EM Clerkship

Basic Approach

* Step 1: Is this SINUS tachycardia? * P before every QRS? * Treat the underlying condition* Step 2: Is this a NARROW and REGULAR rhythm?* SVT* Treat with vagal maneuvers or adenosine* Another new trend is treating with calcium channel blockers!! * ORTHOdromic Wolf Parkinson White* Treat with adenosine* Atrial flutter with fixed block* Treat with AV blockers (diltiazem)* Slows the heart rate* Step 3: Is this a NARROW and IRREGULAR tachycardia?* Almost always atrial fibrillation* Treat with AV blockers (diltiazem)* Other (less common) diagnoses* Atrial flutter with variable block* Multifocal atrial tachycardia* Step 4: Is this a WIDE and REGULAR tachycardia?* Assume ventricular tachycardia until proven otherwise* Treatment is immediate cardioversion if unstable* May try chemical cardioversion if stable* Procainamide* Amiodarone* Lidocaine* Other diagnoses* ANTIdromic Wolf Parkinson White* Narrow complex tachycardias PLUS aberrancy* Step 5: Is this a WIDE and IRREGULAR tachycardia?* Atrial fibrillation with bundle branch block* Extremely fast and bizarre in appearance? * Consider atrial fibrillation with Wolf Parkinson White

Additional Reading

* Calcium Channel Blockers for Stable SVT (ALiEM)* Atrial Fibrillation in WPW – Pearls and Pitfalls (County EM)

Introduction

* Simple seizure* Seizure ends in <5 minutes AND* Patient wakes up before next seizure* No meds required* Status epilepticus* Seizure lasts >5 minutes OR* Patient has a 2nd seizure before waking up from 1st* Initiate status epilepticus pathway

Approach to Status Epilepticus

* Step 1: Give a benzodiazepine* Lorazepam (IV)* Diazepam (IV or PR)* Midazolam (IV or IM)* Step 2: Give an anti epileptic* Levetiracetam (Keppra)* Fosphenytoin* Valproic Acid* Step 3: Continue attempting agents for 30 minutes* If seizure continues, you must move onto step 4… * Step 4: Sedate and intubate the patient* Propofol* Phenobarbital* Step 5: Start patient on continuous EEG* Detects non-convulsive status epilepticus* Usually started once patient is in ICU

Additional Reading

* Round 9 – Seizure (EM Clerkship)* Emergency Management of Status Epilepticus (EM Cases)

Basic Approach

* Step 1: Describe the seizure* Did patient have an aura? * Was there loss of consciousness?* What did the movements look like?* Did they have postictal phase? * Did they have a trauma as well?* Step 2: Ask about TIME (mnemonic)* Tongue biting* Usually occurs on the lateral sides of tongue* Incontinence* Medication changes/adjustments* Ethanol use* Step 3: Do a FULL neurologic examination* Mental Status* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Reflexes* Gait* Step 4: Testing plan* Glucose* Pregnancy Test* CBC* Electrolyte panel* Urine drug screen* Drug levels of anti-epileptic agents* Step 5: Simple seizures (<5 minutes) do not require immediate treatment* Roll them on side* Suction

Additional Reading

* Approach to Status Epilepticus (EM Clerkship)

Hard, fast, unrelenting chest compressions are the core of ACLS!!!

Step 1: Check the Patient’s Pulse

* If the patient does not have a pulse, start CPR* Hard, fast, unrelenting compressions* Intubated patients* Continuous Compressions* Non-intubated adults* 30 compressions then 2 breaths… Repeat* Non-intubated pediatrics* 15 compressions then 2 breaths… Repeat

Step 2: Determine if the Rhythm is Shockable or Non-shockable

* Shockable rhythms* Ventricular Fibrillation (VF)* Ventricular Tachycardia (VT)* Non-shockable rhythms* Pulseless electrical activity (PEA)* Asystole

Step 3: Start a Timer For 2 Minutes

* Do a rhythm/pulse check every 2 minutes

Step 4: Is the Patient in a Shockable Rhythm?

* Repeat/coordinate shocks with every 2-minute pulse check* Give 1mg IV/IO epinephrine every 3-5 minutes* Give amiodarone* 300mg with first dose* 150mg with a repeat dose

Step 5: Is the Patient in a Non-Shockable Rhythm?

* Give epinephrine every 4 minutes (every other cycle)

Quick Facts

* Shockable rhythms (VT/VF) have best prognosis* Frequently related to myocardial infarction* Asystole has the worst prognosis* PEA has mixed prognosis (depends on diagnosis)* Two types (wide and narrow)* “Wide” PEA frequently caused by metabolic abnormalities* Consider bicarb and calcium chloride* “Narrow” PEA frequently caused by shock state* Perform bedside ultrasound in attempt to determine cause* “The H’s and T’s”* Hypoxemia* Hypovolemia* Hydrogen Ions* Hyper/hypokalemia* Tension pneumothorax* Tamponade* Toxins* Thrombosis (MI/PE)

Additional Reading

* When to Stop CPR (EM Clerkship)

There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain.

Cholelithiasis and Biliary Colic

* Cholelithiasis = Gallstones in the gallbladder* Frequently seen on CT scan or RUQ ultrasound* Present in 15% of the population* Biliary colic = Intermittent episodes of pain if stone passes* Classically colicky/crampy/spasmy pain in RUQ* Frequently radiates to right shoulder/flank* Pain is intermittent and resolves after a few hours* Patients need pain control and outpatient follow up with general surgery

Cholecystitis (Inflammation of the Gallbladder)

* Caused by obstruction of the cystic duct* Increased pressure in the gallbladder results in ischemia/inflammation* Diagnosis* RUQ Ultrasound* Gallbladder wall thickening* Pericholecystic fluid* Cholelithiasis* CT of the abdomen and pelvis also has decent sensitivity/specificity* Admit for cholecystectomy

Choledocolithiasis (Common Bile Duct Obstruction)

* Terminology* Cholecystitis = Stone in CYSTIC DUCT* Choledocolithiasis = Stone in COMMON BILE DUCT* Symptoms similar to cholecystitis* Testing* LFTs will be elevated* Results from blockage of bile outflow from liver* RUQ Ultrasound* Shows dilation of the common bile duct* Treatment* GI Consult* Endoscopic Retrograde Cholangiopancreatography (ERCP)

Cholangitis (Infection of Bile Duct/Liver)

* Common complication of choledocolithiasis* Charcots triad* RUQ pain* Fever* Jaundice* Reynolds pentad* RUQ pain* Fever* Jaundice* Altered mental status* Shock/hypotension* Treatment* Fluids* IV antibiotics* ERCP

Gallstone Pancreatitis

* Gallstone obstructs PANCREATIC DUCT* Testing* Lipase will be elevated* LFTs will be elevated* RUQ will show dilation of the CBD* Treatment* Fluids* Pain medicine* ERCP

Additional Reading

* Biliary Diseases and Pancreatitis (EM Clerkship)* Biliary Anatomy (TeachMeAnatomy)

Not all patients with chest pain are having a STEMI, or massive PE, or aortic dissection. In fact, most patients with chest pain will have a set of normal labs, feel better, and we then have to decide what to do next. Admit or Discharge? What if we send this low risk patient, complaining of chest pain, home? What if they get home and die of a massive MI, and you had seen them the day before for chest pain? That’s why this is a huge topic that your attendings will want you to understand. In this episode we will talk low risk chest pain, and specifically, the HEART score.

Evaluate 5 important structures when evaluating gunshot wounds in an extremity.

Blood Vessel Injuries

* 3 Categories* Hard-Signers* Mnemonic: HARD Bruit* Hypotension* Arterial/pulsatile bleeding* Rapidly expanding hematoma* Deficits (pulse)* Audible BRUIT/thrill* These patients likely need OR* Soft-Signers* Significant vascular oozing/bleeding* Large hematoma* These patients need to be screened with ABI (ankle brachial index)* ABI <0.9 or asymmetry between extremities is concerning for vascular injury* If abnormal, obtain a CTA* No-Signers* No additional management for vascular injury required

Nerve Injuries

* Relatively rare* Document neuro exam in the extremity* Consult if abnormal

Bone Injuries

* Relatively common* Diagnosed by x-ray* Consult orthopedics for fracture

Soft Tissue Injury

* Be sure to count/document number of holes* Typically do not need laceration repair unless cosmetic area* Don’t miss compartment syndrome* Mnemonic: “P’s”* Pain out of Proportion* Pain with Passive range of motion* Paresthesias* Pallor* Paralysis* Poikilothermia

The Bullet: What To Do With It?

* The bullet is almost never removed, unless…* Very superficial/cosmetic and easy to remove* In a joint

Additional Reading

* NBME Shelf Review Part 2- Trauma (EM Clerkship)

5 core treatments and 5 MORE treatments

5 Core Treatments

* Albuterol* Beta agonist* Bronchodilator* Core treatment for asthma* Ipratropium* Anti-muscarinic* Relax muscles around the airways* Works synergistically with albuterol* Steroids* Decrease inflammation in the airways* Prednisone (PO)* Methylprednisone (IV)* BiPAP (COPD)* Decreases work of breathing* Decreases rates of intubation* Decreases mortality* Antibiotics (COPD)* Infection common cause of inflammation

5 More Treatments

* Magnesium sulfate* Ketamine* Epinephrine (systemic beta agonist)* Heliox* LAST RESORT – Intubation* Decrease rate and volume* Increase expiratory time and inspiratory flow

Additional Reading

* Antibiotics in COPD (AAFP)* The Crashing Asthmatic (REBEL EM)

Basic Categories

* Upper GI Bleed* Symptoms* Coffee ground emesis* Melena* Black tarry stool* Digested blood* Common causes* Peptic ulcer disease* Varices* Lower GI Bleed* Symptoms* Bright red blood per rectum (BRBPR)* Maroon/bloody stools* Common causes* Diverticulosis* Colon cancer* Angiodysplasia* AV Malformations

History

* Ask about risk factors for upper GI bleed* Peptic ulcer risk factors* NSAIDS* Steroids* History of ulcers* Varices risk factors* Heavy alcohol use* History of liver disease

Exam

* Abdominal exam* Usually minimal tenderness* If patient has severe tenderness/peritoneal signs consider alternative diagnosis* Perforation* Rectal exam* Identify stool color* Guaiac testing* Hemorrhoids* Are they bleeding* Anal fissures

Testing Plan

* CBC* Looking for anemia* Electrolytes* Elevated BUN* Commonly present in upper GI bleed* Coagulation panel* Type and screen

Treatment Plan

* Proton pump inhibitor (upper GI bleeds)* “-prazoles” such as pantoprazole* Octreotide/Antibiotics if varies suspected

Disposition

* Most upper GI bleeds get admitted* Lower GI bleeds depend on risk factors* Comorbidities* Clinical findings/stability* Vital signs* Hemoglobin/Hematocrit

Additional Reading

* GI Bleed Emergencies (EM Cases)* GI Bleed (emDOCs)

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