EM Clerkship

Phase One: CNS

* Ataxia, Slurred Speech, Confusion, N/V, Seizures

Phase Two: Cardiopulmonary

* CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS

Phase Three: Renal

* Flank pain, Hematuria, Oliguria, Renal Failure

Diagnosis:

* HIGH INDEX OF SUSPICION

* Ethylene Glycol Serum Level

* Elevated Osmolar Gap

* Serial Anion Gap Measurements

Treatment:

* Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid

* Hemodialysis

* Consider Bicarb drip, pyridoxine, and thiamine

Further Reading:

EMCrit Toxic Alcohols

You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again

Initial Vitals:

HR: 116

BP: 150/70

Temp: 98.8

RR: 26

O2: 85% (Room Air)

Critical Actions:

* Recognize Hypoxemia

* Diagnose Toxic Alcohol Ingestion

* Consult Nephrology Emergent Dialysis

* Administer Fomepizole

* Workup Anion Gap Metabolic Acidosis

Hypertensive Emergencies of Pregnancy

PreEclampsia, Eclampsia, HELLP syndrome

Diagnosis: BP >140/90 plus end organ dysfunction

* Acute Kidney Injury

* Proteinuria

* Thrombocytopenia

* Transaminitis

* Hemolysis

* Pulmonary Edema

* Cerebral Edema / Hemorrhage

* Headache refractory to tylenol

* Visual Changes

* RUQ Pain not attributable to another diagnosis

Treatment

* Loading Dose: IV Magnesium 4-6g over 20-30 min OR 5g IM in each buttock

* Maintenance Dose: 1g/hr IV

* Antihypertensives (goal 20% reduction): Labetalol, Nicardipine, Hydralazine

* Delivery of fetus and placenta

You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache.

Initial Vitals:

HR: 56

BP: 172/93

Temp: 98.8F

RR: 18

O2: 97%

Critical Actions:

* Check a Blood Glucose

* Diagnose Preecclampsia/Ecclampsia

* Administer Magnesium

* Treat the Hypertension

* Discuss with OBGYN and Admit

Diagnosing PE:

Step 1: Consciously consider the diagnosis

Step 2: Risk Stratify into low, intermediate, and high risk

Step 3: Choose appropriate testing based on pre-test probability

Classification of PE

* High Risk/Massive PE: Hemodynamic Instability

* Intermediate Risk/Submassive PE: Right Heart Strain without instability ; or PESI Class 3+

* Low Risk/Non-Massive PE: Everything else (no instability, no heart strain, PESI Class 1-2)

Treatment of PE

* High Risk/Massive PE: Thrombolytics and often thrombectomy

* Intermediate Risk/Submassive PE: Heparin and sometimes intervention

* Low Risk/Non-Massive PE: Either discharge with DOAC or admit with heparin

You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.”

Initial Vitals:

HR: 122

BP: 75/40

Temp: 100.1

RR: 24

O2: 74%

Critical Actions:

* Obtain full set of vital signs

* Treat the patient’s pain

* Diagnose PE without imaging

* Stabilize patient prior to imaging

* Transfer the patient for thrombectomy

Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion

* Hypovolemic Shock

* Hemorrhage

* Volume Loss (vomiting/diarrhea, dehydration)

* Cardiogenic Shock

* ACS, Myocarditis, CHF, Valve failure, Endocarditis, etc

* Obstructive Shock

* Massive PE, Tension Pneumothorax, Cardiac Tamponade

* Distributive Shock

* SIRS (Septic Shock, Pancreatitis, Severe Burns)

* Anaphylactic Shock

* Neurogenic Shock

* Adrenal Crisis

You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision”

Initial Vitals:

HR: 65

BP: 88/50

Temp: 97.0F

RR: 20

O2: 96% Room Air

Critical Actions:

* Apply Cervical Collar

* Treat the Patient’s Pain

* Give Antibiotics for Open Fracture

* Identify and Prioritize Etiologies of Shock in Trauma

* Start Vasopressors for Neurogenic Shock

* Differential

* Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter

* Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors

* Work-up

* XRay

* Labs to evaluate for septic arthritis – CBC BMP ESR CRP

* Kocher Criteria

* Non-weight bearing

* Fever >38.5C

* ESR >40

* WBC >12

* Kocher Criteria Statistics

* 0 points: 0.2% (or 2% in prospective studies)

* 1 point: 3% (or 9% in prospective studies)

* 2 points: 40%

* 3 points:93%

* 4 points: 99%

* Septic Arthritis DX

* >50,000 WBC

* Age 0-3mo : group B strep

* Age 3mo – 12 years: Staph Aureus

* Age 12-18 years: Gonorrhea

* Sickle Cell Disease: Salmonella

You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury.

Initial Vitals:

HR: 112

BP: 97/67

Temp: 99.2F

RR: 20

O2: 97% Room Air

Critical Actions:

* Consider Non-Accidental Trauma

* Evaluate for Septic Arthritis

* Treat the Childs Pain

* Diagnose Lyme Disease

* Prescribe Antibiotics (Avoid Doxycycline)