EM Clerkship

General Bite Wound Management

* Irrigate thoroughly* Update tetanus* LOW RISK bites get sutured* High risk bites to cosmetic areas (face) get sutured AND antibiotics* High risk bites to non-cosmetic areas are left open AND get antibiotics

Rabies

* Give vaccine if… * ANY suspicion for bat bite (bat in room, cave, etc)* Bite by wild animal that can’t be monitored* Bite by domestic animal that develops symptoms during observation

Black widow spider

* Painful bite* Symptoms* Abdominal pain* Diaphoresis* Myalgias* Muscle spasms/cramping* Supportive care

Pit Viper Bite

* Causes Coagulopathy/DIC* Swelling around bite site* Treat with CroFab antivenin

Brown Recluse Bite

* Painless bite* Ulceration/necrosis around bite site

Altitude Illnesses

* Acute Mountain Sickness (AMS)* Headache* Nausea and vomiting* Treat with acetazolamide or decent* High Altitude Pulmonary Edema (HAPE)* Shortness of breath* Treat with supplemental oxygen and immediate decent* Consider nifedipine or sildefenil* High Altitude Cerebral Edema* Ataxia* Confusion* Cushings reflex* Bradycardia* Hypertension* Cheyne-Stokes respirations* Treat with supplemental oxygen and immediate decent* Consider dexamethasone

Digit Amputation

* Wrap in saline soaked gauze* Put in plastic bag* Place on ice* Send to surgeon

Tooth avulsion

* Reimplant tooth in socket* Place in glass of milk

Frostbite

* Remove wet clothing* Rewarm at body temperature

Additional Reading

* Rabies Prophylaxis (EM Clerkship)

Febrile Seizures

* Simple (All features must be present)* Age 6 months – 5 years* Febrile* Lasts less than 15 minutes* Only one seizure in 24 hour period* No focal neuro deficits on exam* Generalized seizure (must have LOC)* Treat with acetaminophen and reassurance* Complex* Does not meet ALL of the criteria for a simple febrile seizure* Consider full workup including lumbar puncture

Pediatric Abdominal Pain

* Intussusception* Classic history* Severe emesis* INTERMITTENT severe abdominal pain* Common causes* Meckles diverticulum* Henoch-Schonlein purpura* Diagnose with abdominal ultrasound* Look for target sign* Treat with air enema* Malrotation with Volvulus* Classic symptoms* Bilious emesis* Projectile* CONSTANT severe abdominal pain* Peritonitic abdominal exam* Common tests (if stable)* Upper GI Series* Corkscrew sign* Coffee-bean sign* Necrotizing Enterocolitis* Classic symptoms* Premature neonate* Bloody stool* X-Ray shows pneumotosis intestinalis* (Air in the bowel wall)* Hirschsprungs Disease* Delayed passage of meconium* Diagnosis* Contrast enema (not typically done in ED)* Look for distal transition point* Rectal suction biopsy (DEFINITELY not done in the ED)* Gold standard for diagnosis

Bronchiolitis

* Commonly caused by RSV* Initial fever and URI* Progresses to respiratory distress

Croup (laryngotrachealbronchitis)

* Commonly caused by parainfluenza* Initial fever and URI* Progresses to stridor* Barky cough* Neck xray will show “steeple sign” (subglottic narrowing)* Treatment* Steroids* Nebulized epinephrine

Epiglottitis

* Commonly caused by Haemophilus influenzae * Classic symptoms* Fever* Sore throat* Drooling* Muffled voice* Treatment* Keep the child calm* Intubation in a controlled environment* Antibiotics

Additional Reading

* Pediatric Abdominal Pain (EM Clerkship)* Peds O – Oxygen, Airway, and Respiratory Disorders (EM Clerkship)

Penetrating Abdominal Trauma

* Anything below the 4th intercostal space (nipple) is potentially an abdominal injury* Gunshot wounds to the abdomen* Needs immediate exploratory laparotomy* Stab wounds to the abdomen* Needs immediate exploratory laparotomy IF…* Hemodynamically unstable* Peritonitis on exam (rebound, rigidity, guarding)* Organs hanging out of abdomen

Blunt Abdominal Trauma

* If the patient is unstable* Perform FAST exam* If the patient is stable* CT scan of the abdomen/pelvis with contrast

Basilar Skull Fracture

* Bilateral post-auricular ecchymosis (Battle’s Sign)* Raccoon eyes* Hemotympanum* Otorrhea/Rhinorrhea

Tension Pneumothorax

* Classic findings* Hypotension* Obstructive shock* Absent breath sounds* Jugular vein distension (JVD)* Treatment* Needle decompression* 2nd intercostal space* Mid-clavicular line* Tube thoracostomy

Hemothorax

* Hypotension* Hemorrhagic shock* Absent breath sounds* NO jugular vein distension

Cardiac Tamponade

* Beck’s Triad* Hypotension* Obstructive shock* Jugular vein distension* Muffled heart sounds* Perform bedside ultrasound* Diastolic collapse of right ventricle (RV)* EKG* Electrical alterans

Traumatic Aortic Rupture

* Rapid deceleration injuries* Tears at ligamentum arteriosum* Widened mediastinum on chest X-Ray

Pulmonary Contusion

* Blunt chest trauma* Respiratory distress* NO paradoxical chest movement with breathing* Chest X-Ray* Shows non-lobar infiltrates* Located near location of injury

Additional Reading

* Abdominal Trauma (EM Clerkship)* Head Trauma (EM Clerkship)* Thoracic Trauma (EM Clerkship)

General Approach to a Test Question

* Read the last sentence of the question* Read the answer choices* THEN read the vignette

Common Scenarios with Quick Answers

* Hypotensive patients* Give a fluid bolus* Altered mental status* Check a blood glucose* Hypoglycemia* Orange juice if can swallow safely* D50 if patient cannot swallow and mildly altered* IM glucagon if unresponsive* Patient with altered mental status and possible drug overdose* Give empiric naloxone * Female patients of childbearing age* Get a pregnancy test* If you need to give contrast for a CT scan (example CTA for pulmonary embolism)* Need renal function

Hyperkalemia

* Common scenarios* Crush injury* Severe burns* End stage renal disease* Especially if missed dialysis* Leukemia on chemotherapy* Remember: Don’t give succinylcholine to a patient with hyperkalemia* Common EKG findings on test* Hyperacute T waves* Sinusoidal waves* Treatment* Stabilizes cardiac cell membranes* Calcium* Shifts potassium into the cells* Insulin/Glucose* Albuterol* Sodium Bicarbonate* Removes potassium* Furosemide* Dialysis* Kayexalate

Hypokalemia

* EKG findings* Flattened T waves* QTC prolongation* U waves* At risk for ventricular arrhythmias* Treatment* Oral potassium replacement* IV potassium replacement* Consider magnesium replacement

Hyponatremia

* Hypertonic saline IF* Comatose* Actively seizing* Otherwise treat with normal saline* Pseuohyponatremia * Correct the sodium if patient has severe hyperglycemia* Add 1.6 to sodium for every 100 glucose above normal limit

Hypercalcemia

* Symptoms* “Stones, bones, groans, psychiatric overtones”* Treatment* IV fluids (promotes excretion) FIRST* Then calcitonin/bisphosphates

Torsade de Pointes

* Common in patients with prolonged QTc* Hypokalemia* Hypocalcemia* Treat with magnesium

Additional Reading

* Hyperkalemia (EM Clerkship)

C→ Episode Summary

C→ Episode Summary

Why is this Important?

* It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal. * Hospitals need to steward their resources to distribute equitable care between its patients

When is it Appropriate to Stop CPR on a Pulseless Patient?

* Patient shows signs of irreversible death* Rigor mortis* Decapitation* Rotting/decaying* Patient has dismal prognosis (3 studies discuss this)* Implementation of the universal BLS termination of resuscitation rule in a rural EMS system* Non-EMS witnessed arrest* No return of spontaneous circulation prior to transport* Only non-shockable rhythms present* Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation* Non-EM witnessed arrest* Non-shockable INITIAL rhythm* No ROSC despite 3 doses of epinepherine* Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study* Less than 1% chance of recovery after 46 minutes of resuscitation

Additional Reading

* Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.* Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.* Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.

Kidney Stones are a Diagnosis of Exclusion!!!

History

* Risk factors* Age >60* Tobacco use* Classic presentations* Stable with sudden flank/back/abdominal pain or syncope* Unstable with pallor, hypotension, and ill appearance

Exam

* Pulsatile abdominal mass* Unstable vitals

Testing Plan

* Labs* TYPE AND SCREEN* CBC* Electrolytes* Coagulation studies* Lactic acid* Imaging* Bedside ultrasound (optimal)* Aorta protocol* Look for aorta >3cm* RUSH protocol* Mnemonic: HI-MAP* Heart* IVC* Morrisons Pouch (RUQ)* Aorta* Pulmonary* CT scan with IV contrast (less optimal)

Treatment Plan

* 2 Large bore IVs (16G)* Massive transfusion protocol* PRBCs* Platelets* Fresh Frozen Plasma* Blood pressure management* Goal Systolic ~100* Goal MAP ~60-65

Clerkship Pearls

* Put AAA in your differential during your presentation for all older patients with back/flank pain* Attempt to perform a bedside ultrasound of the aorta OR find recent CT of the abdomen with normal sized aorta

Additional Reading

* Abdominal Aortic Aneurysm Review (Medscape)

Kidney Stones are a Diagnosis of Exclusion!!!

Introduction

* Testicular torsion is a time sensitive diagnosis (risk of infertility, etc)* Commonly mimics kidney stones

History

* Sudden onset pain* Epididymitis tends to be slower in onset* Flank/lower abdomen/scrotal pain* Frequently causes vomiting* Uncommon in geriatric patients

Exam

* Perform a GU exam and look for* Unequal/horizontal “lie”* Testicular tenderness* Swelling* Absent cremasteric reflex

Testing Plan

* Testicular/Scrotal Ultrasound* Urinalysis

Treatment Plan

* Consult urology when suspected (even if ultrasound hasn’t returned yet)* Manual detorsion* “Open the Book”* Twist medial to lateral* Switch directions if no pain relief

Additional Reading

* Flank Pain Practice Case (EM Clerkship)* Pediatric Abdominal Pain (EM Clerkship)

Kidney Stones are a Diagnosis of Exclusion!!!

Step 1: Consider the Differential Diagnosis for Flank Pain

* Appendicitis* Abdominal Aortic Aneurysm* Ectopic Pregnancy* Testicular/Ovarian Torsion* Kidney Stone

Step 2: Diagnose the Kidney Stone

* Option 1- Renal Ultrasound* Findings consistent with kidney stone diagnosis* Hydronephrosis* Lack of ureteral jets (in bladder)* Kidney stones (poor sensitivity for this)* Benefits* Can be performed at bedside* No radiation* Option 2- Non-contrast CT scan* Great for identifying alternative diagnoses

Step 3: Rule Out Infection

* Fevers* Urinalysis with nitrites or bacteria* If present, patient needs antibiotics

Step 4: Control Symptoms

* Analgesics* NSAIDS (such as ketorolac)* Opiates* Antiemetics* Zofran

Step 5: Rule Out Kidney Injury

* Elevated creatinine* Solitary kidney

Admission Criteria for Kidney Stones

* Coexisting Urinary Tract Infection* Unable to Control Symptoms* Renal Injury/Solitary Kidney

Additional Reading

* How to Interpret a Urinalysis (EM Clerkship)