EM Clerkship

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Case Introduction

A young gentlemen runs out to triage yelling “I can’t breath!” and collapses to the floor in front of the nurse…

Initial Vitals

* Temp 98.8* HR 145* RR 45* BP 60/30* O2 85%

Critical Actions

* Give Supplemental Oxygen* Identify Pneumothorax Prior to Imaging* Correctly Perform Needle Thoracostomy* Correctly Perform Tube Thoracostomy

Final Diagnosis

Pneumothorax Secondary to Penetrating Chest Trauma

Tips and Tricks

Be careful, lack of visual cues during oral cases can mislead you!

Additional Reading

* Thoracic Trauma (EM Clerkship)* NBME Trauma Review (EM Clerkship)

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Case Introduction

You are having a busy day in the department when you are paged overhead to the resuscitation bay for an ill appearing patient with a headache…

Initial Vitals

* Temp 98.9* HR 99* RR 18* BP 180/110* O2 94%

Critical Actions

* Verbalize a Full Neurologic Examination* Obtain CT Scan Without Contrast* Consult Neurosurgery for Subarachnoid Hemorrhage* Reverse Warfarin Coagulopathy* Administer Antihypertensives

Final Diagnosis

Acute Subarachnoid Hemorrhage on Anticoagulation

Tips and Tricks

Always ask the patient if they have allergies prior to administering ANYTHING.

Additional Reading

* Basics of Subarachnoid Hemorrhage (EM Clerkship)* How to Reverse Warfarin (AHA)

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Case Introduction

A 45 year old female is exposed to peanut butter and shrimp pizza and begins to have an apparent allergic reaction…

Initial Vitals

* Temp 98.8* HR 130* RR 35* BP 70/40* O2 92%

Critical Actions

* Verbalize Airway Evaluation* Complete a FOCUSED History and Exam* Normal Saline Bolus* Epinephrine both IM and (subsequently) IV* Glucagon 1mg IV

Final Diagnosis

Refractory Anaphylaxis Due to Beta Blockers

Tips and Tricks

You still need to obtain a quick history and exam even if you know the diagnosis in the first few seconds of the case

Additional Reading

* Basic approach to anaphylaxis (EM Clerkship)* Tranexamic acid as first-line emergency treatment for episodes of bradykinin-mediated angioedema induced by ACE inhibitors. (PubMed)* Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. (PubMed)

I → Episode Summary

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Case Introduction

The nurse brings back a young adult male from the lobby who is having a seizure…

Initial Vitals

* Temp 98.8* HR 90* RR 10* BP 120/80* O2 92%

Critical Actions

* Verbalize ABCs on a Critical Patient* Obtain Immediate Blood Glucose Level* Give Benzodiazepine* Initiate Workup of New-Onset Seizures* Give Pyridoxine (Vitamin B6)

Final Diagnosis

Isoniazid Toxicity

Tips and Tricks

When the patient is unable to provide history, attempt to obtain the information from external sources

Additional Reading

* Isoniazid toxicity overview (Life in the Fast Lane)* Basic approach to seizures (EM Clerkship)* Basic approach to status epilepticus (EM Clerkship)* Ketamine for refractory status epilepticus (PubMed)

Corrections

Ketamine not Keppra as potential induction agent for status epilepticus (32:40)

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Case Introduction

EMS brings in an elderly man who has fallen…

Initial Vitals

* Temp 98.6* HR 58* RR 16* BP 105/60* 99%

Critical Actions

* Treat the patient’s pain* Consult orthopedics for a hip fracture* Obtain an EKG* Treat Severe Hyperkalemia* Consult nephrology for dialysis

Final Diagnosis

Ground level fall resulting in hip fracture, missed dialysis, and severe hyperkalemia

Tips and Tricks

Patient’s will frequently have more than one final diagnosis. Do not prematurely close an the initial, obvious, diagnosis.

A man can have as many diseases as he damn well pleases! Hickam’s dictum

Additional Reading

* Basic approach to hyperkalemia (EM Clerkship)* EKG manifestations of hyperkalaemia (LITFL)

Special Thanks to Mohamed Soliman for contributing this episode!

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Case Introduction

Just a routine day at your hospital, your next patient has a chief complaint of headache…

Initial Vitals

* Temp 98.8* HR 88* RR 16* BP 130/80* O2 99%

Critical Actions

* Identify Acute Angle Closure Glaucoma* Initiate Appropriate Treatment for Acute Angle Closure Glaucoma* Emergent Consult to Ophthalmology* Recheck Intra-Ocular Pressure After Initiating Treatment

Dangerous Actions

* Giving NSAIDS (The Patient Had This on Allergy List)* Performing a Lateral Canthotomy

Final Diagnosis

Acute Angle Closure Glaucoma

Tips and Tricks

Do not be surprised or scared when an examiner has a monotone voice and flat affect

Additional Reading

* Management of acute angle closure glaucoma (PubMed)* Basic approach to eye complaints (EM Clerkship)

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Case Introduction

A notorious, disheveled frequent flyer presents to your emergency department for her back pain and is asking for more Dilaudid…

Initial Vitals

* Temp 99.0* HR 99* RR 18* BP 118/78* O2 99%

Critical Actions

* Ask about Red Flags for Spinal Infection* Perform a Thorough Spinal Exam* Obtain MRI Spine with Contrast* Initiate Broad Spectrum Antibiotics* Treat Pain when Pathology Identified

Final Diagnosis

Spinal Epidural Abscess

Tips and Tricks

Don’t let consultants or other members of your team talk you out of appropriate management of a patient

Additional Reading

* Basic approach to Back Pain (EM Clerkship)* Epidural Abscess Overview (AAFP Website)