EM Clerkship

Step 1: Protect the Spine

* Apply cervical collar

Step 2: Apply NEXUS Criteria

* Use the “SPINE” mnemonic* Spinal midline tenderness* Painful distracting injury* Intoxication* Neurologic deficit* Encephalopathy

Step 3: If Patient Has None of the NEXUS Criteria… You Are Done!

Step 4: If Patient Has Positive NEXUS Criteria…

* Obtain CT scan of the cervical scan without contrast

Step 5: Clear the C-Spine

* If CT scan negative -> Have patient turn head 45 degrees to right and left* If patient has no limitation and no paresthesias or neurologic deficit…* Remove collar* If still concerned for spinal injury despite normal CT* Keep collar on and have patient follow up in clinic for reexam

Unstable Cervical Spine Fractures

* Mnemonic: Jefferson Bit Off a Hangmans Tit* Jefferson fracture* Bilateral facet dislocation* Odontoid fracture* Atlantooccipital dislocation* Hangman’s fracture* Teardrop fracture

Additional Reading

* NEXUS Criterial for C-Spine Imaging (MDCalc)* Unstable Spine Fractures (WikEM)

There are 6 major areas/injuries to the face.

Basic Approach to Facial Injury

* Step 1: Airway* Indications for intubation after trauma* Burns to the airway* Rapidly expanding hematoma* GCS <8* Step 2: CT Maxillofacial Without Contrast* Step 3: Supportive Care* Stop bleeding* Apply pressure* Control epistaxis* Caution advised with packing if patient has basilar skull fracture* Ice* Analgesics* Step 4: Antibiotics* Common indications* Fractures of a sinus* Open fractures* Step 5: Consider Consulting the Appropriate Specialist* Eye trauma -> Ophthalmology* ENT trauma -> ENT* Oral/Dental trauma -> Oral/maxillofacial surgery or dentistry

Six Key Facial Injuries

* Frontal bone* Fractures of the INTERNAL frontal sinus wall = BAD* Eyes and orbits* “Blowout” fractures with entrapment of the extra-occular muscles = BAD* Nose* Septal hematoma = BAD* Zygoma (Cheekbone)* Zygomaticomaxillary complex fracture (aka Tripod fracture) = BAD* Maxilla (Upper jaw)* Le Fort fractures = BAD* Mandible (Lower jaw)* Open fractures (intraoral laceration) = BAD

Additional Reading

* Trauma Basics (EM Clerkship)* CORE EM: Facial Fractures (emDOCs)

C→ Episode Summary

CT scan without contrast is your test of choice.

Step 1: Consider Your Differential Diagnoses

* Five high-yield head trauma diagnoses* Skull fracture* External skull fracture* Basilar skull fracture* Epidural hematoma* Subdural hematoma* Traumatic subarachnoid hemorrhage (SAH)* Concussion

Step 2: Important Add-ons When Taking History

* Specific mechanism of injury* Loss of consciousness* Blood thinners/antiplatelet agents

Step 3: Important Add-ons To Your Physical Exam

* GCS Score (MDCalc)* Pupils* Basilar Skull Findings* Raccoon eyes* Battle sign* CSF rhinorrhea* Hemotympanum

Step 4: Calculate Canadian Head CT Rule

* Only apply to patients with…* Loss of consciousness* Amnesia to event* Witnessed disorientation* Exclude patients with* Blood thinners* Seizure(s)* Age <16* High risk criteria* GCS <15 2 hours post injury* Suspected open/depressed skull fracture* Signs of basilar skull fracture* 2 or more episodes of vomiting* Age >65* “Moderate” risk criteria* Retrograde amnesia >30 minutes* Dangerous mechanism* Fall >3 ft* Motor vs pedestrian* Ejected from MVA

Additional Reading

* Canadian CT Head Injury/Trauma Rule (MDCalc)* Evaluation and Management of Concussion in Sports (AAN)

W→ Episode Summary

Elderly people die from abdominal pain Step 1: Risk Stratify Certain patient groups have VERY high mortality when having abdominal pain Geriatrics Immunocompromised Diabetics Step 2: Consider Genitourinary Causes Be especially cautious with lower abdominal/flank pain Mention that you performed or considered performing GU exam during presentation! Common GU causes of abdominal pain Testicular/ovarian torsion […]

Get your attending!

Step 1: Obtain Last Known Well

* Stroke treatments including tPA and thrombectomy both require last known well* <3-4.5 hours for tPA* <24 hours mechanical thrombectomy

Step 2: Finger Stick Blood Glucose

* Hypoglycemia is classic mimic of CVA* Results can be obtained immediately

Step 3: STAT Head CT Without Contrast

* Poor sensitivity for ischemic stroke* Primary use is identification of hemorrhagic stroke* Required prior to administration of tPA!

Step 4: Perform NIHSS

* Use calculator (MDCalc)

Step 5: Give tPA (If No Contraindications)

* Follow department protocol and contraindications* Frequently being updated

Additional Reading

* tPA Basics (EM Clerkship)* 2013 AHA Stroke Guidelines (AHA)* NIH Stroke Scale/Score (MDCalc)

You need an organized, anatomical approach. Step 1: Consider Differential Diagnosis Upper airway Angioedema Foreign body Abscess Lower airway COPD Asthma Alveoli Pneumonia Pulmonary edema Blood Anemia Acidosis DKA Sepsis (lactic acid) Toxins (salicylic acid) Blood vessels Pulmonary embolism Aortic dissection Heart Myocardial infarction Acute heart failure Cardiac tamponade Step 2: Examine Anatomically Upper airway […]

6 EKG Findings. 6 Risk Factors. 6 Mimics.

Step 1: Get an EKG

* This is the only “required” test for a patient with syncope* Other common tests* CBC* Evaluate for anemia* hCG* If patient might be pregnant

Step 2: Look For 6 High Risk EKG Patterns

* Mnemonic: QT-BRIDE* QT prolongation* Especially QTc >500* Brugada pattern* Right heart strain* Tachycardia* S1Q3T3* Inverted T waves precordial leads* Ischemic changes* ST segment elevation/depression* T wave inversion* Delta waves* Seen in Wolf-Parkinson White (WPW)* Epsilon waves* Seen in arrhythmogenic right ventricular dysplasia (ARVD)

Step 3: Ask the 6 High Risk Historical Questions

* Mnemonic: CHESS +1* Cardiac history* CHF* Structural heart disease* Hematocrit <30%* “Elderly”* Shortness of Breath* Systolic BP <90* (+1) Family history of sudden cardiac death

Step 4: Consider 6 Deadly Syncope Mimics

* 15% of the following diseases reportedly present as “syncope”* AKA “Rule of 15s”* Subarachnoid hemorrhage* Myocardial infarction* Pulmonary embolism* Aortic dissection* Abdominal aortic aneurysm* Perforated GI* Ulcers* Ectopics

Additional Reading

* QT Intervals (LITFL)* Brugada Syndrome (LITFL)* Right Heart Strain (LITFL)* Delta Wave (LITFL)* Epsilon Wave (LITFL)

Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone.

Oral Acetaminophen (Tylenol)

* Give every 4-6 hours* Regular strength – 325mg* Extra strength – 500mg* Maximum Daily Dose – 3000mg

Oral Ibuprofen (Advil)

* NSAID* Give every 4-6 hours* Regular strength – 200mg* Therapeutic Ceiling – 400mg

Oral Hydrocodone-Acetaminophen (Vicodin, Norco)

* Give ever 4-6 hours* Common doses – 5-325mg, 7.5-325mg, and 10-325mg

IV/IM Ketorolac (Toradol)

* NSAID* Common dosing – 15-30mg* Therapeutic ceiling – 10mg

IV/IM morphine

* Classic dose (0.1mg/kg)* This would be 7-10mg in adults!* More COMMON dosing is 4mg* Repeat as needed

IV/IM Hydromorphone (Dilaudid)

* COMMON dosing – 0.5-1mg * This drug is notorious for bringing you to peer-review/MM conference* Be careful!

Contraindications to NSAIDS

* Pregnant patients* Elderly patients* Renal disease patients* Cardiac patients* GI/ulcer patients

Side Effects of Opiates

* Sedation* No driving* Do not mix with alcohol* Do not mix with other sedatives* Constipation* Opiate dependency/addiction

Additional Reading

* Pain Management In the Emergency Department: A Review (PubMed)* Myths in EM: The Anti-Inflammatory Properties of NSAIDS (ACEP Now)