next chart gets put in your rack. You groan. The chief complaint is dizziness..

Initial Vitals

* Temp 98.6* HR 109* RR 20* BP 105/69* O2 100%

Critical Actions

* Diagnose Upper GI Bleed* Initiate IV Proton Pump Inhibitor* Obtain Type and Screen* Admit Patient to the Hospital* Identify Medications That Increase Risk of Ulcer (If Prompted)

Final Diagnosis

Upper GI Bleed due to Peptic Ulcer

Tips and Tricks

If you get stuck in a case and don’t know what to do next. Identify all abnormal findings that you have been provided

Additional Reading

* Why You Should Never Ask “What Do You Mean By Dizzy?” (PubMed)