EM Clerkship

* Focused Physical Exam

* Tachypnea and Hypoxemia

* Able to speak in complete sentences

* Accessory muscle use/retractions

* Moving air or quiet on auscultation

* Basic Treatment Algorithm

* Albuterol Inhaler

* Albuterol/Ipratropium Nebulized (Duoneb)

* Steroids

* IV Magnesium

* Non Invasive Ventilation (CPAP or BiPAP)

* Decreases Work of Breathing

* Epinepherine

* Less Common Treatments

* Benzodiazepines

* Ketamine

* Heliox

* Intubation (Last resort)

* Use a large ETT (8.0)

* Increase the Expiratory Time

* “Permissive Hypercapnea”

* Appropriate ventilator management of asthma frequently results in mild hypercapnia and respiratory acidosis. IT’S OK

* Air Trapping

* Results in decreased preload, obstructive shock and pneumothorax

* Suspect with high airway pressures and when waveform doesn’t return to zero (see media)

* Treat by briefly unhooking ventilator and gently pressing on the patient’s chest to get out the trapped air

* Ventilator Settings

* Decrease the respiratory rate (ex 10)

* Increase the tidal volume (although some hypercapnia is permitted)

* Increase I:E ratio (1:4 or greater)

You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes”

Initial Vitals:

HR: 123

BP: 142/78

Temp: Unknown

RR: 36

O2: 97% (NonRebreather)

Critical Actions:

* Give Albuterol, Steroids, and Magnesium

* Give either Epinephrine or Terbutaline

* Post Intubation Checklist: Sedation, Tubes, and Xray

* Choosing Appropriate Vent Settings

* Allow permissive hypercapnia

Introduction

* Used as pesticides

* Used as weapons (nerve agents)

* Sarin Gas, VX Gas, Novichok

* Transdermal, Inhalation, Ingestion

Clinical Presentation

* Muscarinic Activation (Dumbels Mnemonic)

* Defication

* Urination

* Myosis

* Bradycardia, Bronchospasm, and Bronchorrhea

* “The Killer B’s”

* Emesis

* Lacrimation

* Salivation and Sweating

* Nicotinic Activation

* Muscle weakness and paralysis

* CNS Activation

* Respiratory Depression

* Altered Mental Status

* Seizures

Treatment

* Atropine

* Reverses Dumbels

* Keep giving and doubling the dose until brochorrhea and bradycardia resolve

* Pralidoxime

* Only works before ‘aging’ occurs

* Diazepam

* Stops the seizures

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General. We are bringing you an unresponsive 6-year-old female found foaming at the mouth by her babysitter. ETA 2 minutes.”

Initial Vitals:

BP: 125/80

HR: 62

RR: 34

O2: 81% (Non Rebreather)

Critical Actions:

* Grab the Broslow!

* Fingerstick Glucose

* Choose Endotracheal Tube Size

* Administer Atropine until bronchial secretions stop

* Pralidoxime

Shoulder dystocia is an OB emergency. Remember McRobert’s maneuver and suprapubic pressure. For more information, take a look at the resources below.

References

ACOG- Shoulder Dystocia

AAFP- Shoulder Dystocia

Maddie’s 7 Cardinal Movements of a Successful Delivery:

1. Head comes out

2. Head turns

3. Cord Assessment

4. Anterior shoulder delivered

5. Posterior shoulder delivered

6. Body delivered.

7. Baby on mom’s chest

T’s of Postpartum Hemorrhage:

1. Tone

2. Trauma

3. Tissue

4. Thrombosis

The 6 STEMI Equivalents:

* Posterior MI

* ST Depression V2/V3 (or STE in V7-V9)

* Right Ventricular MI

* STE V1 associated with inferior MI ; or STE V4R-V6R

* Wellens Syndrome

* Type A: Biphasic T-waves V2/3

* Type B: Deep Symmetric T-wave Inversion V2/V3

* De Winter’s T Wave

* ST Depression with a large, symmetric, upright T wave

* STE avR with diffuse ST-Depression

* Usually a strain pattern due to underlying pathology, in correct clinical context can represent a left main or proximal LAD coronary occlusion

* Modified Sgarbossa Criteria in LBBB

* Concordant STE in any lead

* Concordant ST Depression in V1-V3

* Excessive Discordance (ST/S ratio >0.25)

Other atypical ischemic EKG findings:

* Isolated TWI in avL – early sign of inferior MI

* Hyperacute TWave

* NTTV1 (New Tall T-wave in V1)

Further Reading (see photos in the article):

ECG Diagnosis of Life-Threatening STEMI Equivalent’s: Journal of the American College of Cardiology

You are working at Clerkship Rural when the nurse hands you your next chart to see. It’s a 59 year old farmer with chest pain.

Initial Vitals:

BP: 156/97

HR: 110

RR: 22

O2: 98% (Room Air)

Temp: 98.8F

Critical Actions:

* Give Aspirin, Nitroglycerin, and Heparin

* Identify Posterior STEMI

* Assess for Thrombolytic Contraindications and Consent

* Transfer for PCI

* Diagnose Accelerated Idioventricular Rhythm (AIVR)

* The MILDLY agitated patient : verbal de-escalation or PO benzo/antipsychotic

* The MODERATELY agitated patient : IM benzo/antipsychotic

* The SEVERELY agitated patient : IM Ketamine 5mg/kg

Consider removing the terminology “Agitated Delirium” from your vocabulary, as there is significant racial bias behind this term.

You are working at Clerkship General when you hear an EMS call on the radio…

“CLERKSHIP GENERAL – We are bringing you an agitated and combative 30 year old male, we’ll see you in 5 minutes.”

Initial Vitals:

BP: 192/105

HR: 134

RR: 22

O2: 99% (Room Air)

Temp: 98.8 F

Critical Actions:

* Administer Sedation for Patient/Staff Safety

* Intubate the Patient and Obtain Chest Xray

* Diagnose Intracranial Hemorrhage

* Treat Patients Hypertension

* Diagnose Rhabdomyolysis and Give Fluids

Dangerous Actions:

* Giving Succinylcholine

* Giving B-Blocker (Controversial)

Check Out:

Procrastinators Guide to Emergency Medicine