EM Clerkship

If a returning traveler has a fever, think malaria malaria malaria!!!

Step 1: Ask your patient if they have traveled within the last year

* If yes… You should at least CONSIDER malaria

Step 2: If patient says yes, take a travel history

* When did they go* Where did they stay* Where they exposed to anything concerning* Mosquitos* Animals* Weird foods* Sexual partners* Sick people* Where they in developed/tourist areas or “off the trail”

Step 3: Ask about prophylaxis

* Did they see a doctor before leaving?* Did they take any immunizations or medicines prior to departure?* Did they continue prophylaxis as instructed?

Step 4: Go to the CDC website

* Look up the country of concern* Will help establish your differential

Step 5: Test for malaria

* If you are concerned that patient has malaria…* Order thick and thin blood smear

Additional Reading

* CDC Yellow Book (CDC Website)

If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!!

3 Big (Non-Viral) Causes of Diarrhea

* The Icky ‘I’s* Ischemia* Frequently require surgery consult* Infection* Frequently require antibiotics* Inflammatory bowel disease* Frequently require GI consult, steroids, or salicylates

5 Red Flags

* Is it bloody? * Consider performing a guaiac test* Bloody diarrhea usually isn’t “just a virus”* Is it severely painful? * (Viral gastroenteritis may cause gas cramping but shouldn’t be tender or severely painful)* Bonus red flag!!!* POST-PRANDIAL pain* Consider mesenteric ischemia* Recent antibiotics or hospitalization?* Consider C. difficile* Treat with PO vancomycin* Recent travel? * ~80% travelers diarrhea is bacterial* Treat with ciprofloxacin* Note: See FDA black box for fluoroquinolones prior to prescribing* Do you have history of atrial fibrillation? * Increases risk for mesenteric ischemia and ischemic colitis

Consider Testing if Patient is Ill or has Red Flags

* CBC* Electrolytes* Stool studies* Stool WBCs* Stool culture* C-diff* Ova/Parasite* CT abdomen/pelvis with IV contrast

Common Antidiarrheals

* Loperamide (Imodium)* Bismuth (Pepto-Bismol)* Dphenoxylate (Lomotile)

Additional Reading

* Fluoroquinolone Black Box Update (FDA)

I’ve been getting lots of emails regarding which CT scan is the right scan to order in different situations. Contrast? No contrast? ORAL contrast? There are so many options! I recommend you know the core, high yield CT scans, and over time you’ll pick up the rest.

Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!!

Three Stages of Appendicitis

* Stage 1: ~12 hours of “gastroenteritis” like symptoms* Stage 2: Direct somatic irritation* This is when pain over McBurney’s develops!* Stage 3: Perforation* Patient is now sick and septic

Approach to Appendicitis

* Step 1: Consider getting labs* Always remember “The white blood cell count is the last refuge of the intellectually destitute”* The WBC count has both low sensitivity and low specificity for acute appendicitis* Step 2: Get a detailed history* When did the pain start? * How many HOURS into their syndrome are they (remember stages of appendicitis)* Is the pain migrating?* Objective fever?* Did the pain start before the vomiting started?* Does the patient have decreased appetite?* Step 3: Perform a physical exam* Pain over McBurney’s point* Right lower quadrant* 1/3 the distance from the ASIS to the umbilicus* Peritoneal signs (Rigidity, Rebound, Guarding)* Psoas sign* Lie patient on left side with legs extended* Extend their hip behind them* Pain = Suspected retroperitoneal inflammation* Obturator sign* Have patient lie on back with hip/knee flexed at 90 degrees* Internally rotate hip (move ankle away from body)* Pain = Suspected obturator internus inflammation* Step 4: Imaging* Most adults* CT scan +/- IV contrast* Pregnant women* MRI abdomen* Pediatric patients* RLQ ultrasound* Step 5: Disposition* Perform a repeat abdominal exam* Even if CT is negative, consider followup in ED in 12-24 hours

Additional Reading

* McBurney’s Point (Wikipedia)* Psoas Sign (Wikipedia)* Obturator Sign (Wikipedia)

Common Complaints

* Red Eye* Decreased Vision* Trauma to the Eye

Approach to a Vision Complaint

* Step 1: Assess visual acuity* Visual acuity is the “vital sign of the eye”* Snellen eye chart is best* If patient unable to see chart…* Count fingers?* Able to see light?* Step 2: Examine the conjunctiva/cornea with fluorescein* How to apply fluorescein* Recline patient 45 degrees* Pull down on lower eyelid to create pocket* Place anesthetic eye drops in pocket (ex. tetracaine) * Wet the fluorescein strip with eye drops and apply to pocket* Have the patient blink to distribute the dye* Look under woods lamp for bright “uptake” areas that don’t move with blinking* These represent abrasions, ulcers, etc* This step is also a good opportunity to evert the eyelids and examine for foreign bodies if appropriate* Step 3: Examine the anterior chamber with slit lamp * “Cell and flare” (example HERE)* Representative of iritis, uveitis* This is also a good opportunity to examine any other abnormal areas of the eye under magnification!!! * Step 4: Check intraocular pressure* Pressure >20mmHg (especially when unequal) is concerning for acute angle closure glaucoma* Multiple tools to measure pressure on market, ask somebody to show you how to use* Step 5: If appropriate, use ultrasound to evaluate posterior eye* Multiple things can be diagnosed with ultrasound of the eye* Retinal detachment* Optic neuritis* Papilledema* Foreign bodies

Additional Reading

* Introduction to Slit Lamp (YouTube)* Cell and Flair (TimRoot.com)

Differential Diagnosis

* Mnemonic: HE DIES* Hypothyroidism* Elevated intracranial pressure (ICP)* Cushings reflex* Bradycardia* Increased blood pressure* Irregular breathing* Drugs* Beta blockers* Calcium channel blockers* Digoxin* Ischemia* Electrolytes* Especially potassium!!!* Sick Sinus Syndrome

Approach to Bradycardia

* Step 1: Get an EKG* Ischemia?* Heart block?* 1st degree = PR interval >200ms (5 small boxes)* 2nd degree type 1 = PR gradually prolongs until dropped beat* 2nd degree type 2 = Intermittent dropped beats* 3rd degree = None of the atrial beats result in a ventricular beat* Evidence of hyperkalemia?* Step 2: Determine if patient is SYMPTOMATIC* Hypotension* Chest Pain* Syncope* Lightheadedness* Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications* Step 3: If patient is having symptoms… Give atropine!* Typical dose is 0.5mg IV atropine* Step 4: If patient still having symptoms… Give epinephrine!* Step 5: If patient still having symptoms… Cardiac pacing!* If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology* Transcutaneous pacing* Sometimes difficult to get mechanical capture* Transvenous pacing* Place through the right internal jugular vein

Additional Reading

* How to Read an EKG (EM Clerkship)* Transcutaneous Pacing Procedure (EM Clerkship)

Airway and Epi! Airway and Epi! Airway and Epi!

Introduction

* Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen”* The antigen causes extensive mast cell and basophil cross-linking/activation* Common antigens* Foods* Drugs* Insect venoms

Basic Approach

* Step 1: Diagnose anaphylaxis* Consider anaphylaxis if the patient has TWO body systems involved* Dermatologic symptoms* Flushing* Rash* Urticaria* Pulmonary symptoms* Shortness of breath* Wheezing* Cardiovascular symptoms* Hypotension* Lightheadedness* Gastrointestinal symptoms* Nausea/Vomiting* Diarrhea* Step 2: Give epinepherine* A major pitfall in the treatment of anaphylaxis is delay of epinephrine!!!* Normal adult “EpiPen” contains 0.3mg epinephrine* Normal dosing of IM epinephrine is 0.01mg/kg* Step 3: Consider intubation* The second biggest pitfall in the treatment of anaphylaxis is delaying intubation until it’s extremely difficult to intubate!!!* Step 4: Give adjunct medications* H1 blocker* Diphenhydramine* H2 blocker* Ranitidine* Steroids* Prednisone, dexamethasone, etc* Step 5: Send the patient home with an EpiPen prescription* Education them on this* Articulate this part of the plan to your attending* Bonus* Refractory anaphylaxis* Beta-blockers? * Treat with glucagon

Additional Reading

* Round 10 – Allergic Reaction (EM Clerkship)* How to Use an EpiPen (YouTube)

IV fluids are something we deal with everyday in the emergency department. This podcast will teach you what you need to know about giving fluids.

There are 6 core apps that I’m currently using while running around the emergency department during my shifts, and we’ll cover the list in this episode. Also, we will soon be launching The EM Clerkship Pocket Guide which will replace the current, outdated, episode summaries. No specific date yet, but I already have the user interface designed and the content is now being written.  Stay tuned.

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