EM Clerkship

Episode summary coming soon!

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General, we are bringing you a 3 year old female with complaints of altered mental status. We are pulling in now.”

Initial Vitals:

HR: 129

BP: 98/66

Temp: 99.7F

RR: 35

O2: 99% Room Air

Critical Actions:

* Check blood glucose

* Check ingestion labs

* Start bicarbonate drip

* Call nephrology

* Check venous blood gas

Guillain-Barre Syndrome (GBS) – Autoimmune polyneuropathy that results in widespread demylination of peripheral nerves

Typically occur 1 week after a triggering infection

Paresthesias/Neuropathic Pain -> Ascending symmetric paralysis -> Respiratory Failure

Major Diagnostic Criteria

* Progressive limb weakness in multiple limbs that is relatively symmetric

* Diminished/Absent deep tendon reflexes in affected limbs

* No alternative diagnosis

* CSF studies have false-negatives – May see albuminocytologic dissociation (Elevated protein with normal cell counts)

Treatment – IVIG and monitor respiratory status

Critical Actions:

* Treat the Patient’s Pain

* Perform a detailed neurologic exam (including reflexes)

* Perform LP

* Administer IVIG

* Check NIF or FVC and intubate prior to transfer

Orbital Compartment Syndrome – needs to be diagnosed CLINICALLY

On exam, LOOK for: Proptosis, Ophthalmoplegia, Afferent Pupillary Defect, Vision Loss

On exam, FEEL for: Rock hard globe, tense eyelids, resistance to retropulsion

IOP > 40 means immediate canthotomy is indicated!

Don’t perform if open globe is present

Lateral Canthotomy Procedure: Anesthetize, Devascularize, Canthotomy, Cantholysis (inferior crus first)

Paperclip Eyelid Retractors

You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen.

Initial Vitals:

HR: 101

BP: 138/85

Temp: 98.0F

RR: 20

O2: 99% (Room Air)

Critical Actions:

* Diagnose Retrobulbar Hematoma

* Diagnose Subdural Hematoma

* Reverse Anticoagulation

* Perform a Lateral Canthotomy Procedure

* Administer Tetanus Shot

* Elevate the Head of Bed

Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.  

The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags. 

Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’s paralysis.  

Management/treatment – thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (<185/110 if treating, <220/120 if no treatment). 

Remember that time is brain, so move fast! 

AAEM tPA Infographic

AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.”

Initial Vitals:

HR: 51

BP: 201/98

Temp: 98.0F

RR: 18

O2: 99% (Room Air)

Critical Actions:

* Check a Blood Glucose

* Activate a Stroke Alert

* Assess Contraindications to tPA

* Consent for tPA

* Transfer via Air for Thrombectomy

* Common during the first year of life as well as during puberty

* Presents with nausea/vomiting, abdominal pain, and/or testicular pain

* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)

* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex

* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound

* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US

* Attempt manual detorsion if there will be a significant delay to surgery

You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting

Initial Vitals:

HR: 119

BP: 104/63

Temp: 98.0F

RR: 20

O2: 99% (Room Air)

Critical Actions:

* Finger Stick Blood Glucose

* Treat Patient’s Pain

* Diagnose Testicular Torsion

* Immediate Urology Consult

* Perform Manual Detorsion

References:

Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.