EM Clerkship

Don’t forget to do a thorough GU exam!

Step 1: Write Out Your Differential Diagnosis

* Remember 2-4-2-4* (2) In the upper abdomen* Pyloric stenosis* Pneumonia* (4) In the lower abdomen* Hirschsprung’s disease* Intussusception* Appendicitis* Hernia* (2) Genitourinary* UTI* Testicular/Ovarian torsion* (4) Generalized* Volvulus* Necrotizing enterocolitis* Henoch Schonlein Purpura* Diabetic ketoacidosis

Step 2: Do Pediatric History and Exam

* Pediatric assessment triangle* Appearance* Breathing* Color* Birth history* Gestational age* Complications* Eating/drinking/peeing/pooping* Immunizations* Physical exam* Don’t forget GU exam!

Step 3: Five Important Tests

* Finger stick blood glucose* Urinalysis* Chest x-ray* Abdominal x-ray* Abdominal ultrasound

Step 4: Common Treatments

* Fever/Pain* Acetaminophen* Vomiting* Zofran* Diarrhea* NOTHING* Dehydration* Pedialyte

Additional Reading

* Pediatrics History (EM Clerkship)* Pediatrics Exam (EM Clerkship)

Tank. Clogged Pipes. Broken Pipes. Pump.

Introduction

* “Tank”* Hypovolemic shock* Hemorrhagic shock* “Clogged Pipes”* Cardiac tamponade* Tension pneumothorax* Pulmonary embolism* “Broken Pipes”* Septic Shock* Neurogenic Shock* Anaphylactic Shock* “Pump”* Cardiogenic Shock

Step 1: Fill the Tank

* Establish an IV* IO line alternative in emergent situations

Step 2: Consider Clogs

* Cardiac tamponade* Diagnosis: Ultrasound* Treatment: Pericardiocentesis* Tension pneumothorax* Diagnosis: Clinical/Xray/Ultrasound* Treatment: Needle decompression and tube thoracostomy* Pulmonary embolism* Diagnosis: Clinical/CTA* Treatment: Thrombolytics

Step 3: Squeeze the Pipes

* Administer vasopressors* Most common: Norepinephrine* Alternatives: Epinephrine, Phenylepherine

Step 4: Analyze the Pump

* Get an EKG* Ischemia = Aspirin/Heparin/Cath lab* Dysrhythmia = Electricity

Additional Reading

* Airway Part 1 – Immediate Actions (EM Clerkship)* Breathing (EM Clerkship)* RUSH Exam (EMCrit)

Hypoxemia fixed by only TWO things: FiO2 and PEEP

Step 1: Add FiO2

* If the patient is breathing…* Nasal cannula* Non-rebreather mask* If the patient is NOT breathing…* Bag-valve mask

Step 2: Add PEEP

* *Cannot be completed in 60 seconds, but equipment can be requested* If patient is breathing…* BiPAP* If the patient is NOT breathing…* Intubation

Additional Reading

* Ventilator Basics (EM Clerkship)* Airway Part 1 – Immediate Actions (EM Clerkship)* Circulation (EM Clerkship)

“Airway” does not necessarily mean “Intubation”

Introduction

* In emergency medicine we are taught “A-B-Cs”* These are actions that can be accomplished in first 60 seconds of patient encounter* Intubation takes several minutes to accomplish* Intubating a crashing patient might even KILL them!* Resuscitate THEN intubate

Step 1: Suction

* Immediately suction if patient is…* Altered and vomiting* Gurgling

Step 2: Move the Tongue

* Bedside maneuvers* Head tilt* Chin lift* Jaw thrust* Adjunct equipment* Oropharyngeal airway* Nasopharyngeal airway

Additional Reading

* Airway Part 2 – BVM Adjuncts (EM Clerkship)* Airway Part 3 – Rapid Sequence Intubation (EM Clerkship)* Airway Part 4 – What to Do If Intubation Fails (EM Clerkship)* Laryngoscope As A Murder Weapon – Hemodynamic Kills (EMCrit)

Don’t forget to wear protective gear. Gown up!

Initial Encounter

* History* Anticoagulants* Easy bleeding/bruising* Lightheadedness* Exam* Pallor* Tachycardia/Hypotension

Step 1: Put on Personal Protective Equipment

* Gown* Gloves* Mask* Eye Protection

Step 2: Clear Nose and Visualize Bleeding

* Have patient blow out/remove any clot and look for source of bleed* Kiesselbachs plexus* “Anterior” epistaxis* Sphenopalatine artery* “Posterior” epistaxis* Most severe/dangerous form

Step 3: Spray In Oxymetazoline (Afrin)

* Hold pressure for 15 minutes after initial application

Step 4: Cauterize With Silver Nitrate

* Avoid bilateral cauterizations* Can cause septal perforation* Anesthetize as necessary* 4% lidocaine on gauze and leave in nose for 10 minutes prior to cauterization

Step 5: Pack the Nose

* Multiple commercial products available for this* The utility of antibiotic prophylaxis at this step is unclear* Patient goes home with packing in place

Additional Reading

* Epistaxis Management (EM:RAP)

There are six cardiopulmonary causes of chest pain that you need to know.

The SIX Causes

* Cardiac* Acute coronary syndrome (ACS)* Pericarditis with tamponade* Pulmonary* Pneumonia* Pneumothorax* Vascular* Pulmonary embolism* Aortic dissection

Step 1: Core Measures

* Aspirin* EKG

Step 2: Look for the “King” (Acute Coronary Syndrome)

* Four high yield symptoms* Radiation to the RIGHT shoulder* Vomiting* Worsens with exertion* Diaphoresis

Step 3: Look for the “Queen” (Pulmonary Embolism)

* Wells score* PERC rule

Step 4: Print a Previous Cath Report

* Major bonus points with attending!* Other useful information* Previous echocardiograms* Previous stress tests* Previous CTAs for PE

Step 5: Basic Testing Plan

* If concerned for cardiac causes* Troponin* If concerned for pulmonary causes* Chest x-ray* If concerned for vascular causes* CTA of the chest

Additional Reading

* STEMI (EM Clerkship)* Pulmonary Embolism (EM Clerkship)

Patient presentations are the single most important skill to develop for your Emergency Medicine rotation.

General Principles

* Stay focused, thorough, and organized* Write out the basic 8-step presentation for reference

The 8-Step Patient Presentation

* Summary statement* Demographics* Risk factors/Past medical history* Chief complaint* History* OPQRST* Try to give at least 4 descriptors* This is for billing reasons* Pertinent positives/negatives* Give approximately 5 most pertinent symptoms* Vitals* Physical exam* Give approximately 3 MOST pertinent findings * Differential diagnosis* Briefly argue for/against* Include both most likely and most dangerous* Testing plan* Treatment plan* This is the most commonly forgotten step of presentation

Additional Reading

* Abdominal Pain Presentation – History (EM Clerkship)* Abdominal Pain Presentation – Exam, Plan, and Disposition (EM Clerkship)* Patient Presentations in Emergency Medicine (EMRA)

To Do Well On WRITTEN Exam

* Study the “Core 4” body systems* Neurology* Headache* Strokes* Meningitis* Cardiology* Chest pain* ACS* EKG interpretation* Pulmonary* Shortness of breath* PE* GI* Abdominal pain* Nausea/vomiting* Appendicitis

To Do Well In the DEPARTMENT

* Study the “other stuff”* Epistaxis* Foley catheter issues* Rectal bleeding* Laceration repair* Rashes* Geriatric falls* Suicidal ideation* The list goes on and on…

Additional Reading

* Emergency Medicine Advanced Clinical Subject Exam Content Breakdown (NBME Website)