EM Clerkship

Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses

* Aortic Dissection and Abdominal Aortic Aneurysm (AAA)* Age >50* Hypertension* “Ripping” or “Tearing” pain* Absent pulses in lower extremities* Spinal Infections* Fever* Immunocompromized* HIV* Diabetes mellitus* Transplant patients* Spinal cord compression (especially cauda equina)* Urinary retention* Consider obtaining post-void residual* Saddle anesthesia* Fecal incontinence/decreased rectal tone* Fracture* Recent trauma* Advanced age* Cancer* History of cancer* Night sweats* Weight loss

Step 2: Testing Plan (If Patient Has Red Flags)

* X-ray or CT scan if concerned for fracture* MRI if concerned for infection, cord compression, or cancer

Step 3: Symptom Management

* NSAIDS* Naproxen* Ibuprofen* “Muscle relaxants” * Cyclobenzaprine* Other agents* Opiates* Topical therapy* Lidocaine patches

Step 4: Counseling

* Remain active* Avoid heavy lifting* Red flags = immediate return to ED

Additional Reading

* Round 6 – Back Pain (EM Clerkship)* Back Pain Red Flags (WikEM)

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Minor complaint. Huge SLOE points!

Step 1: Identify Which Tooth is Causing Pain

* Bonus points if you number teeth correctly!* Number 1-32* Tooth #1 is top right* Tooth #32 is bottom right* Refer to dental chart for reference

Step 2: Correct Terminology When Making Diagnosis

* Pulpitis* Pain in the tooth itself* Reversible* Triggered by hot/cold etc (then goes away)* Irreversible* Does not resolve* Gingivitis* Pain of the gingiva around the tooth* Periapical abscess* Pain with percussion of tooth

Step 3: Give Pain Medicine

* NSAIDS have been shown to work best* Naproxen* Ibuprofen* Opiates for breakthrough pain* Hydrocodone-acetaminophen (Norco)* Oxycodone-acetaminophen (Percocet)

Step 4: Consider Antibiotics

* Pulpitis does not require antibiotics* Gingivitis/Periapical abscess frequently improve on antibiotics* Penicillin VK

Step 5: Inferior Alveolar Nerve Block

* Watch HERE

Additional Reading

* Inferior Alveolar Nerve Block (YouTube)* Common Dental Emergencies (AFP)

Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo?

Step 1: How Does Patient Describe the Vertigo?

* Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is)* Central vertigo* Mild* Vague* Peripheral vertigo* Severe* Sudden

Step 2: What Are the Associated Symptoms?

* Central vertigo frequently associated with “The Dangerous D’s”* Diplopia (double vision)* Dysphagia (difficulty swallowing)* Dysmetria (uncoordinated movement)* Dysarthria (difficulty speaking)

Step 3: Does this Patient Have Risk Factors for Central Vertigo?

* History of stroke* Atrial fibrillation* Diabetes* Recent trauma

Step 4: Do a Neuro Exam

* Important exam findings for central vertigo* Abnormal gait* Abnormal finger-to-nose* Nystagmus* Important exam findings for peripheral vertigo* Dix-Hallpike

Step 5: Plan

* If concerned for CENTAL vertigo* MRI head/neck* If concerned for PERIPHERAL vertigo* Treat with meclizine

Additional Reading

* Posterior Circulation Strokes and Dizziness (emDOCs)

Hyperkalemia = EKG… EKG changes = Calcium…

Step 1: Recheck the Potassium

* Most common cause of hyperkalemia is PSEUDOhyperkalemia* Caused by too aggressive/fast of a blood draw* Causes RBCs to break open and falsely increase serum potassium

Step 2: Get an EKG

* Earliest EKG change* Peaked T waves* Late EKG changes* Flattened P wave* Prolonged QRS* Critical/Emergent EKG changes* Sine wave

Step 3: Protect the Heart

* EKG Changes = Give Calcium* Calcium gluconate (can be given IV)* Stabilizes the myocardium against dysrhythmia

Step 4: Shift Potassium Into Cells

* Insulin (plus D50)* Albuterol

Step 5: Remove Potassium from Body

* Kayexalate* Notorious for causing intestinal necrosis* Falling out of favor* Furosemide

Additional Reading

* Round 8 – Fall (EM Clerkship)* Emergency Management of Hyperkalemia (EM Cases)

This episode is for the dedicated listeners who would like to know the details of what is going on behind the scenes and what the podcasting goals and objectives will be for the upcoming season. Happy New Year!

As a physician, everything you do has a fee. Patients may or may not pay that fee, but everything you do still has a price that is set by the government. In this episode we will cover how much your work costs the patient as well as discuss several specific examples.

A-B-C-D-E-F-G

Two Types of X-Rays

* Anterior-Posterior (“AP”)* Classic “portable” xray* The beam shoots from in front of the patient (anterior)* TO* The plate sitting behind the patient (posterior)* Posterior-Anterior (“PA”)* Requires trip to radiology* Results in a better picture* The beam shoots from behind the patient (posterior)* TO* The plate sitting in front of the patient (anterior)

Three Indicators of a High Quality Chest X-Ray

* Well inflated lungs* Visualize spine through cardiac silhouette* Medial aspect of both clavicles lined up* Evaluates for rotation

Chest X-Ray Interpretation Mnemonic

* A-B-C-D-E-F-G* A = Airway* Trachea midline (rule out tension pneumothorax)* B = Bones* Rib/Clavicle/Shoulder fractures* C = Cardiac silhouette* Should be no bigger than 50% of distance from chest wall to chest wall* Larger than this may represent cardiomyopathy* D = Diaphragm* Costophrenic angles should be sharp* Blunted in pleural effusion* E = Equipment* Central lines* Endotracheal tubes* Chest tubes* F = Lung Fields* The most important step* Look at lung markings/tissue to evaluate for…* Pneumothorax* Consolidation* Nodules* Pulmonary Edema* G = Great vessels* Look for mediastinal widening (> 8cm)* Can be a sign of aortic injury* Looks falsely widened on AP/portable chest x-ray

Additional Reading

* How to Read a Chest X-Ray (Medgeeks)* Learn to Read a Chest X-Ray in 5 Minutes (YouTube)