EM Clerkship

One of the best events you can volunteer for as a medical student is your local marathon. You learn about musculoskeletal injuries, heat injuries, electrolyte emergencies, as well as prepare yourself for the occasional seizure, cardiac arrest, and case of anaphylaxis. You learn procedures like starting IVs, obtaining vitals, and basic wound care. It really is a great place to learn the basics of Emergency Medicine. In this episode, we will discuss marathon related emergencies.

Y→ Episode Summary

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!!

Signs and Symptoms

* Vomiting* Abdominal pain* Polydipsia* Polyuria

Step 1: Test for DIABETIC-KETO-ACIDOSIS

* Diabetes* Blood sugar* Typically notably elevated (>250 mg/dL)* Can be normal in certain circumstances* Ketones* Easiest test is a urinalysis* Serum ketones also can be obtained* Acidosis* Blood gas (arterial or venous)* pH <7.3

Step 2: Check Potassium Level

* Patients frequently depleted of whole body potassium* Insulin administration will causes further drops in serum potassium level

Step 3: Replace Potassium

* If potassium <3.3, do not give insulin* Replace potassium prior to insulin* If potassium >3.3 but <5.5* Consider supplementing potassium at this point* May continue insulin

Step 4: Give Fluids

* Adult patients are frequently 3-6 LITERS depleted* 20 ml/kg NS during first hour

Step 5: Start an Insulin Drip

* This accomplishes 2 things…* It decreases blood sugar* It also decreases acid production

Additional Reading

* Peds H- Hyperglycemia and Hypoglycemia (EM Clerkship)* DKA Myths (REBEL EM)

A→ Episode Summary

Step 1: Pain Control

* Local anesthesia* Most common agent is lidocaine (frequently already in laceration repair kits)* Inject through wound edges (not through epidermis)* This decreases pain* Alternative is digital/regional nerve block

Step 2: Irrigation

* Laceration repair is not a sterile procedure* Copious irrigation is the best method to decrease chance of wound infection* Faucet/sink vs saline

Step 3: Alternative Wound Closure Techniques

* Dermabond/Tissue Adhesive* Works best on easily approximated wound edges and little tension* Commonly used in pediatrics and geriatrics* Staples* Sometimes leaves a poor cosmetic outcome* Commonly used for scalp wounds* Rapidly stops bleeding* Quickest and easiest closure method to perform

Step 4: Choose a Suture Type

* Absorbable (Gut, Monocryl) * Pros: Patient doesn’t need to return for removal* Cons: Loses tensile strength* Non-Absorbable (Prolene)* Pros: Good cosmetic outcomes, easy to see (bright blue)* Cons: Patient must have them removed

Step 5: Repair the Wound

* Gently approximate wound edges* You are not trying to “seal” the wound closed* Primary goal is to improve cosmetic outcome* Keep it simple* Simple interrupted sutures* Instrument tie

Additional Reading

* Laceration Evaluation (EM Clerkship)* Wound Closure for the Emergency Practitioner (LacerationRepair)

Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!!

To Close or Not To Close?

* Closing a wound with sutures, etc = Healing by “primary intention”* INCREASES risk of infection but DECREASES scar* Leaving a wound open = Healing by “secondary intention”* DECREASES risk of infection but INCREASES scar

Step 1: History

* Does patient have comorbidities that increase risk of infection/poor healing?* Diabetes* Renal Failure* Obesity* Smoking* Immunosuppression* How long since injury happened?* Any concern for foreign body?

Step 2: Identify Tetanus Status

* Has patient EVER been immunized against tetanus?* Has it been >5 years since last tetanus shot?

Step 3: Tetanus Prophylaxis

* Give tetanus booster (Tdap) if >5 years since last tetanus shot* Give tetanus immunoglobulin (IG) if patient has never had tetanus immunization

Step 4: Give Specific, Objective Description of Laceration

* EXACT length* Must use a ruler* Most important BILLING categories* 2.5 cm or less* 2.6 cm to 7.5 cm* 7.6 cm to 12.5 cm* Description* Shape* Linear* Stellate* Flap* Depth* Superficial* Muscle* Bone* Neurovascular exam* Sensation* Motor* Cap refill

Step 5: Rule Out Foreign Body

* Consider X-Ray* Not all foreign bodies will show up on x-ray* Especially organic material, clothing, etc* Consider bedside ultrasound* (You are not expected to know how to do this, only to consider this)

Additional Reading

* Laceration Repair (EM Clerkship)* Wound Closure for the Emergency Practitioner (LacerationRepair)

You must know the FOUR emergent causes of sore throat!

Step 1: Apply the Centor Criteria

* Determines if patients is at risk for Group A strep (“strep throat”)* 4 Criteria* Fever* No cough* Tonsiller exudates* Lymphadenopathy* Interpretation* If patient has ALL of the criteria* Treat for strep throat* If patient has NONE of the criteria* Don’t even test for strep throat* If patient has SOME of the criteria* Consider testing for strep throat

Step 2: Prescribe Antibiotics

* B-lactams work best* Penicillin* Amoxicillin* If patient has allergy, consider alternative agent* Azithromycin* Clindamycin

Step 3: Pain Control

* NSAIDS* Steroids

Step 4: Consider EBV (Epstein-Barr Virus)

* Consider in patients not getting better on antibiotics* Examine for splenomegaly* If present, no contact sports

Step 5: Consider the FOUR Emergent Causes of Sore Throat

* Ludwigs angina* Airway emergency* Infection UNDER the tongue* Peritonsillar abscess (PTA)* Complication of bacterial pharyngitis* Causes “trismus” (difficulty opening mouth)* Frequently need to be drained* Retropharyngeal abscess* Airway emergency* Difficult to diagnose by exam alone* Infection is BEHIND airway* Seen on lateral neck xray* Epiglottitis* Airway Emergency* “The Triad”* Drooling* Dysphagia* Distress (respiratory)* Lateral neck xray shows “thumbprint sign”

Additional Reading

* Peds O- Oxygen, Airway, and Respiratory Disorders (EM Clerkship)* Airway Infectious Disease Emergencies (UNM)

I→ Episode Summary

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

* Cardioversion* Orthopedic reductions* Painful procedures

Three Step Approach to Procedural Sedation

* Step 1: Risk stratify the patient* Mallampati score (aka “How visible is the uvula?”)* Level 1: Can visualize THE WHOLE uvula* Level 2: Can visualize MOST of the uvula* Level 3: Can visualize SOME of the uvula* Level 4: Can NOT visualize the uvula* ASA (aka “How healthy are they?”)* Level 1: Healthy* Level 2: Mild illness* Hypertension* Hyperlipidemia* Anemia* Level 3: Major illness* Diabetes* Coronary disease* COPD* Chronic renal disease* Level 4: Extremely unhealthy* Dialysis patient* Severe heart failure* Chronically debilitated* Level 5: Dying* Patient needs operation to live* Intracranial hemorrhage with midline shift* Ruptured aortic aneurysm* Ruptured papillary muscle with cariogenic shock* Dissecting aortic aneurysm* Step 2: Informed consent* Patients sign a GENERAL CONSENT to treat when registering to the department* Many emergency scenarios require physician to operate with IMPLIED CONSENT* Many patients have an ADVANCED DIRECTIVE* In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required* Varies by hospital* Typically required for procedural sedation in stable patients* Step 3: Gather supplies* Nurse and nursing supplies* IV* Cardiac monitor* Respiratory therapy and respiratory supplies* Capnography* Bag-valve mask* Airway box

Top 5 Procedural Sedation Medications

* Midazolam (“Versed”) – 0.02 mg/kg IV* Reduces anxiety prior to procedure* Provides no analgesia* Fentanyl – 1 mcg/kg IV* Reduces pain* Useful for painful procedures* Incision and drainage* Simple reductions* Propofol – 0.5-1mg/kg IV* General anesthetic* Best given “low and slow”* Short acting* Causes respiratory depression and hypotension* Etomidate – 0.15 mg/kg IV* General anesthetic* Less hypotension than propofol* Can cause myoclonus* Ketamine – 1-2mg/kg IV* “Dissociative”* Provides both amnesia AND analgesia* Can cause emergence reactions* Can cause laryngospasm and secretions

Additional Reading

* Mallampati Score (Wikipedia)* ASA Physical Status Classification (Wikipedia)

Lets talk about oxygen. Hypoxia is bad, and we need to know how to help these patients. However, giving TOO much oxygen is also bad. In this episode we will review the basics of oxygen administration as well as review the current literature so you can impress your attendings when they try to pimp you.