EM Clerkship

F→ Episode Summary

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 be performed, blood pressure to be treated, etc* My “medical clearance” order set includes* Electrolytes* CBC* Serum Alcohol* Urine Drug Screen (UDS)* Pregnancy (if appropriate)* Tylenol/Salicylate Levels (especially if suicidal)* Psychiatric patients frequently have other non-psychiatric emergencies* Overdoses (salicylate, acetaminophen, etc)* Trauma (alcoholics with subdural hematoma from falls)* Encephalopathy (hypoglycemia, encephalitis)

Psychiatric Risk Assessment

* Will this patient truly put themself or others at risk if sent home due to mental health?* Do you need to involuntarily hold patient? * Are they having passive thoughts of being dead or true INTENT and PLAN to harm themself? * Did they name a specific person/group of people that they intend to harm?

Additional Reading

* State Laws on Involuntary Mental Health Holds (Psychiatry Online)

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 vaginal bleeding* If sick…* Think ectopic pregnancy (early pregnancy)* Think uterine rupture (late established pregnancy)* Think placental abruption (recent trauma or cocaine)* Don’t forget to order a type and screen* Rh- mothers will need RhoGam* If patient is unstable and you can’t wait for blood type…* Transfuse type O negative blood* Postpartum vaginal bleeding* Most common cause is retained products of conception* Order an ultrasound* Consider endometritis if patient also has fever* Treat with clindamycin and gentamycin

Vaginal Discharge Pearls

* Cervical motion tenderness?* Pelvic Inflammatory Disease (PID)* Thin, grey, and smells like fish?* Bacterial vaginosis (BV)* Treat with metronidazole* Warn patient not to mix metronidazole with alcohol* Thick like cottage cheese?* Vulvovaginal candidiasis* Diagnosis with KOH prep* Look for yeast and pseudohyphae* Treat with fluconazole* Thin Yellow/Green and “frothy”?* Trichomoniasis* Diagnose with wet prep* Look for mobile organisms* Treat with metronidazole* Partners should be checked and treated too

Ovarian Torsion

Severe and sudden pain

* Can be intermittent* Diagnose with Pelvic ultrasound with Doppler* PITFALL: Frequently has normal arterial flow (dual blood supply to ovary)

Additional Reading

* Approach to Non-Pregnant Vaginal Bleeding (EM Clerkship)* Approach to 1st Trimester Vaginal Bleeding (EM Clerkship)

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 (Given orally)* Prevents vasospasm

Causes of Stroke in Young People

* Cervical artery dissection* Vasospasm* Vasculitis* Sickle Cell Disease

Meningitis

* Treatment* Vancomycin, Ceftriaxone* Add ampicillin (covers listeria) in very young/old* Rifampin prophylaxis for close contacts (if patient has petechial rash)* Neisseria Meningitidis

HSV Encephalitis

* Classic symptoms* Fevers* Headache* Altered Mental Status* Seizures* Treat with acyclovir

Altered Mental Status

* The two most common causes on your test* Hypoglycemia* Infections (Especially in elderly)* Aka Delirium

Fat embolism

* Trauma PLUS petechial rash * Common with long bone fracture

Schaphoid Fracture

* Exam shows tenderness over anatomic “snuffbox”* Notorious for being missed on X-ray * High risk of osteonecrosis* If suspicious, place patient in thumb spica splint regardless of X-ray findings* Outpatient followup 1-2 weeks for repeat xray

Pericarditis

* Patient complains of chest pain that is… * Sharp* Positional* Worse when laying flat* Friction rub on exam* EKG Findings* Diffuse ST segment elevation* Diffuse PR depression* Treat with NSAIDS

Kawasaki’s Disease

* Mnemonic: CRASH and Burn* Conjunctivitis* Rash* Adenopathy* Strawberry Tongue* Hands/Feet Swelling* Burn = Fever for 5 days* Treat with aspirin

Burns

* Parkland formula* Weight (kg) x BSA (%) x 4 = Volume of fluid needed in first 24 hours* Give half over first 8 hours* Rule of 9s* Estimates % Body surface area burned

Vascular Injury

* Hard Signs * If present patient needs OR* Mnemonic: ABCDE* Active pulsatile hemorrhage* Bruit* Cerebral ischemia* Diminished Distal pulses* Expanding Hematoma

Infectious Disease Pearls

* Gram positive cocci in CLUSTERS* Staphylococcus Aureus* Gram positive cocci in CHAINS* Streptococcus Pneumoniae

Additional Reading

* Basic approach to altered mental status (EM Clerkship)* Basic approach to neck trauma (EM Clerkship)

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 Chest* If severe contrast allergy or other contraindication* Ventilation/Perfusion (V/Q) Scan

Inferior STEMI

* EKG shows ST elevation in 2, 3, aVF* Can involve AV node (bradycardia)* Avoid beta blockers* Treat with atropine* Can involve RV (preload dependent)* Avoid nitroglycerine* Treat with fluids

Common to Nitroglycerine

* Hypotension* Current sildenafil usage

Aortic Dissection

* Type A (ascending) Dissection* Surgical emergency* Type B (descending) Dissection* Medical management* Testing* CTA of the chest* Chest X-Ray SOMETIMES shows a widened mediastinum* Treatment* Esmolol (decrease heart rate)* Labetelol (decrease blood pressure)* PEARL: Aortic dissection can cause STEMI

Heart Failure

* Treatment* Diuresis* Nitroglycerin* BiPAP* If patient needs fluids* Decrease size of fluid bolus

COPD

* Treatments* Albuterol/Ipratropium* Antibiotics* Steroids* BiPAP

Pneumonia

* If alcoholic/homeless/dementia/parkinson’s* Treat for aspiration (anaerobes)* If recent hospitalization/ventilator* Treat for pseudomonas and MRSA* If pneumonia PLUS atypical symptoms* Treat for legionella* If recent influenza* Treat for MRSA

Additional Reading

* Pulmonary Embolism Basics (EM Clerkship)* Pulmonary Embolism Severity (PubMed)

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

Acute Diverticulitis

* NOTE: DiverticulOSIS is what causes GI bleeding* History/Exam* Fever* Left lower quadrant pain/tenderness* Testing/Treatment* CT abdomen with IV contrast* Liquid diet* Antibiotics* Complications* Abscess* Stricture* Fistula* Perforation* Obstructions

Abdominal Aortic Aneurysm

* If suspected, perform bedside ultrasound of the abdomen* Aortic diameter >3 cm

Spontaneous Bacterial Peritonitis

* Diagnose by performing a paracentesis* Look for >250 white blood cells* Treat with ceftriaxone

Kidney Stones

* CT without contrast* If the stone is <5mm* Treat with analgesics and tamsulosin* If the stone is >5mm* Consult urology

Common Indications for Emergency Dialysis

* Mnemonic: AEIOU * Acidosis (pH <7.1)* Electrolytes (K > 6.5)* Intoxication* Lithium* Ethylene Glycol* Methanol* Aspirin* Overload of volume resistant to diuresis* Uremia that is symptomatic* Altered mental status* Pericarditis

Ectopic Pregnancy

* Testing* BhCG QUANTITATIVE* Type and screen for Rh Status* Pelvic ultrasound* IUP = Gestational sac PLUS a Yolk sac* Beware “heterotopic” pregnancy in fertility treatment patients (IVF)* Treatment* If no IUP visualized, ectopic pregnancy is a possibility, and management depends on hCG* If <1500* Consider sending stable patients home and repeat hCG in 48 hours* If >1500* Ectopic until proven otherwise, consult OBGYN* Rh- needs RhoGAM* Prevents complications in future pregnancies

Additional Reading

* Ectopic Pregnancy (EM Clerkship)* Abdominal Aortic Aneurysm (EM Clerkship)

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* Hematemesis/Melena* Chronic liver disease (hepatitis, alcoholics)* Treatment* Fluid bolus if hypotensive* Octreotide* Ceftriaxone* Transfuse blood as needed* If hemoglobin <7 transfuse* If patient actively bleeding and level <8 transfuse* Consult GI for endoscopy

Hepatic Encephalopathy

* Common findings* Altered mental status* Asterixis* Elevated ammonia level * Treat with lactulose or rifamixin

Peptic Ulcer Disease

* History* Hematemesis or Melena* Epigastric abdominal pain* Chronic NSAIDS or steroids* Treatment* PPI (such as pantoprazole)* Works better than an H2 blocker

Cholecystitis

* RUQ ultrasound* Thickened gallbladder wall* Distended gallbladder* Pericholecystic fluid* Obvious impacted stone* HIDA scan* Inject radioactive material* Absorbed by hepatocytes* Secreted into biliary tree into small intestine* If gallbladder not visualized* Cystic duct obstruction* If common bile duct cannot be visualized* Choledocolithiasis

Ascending Cholangitis

* Charcots Triad* Fever* RUQ Pain* Jaundice* Patient requires ERCP (gastroenterology consult)* Give antibiotics

Acute Pancreatitis

* Diagnosis* Classic description* Epigastric pain radiating to back* Severe vomiting* Lipase* >3x upper limit of normal is diagnostic* CT scan to look for complications of pancreatitis

Additional Reading

* RUQ Abdominal Pain (EM Clerkship)* Biliary Diseases and Pancreatitis (EM Clerkship)

“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* Defibrillation

Polymorphic Ventricular Tachycardia (aka Torsades de Pointes)

* Known complication of prolonged QTc* Side effect of multiple medications* Antipsychotics* Methadone* Ondansetron* Give Magnesium Sulfate

High yield EKG patterns

* Long QTc* Wolf Parkinson White (WPW)* Brugada Pattern

Atrial Fibrillation

* Stable* Patient presents immediately after onset (<24-48 hours)* Synchronized cardioversion* Rhythm control medications* Amiodarone* Procainamide* Flecanide* Patient does not present immediately (or unknown onset)* Rate control* Beta blockers* Metoprolol* Calcium channel blocker* Diltiazem* Anticoagulation (heparin)* Unstable* Synchronized cardioversion* Atrial fibrillation with extremely fast rate (200+) is common in WPW* Atrial fibrillation with slow rate is common with Digoxin toxicity

Bradycardia

* AV Blocks* 1st Degree* 2nd degree (type 1)* 2nd degree (type 2)* 3rd degree* If symptomatic and stable…* Atropine* If they become unstable… * Transcutaneous or transvenous pacing

Additional Reading

* Life in the Fast Lane EKG Library (LITFL)* Tachycardias (EM Clerkship)* Bradycardias (EM Clerkship)

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* Apraclonidine

Giant Cell Arteritis

* Common features* Severe headache* Tenderness of the Temporal Arteries * Jaw claudication* Elevated ESR (“sed rate”)* Treat with steroids

Anterior Uveitis

* Painful red eye* Cell and flair on slit lamp examination

UV Keratitis (“snow blindness”)

* Common in skiers/snowboarders* Diagnose with fluorescein and use woods lamp* Punctate lesions on the cornea

Common Poisons/Antidotes

* Digoxin toxicity* Digibind* Acetaminophen toxicity* N-Acetylcysteine (NAC)* Ethylene glycol or methanol toxicity* Fomepizole* Jimson weed (anticholinergic toxicity)* Physostigmine* Organophosphate toxicity* Atropine* Treat until airway secretions have stopped* Pralidoxime * Opiate toxicity* Naloxone* Benzodiazepine * Flumazenil (falling out of favor)* Cocaine toxicity* DON’T give beta blockers* Unopposed alpha effect* Very little data to support this but commonly believed* Iron toxicity* Deferoxamine* Salicylate overdose* Sodium bicarbonate* Dialysis* Tricyclic antidepressent* Sodium bicarbonate* Beta blocker overdose* Glucagon* Calcium channel blocker overdose* Glucagon* IV Calcium* High dose euglycemic insulin therapy* Sulfonylurea overdose* Octreotide* Dextrose* Heparin reversal* Protamine sulfate* Cyanide toxicity (common in house fires)* Hydroxocobalamin * Sodium Nitrite* Carbon monoxide toxicity* Oxygen oxygen oxygen* Hyperbaric oxygen* BEWARE: pulse oximetry will be normal* Valproic acid toxicity* L-carnitine

Additional Reading

* Approach to Eye Complaints (EM Clerkship)* Acetaminophen Overdose (EM Clerkship)* Salicylate Overdose (EM Clerkship)