EM Clerkship

You have 90 minutes to restore blood flow.

Step 1: Obtain EKG and Call STEMI Alert

* This activates ED resources as well as cath lab, interventional cardiology, etc

Step 2: Stop the Platelets

* Dual anti-platelet therapy* Aspirin 325mg chewed (or PR)* Plavix 600mg (not usually given in ED)* Complicates management if patient needs CABG

Step 3: Stop the Coagulation Cascade

* Heparin 60 units/kg (MAX 4000 units)

Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now

* If you DON’T have cath lab* Option 1: 30 minutes to give thrombolytics* Option 2: 120 minutes to get them to a different hospital with cath lab

Sgarbossa Criteria

* Left bundle branch block (LBBB)* PLUS* Concordant ST elevation (>1mm) in leads with positive QRS* OR* Concordant ST depression (>1mm) in leads with negative QRS* Typically V1-V3* OR* Severely discordant ST elevation (>5mm) in leads with negative QRS

“MONA”

* Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain* Oxygen has been shown to worsen outcomes if given indiscriminately* Not ideal to be giving supplemental O2 when SaO2 is 100%* Nitroglycerine* Nitroglycerine 0.4 mg SL q5min* OR* Nitroglycerin 10mcg/min drip (will need to be titrated UP)* For comparison… * 0.4 mg SL nitroglycerine releases approximately 80mcg/min* Contraindications* Inferior/Right heart infarction* Patients usually preload dependent* Nitro drops preload* Sildenafil (Viagra)* Can cause sudden/severe drop in blood pressure* Hypotension

Additional Reading

* Round 3 – Chest Pain (EM Clerkship)* The Death of MONA in ACS: Part 1 – Morphine (REBEL EM)* The Death of MONA in ACS: Part 2 – Oxygen (REBEL EM)* The Death of MONA in ACS: Part 3 – Nitroglycerine (REBEL EM)* The Death of MONA in ACS: Part 4 – Aspirin (REBEL EM)

Mnemonic: AEIOU-TIPS Step 1: Evaluate the Airway General principles “If they can’t speak, they can’t control their airway” “If GCS is <8, intubate” In the real world, it’s a clinical judgement call Postictal patients? Intoxicated patients? Step 2: Point of Care Labs Finger stick blood glucose EKG Dysrhythmia? Ischemia? Abnormal intervals? Pregnancy test Step 3: […]

Poison Control Hotline: 1-800-222-1222

Step 1: Evaluate the Airway

* General principles* “If they can’t speak, they can’t control their airway”* “If GCS is <8, intubate”* In the real world, it’s a clinical judgement call

Step 2: Toxicology History

* What did they take? * How much did they take?* Why did they take it?* When did they take it?

Step 3: Toxicology Exam

* Vital signs* Pupils* Skin

Step 4: Medication List

* Make note of all bottles with patient* Make EXTRA note if any pills seem to be missing* Bonus points if you bring your attending a med list

Step 5: Common Toxicology Tests

* Assessing for damage* Electrolytes* Liver function test* EKG* Pregnancy* Assessing for co-ingestion* Serum acetaminophen* Serum salicylate* Serum alcohol* Urine drug screen

The “Big 5” Toxidromes

* Anticholinergic* Increased vitals* Big pupils* Dry skin* Treatment – Physostigmine (rarely given)* Cholinergic* Decreased vitals* Small pupils* Moist skin* Treatment – Atropine* Opioid* Decreased vitals* Small pupils* Dry skin* Treatment – Naloxone* Sedative/Hypnotic* Decreased vitals* Normal pupils* Dry skin* Treatment – Flumazenil (rarely given)* Sympathomimetics* Increased vitals* Big pupils* Moist skin* Treatment – Benzodiazepines

Additional Reading

* NBME Shelf Review – Ophthalmology and Toxicology (EM Clerkship)* Toxidromes (Admin EM)

B→ Episode Summary

3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE.

Step 1: Is This a BRUE?

* Brief* <60 seconds* Resolved* Exam and vitals back to baseline in the ED* Unexplained* No symptoms other than event itself* Event* Concerning change in any of the following…* Tone* Color* Breathing* Mental status

Step 2: Is This Low Risk BRUE?

* Five low risk criteria* Age >2 months* Born at >32 weeks gestational age* First and only episode* No CPR by medical providers* No “Red Flags”

Step 3: Do They Have Red Flags?

* For abuse* History of SIDS/BRUE in sibling* Mental illness at home* Drug use at home* For dysrhythmia* Family history of sudden unexplained death* For infection* Fevers* Unimmunized* Sick contacts* Rash

Step 4: Examine for Non-Accidental Trauma

* Bulging fontanelle* Petechia* Torn frenulum* Blood

Step 5: Place Patient Into One of Three Categories

* NOT a BRUE* Treat as you normally would* HIGH risk BRUE* Admit* LOW risk BRUE* Discharge without testing* May consider EKG and pertussis

Additional Reading

* Brief Resolved Unexplained Events (AAP)

Airway/C-spine. Breathing. Circulation. Disability. Exposure. Secondary Survey.

Airway and C-Spine

* General airway principles* “If they can’t speak, they can’t control their airway”* “If GCS is <8, intubate”* In the real world, it’s a clinical judgement call* General c-spine principles* Clear c-spine with NEXUS/Canadian rules* Otherwise stabilize spine and place in cervical collar

Breathing

* If patient has tachypnea, hypoxemia, or respiratory distress* Give O2* Examine for tension pneumothorax* Deviated trachea* Asymmetric breath sounds* If concerned perform needle decompression* THEN* Tube thoracostomy

Circulation

* If patient has tachycardia, hypotension, or obvious blood loss* Stop the bleed* Emergent transfusion* Consider early OR if unstable* In the real world, CT is frequently obtained pre-op regardless of stability

Disability

* Pupils* GCS* If concerned for head injury* Obtain CT head without contrast

Exposure

* Fully undress the patient* Warm blankets

Secondary Survey

* Visualize everything* Palpate everything* Bedside chest/pelvic x-ray and FAST scan

Common Labs

* Type and screen* CBC* Electrolytes* Urinalysis* EKG* Blood alcohol level* Lactic acid (if concerned for shock)

Common Imaging

* CT head without contrast* CT maxillofacial without contrast* CT cervical spine without contrast* CTA neck* CT abdomen/pelvis WITH contrast* Retrograde urethrogram* Additional x-rays

Common Treatments

* Blood products* Tetanus immunization* Analgesics

Additional Reading

* Advanced Trauma Life Support (Wikipedia)* Round 5 – Geriatric Fall (EM Clerkship)

The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock.

Two Types of Priapism

* High flow (non-ischemic)* Common causes* Trauma* AV malformations* Tumors* Priapism from too much blood coming IN* Not painful* Consult urology* Low flow (ischemic)* Common causes* Sickle cell disease* Drug side-effects* Priapism from blood being unable to flow OUT* Patient requires emergent detumescence* 50% chance of erectile dysfunction

Step 1: Prepare (4c approach)

* Collect* 19G needle* 21G needle* Variety of syringes* Gauze* Sterile drape* Betadine* Normal saline* Consent* 50% chance of erectile dysfunction even with successful procedure* Clean* Set up supplies and sterile field* Control pain* Penile nerve block (YouTube)

Step 2: Drain

* Nerve/Artery/Vein on top (12 o’clock)* Urethra on bottom (6 o’clock)* Insert 19G needle at either 3 or 9 o’clock and aspirate* UPDATE: Recommended insertion at either 2 or 10 o’clock* 30% chance of detumescence at this step alone

Step 3: Send Venous Blood Gas

* Confirms high-flow (non-ischemic) from low-flow (ischemic) priapism

Step 4: Irrigate

* Inject normal saline through the needle and then aspirate

Step 5: Phenylepherine

* Dilute 1ml (10 mg/ml) in 9 ml NS (results in 1mg/ml solution)* Inject 0.25 ml of 1 mg/ml solution and repeat q10 minutes* Alpha agonist effect constricts smooth muscle and facilitates venous outflow

Additional Reading

* Dorsal Penile Nerve Block (YouTube)* Drainage of Ischemic Priapism (SinaiEM)

Never ignore a pregnant woman’s blood pressure.

Introduction

* Pre-Eclampsia* Pathophysiology unknown* Pregnancy induced multi-organ dysfunction* Definition* Pregnancy* PLUS* BP 135/85* PLUS* Proteinuria* Eclampsia* Preeclampsia* PLUS* Seizures* HELLP Syndrome* Preeclampsia* PLUS* Hemolysis* PLUS* Elevated liver enzymes* PLUS* Low platelets

Step 1: Evaluate For Four Big Symptoms

* Swelling/edema* Headache* Visual changes* Abdominal pain

Step 2: Testing

* Urinalysis* Proteinuria* CBC* Hemolysis* Thrombocytopenia* Electrolytes* Liver function tests

Step 3: Start Magnesium

* Hypomagnesemia = Hyporeflexia

Step 4: Control the Blood Pressure

* Hydralazine* Labetalol

Step 5: Admit

* OB emergency* All patients need fetal monitoring

Additional Reading

* Round 2 – Seizure (EM Clerkship)* Preeclampsia and High Blood Pressure During Pregnancy (ACOG)

With this complaint, it’s ALL about doing a good history and exam.

Step 1: Write Out Your Differential Diagnosis

* The KING* Subarachnoid hemorrhage* The QUEEN* Meningitis* 3 Killers in the BRAIN* Stroke* Hematomas* Elevated ICP/Tumors* 3 Killers in the VESSELS* Arterial dissection* Brain DVT (Dural Venous Sinus Thrombosis)* Giant cell/temporal arteritis* 3 MISCELLANEOUS killers* Preeclampsia* Carbon monoxide toxicity* Glaucoma

Step 2: How Does This Compare to Previous Headaches?

* Finding the answer to this question is not always easy!

Step 3: Do a FULL Neuro Exam

* Mental status* Neck stiffness* Extra-ocular movements* Visual fields* Cranial nerves* Speech* Motor* Sensation* Finger to Nose* Gait

Step 4: Order Tests As Necessary

* CT head without contrast* MRI brain* Lumbar puncture* ESR* Carbon monoxide level

Step 5: Give “Headache Cocktail”

* Mix and match based on personal and patient preferences* IV Dopamine antagonist* IV Antihistamine* IV Steroid* IV NSAIDS* IV Fluids* Tylenol* Triptans and opiates rarely indicated

Additional Reading

* Round 7 – Headache (EM Clerkship)* Round 11 – Headache (EM Clerkship)* Approach to Headache (SAEM)

D→ Episode Summary