EM Clerkship

By Zack Olson, MD and Michael Estephan, MD

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The purpose of this podcast is to help medical students crush their emergency medicine clerkship and get top 1/3 on their SLOE. The content is organized in an approach to format and covers different chief complaints, critical diagnoses, and skills important for your clerkship.

Episode Date
Interviews Part 1 – Crafting your schedule
Understand the timeline – research programs to find out when they extend invites and when they host interviews Prepare for invitations – set up email and text notifications, get a calendar Accept invitations – respond promptly and keep your calendar updated Optimize invitations – any interview date you get is a good one, but planning […]
Sep 29, 2022
Ectopic Pregnancy (Deep Dive R2 MW)
Summary of Key Points 1. You should consider ectopic pregnancy in every patient who is capable of bearing children 2. If a patient of child bearing age presents with severe abdominal pain or vaginal bleeding and is either hemodynamically unstable or very ill appearing, this is a ruptured  ectopic pregnancy until proven otherwise and I […]
Sep 18, 2022
Round 2 (MW) – Abdominal Pain
You are working at Clerkship General when the next chart gets handed to you – a 31 year old female presenting with abdominal pain. Initial Vitals: BP: 109/65 HR: 96 RR: 21 O2: 99% Temp: 99.1F Critical Actions: Obtain pregnancy test Confirm IUP Administer Rhogam Treat UTI Counsel the patient and discharge them Further Reading: […]
Sep 01, 2022
Selecting Programs
Things to consider when selecting residency programs to apply to:  1.  What type of program (County, Community, Academic) 2.  What length of program (3 year vs. 4 year) 3.  Location 4.  Culture and Lifestyle 5.  Niches in EM Further Resources: EMRA Residency MapDoximity NavigatorSAEM Residency FairEMRA Residency Fair
Aug 17, 2022
3 Steps to assessing your competitiveness for matching in an EM residency:  1.  Get a good advisor. 2.  Look at the data. 3.  Maximize your potential. Further Reading: EMRA – Apply smarter not harderEMRA HangoutsEMRA Student-Resident Mentorship ProgramNRMP Charting the OutcomesNRMP Residency DataALiEM – Match AdviceUTSW Texas STAR
Aug 17, 2022
Should I go into EM? Pt 2
The future of emergency medicine seems bleak. Listen to Zack’s perspective on the future of our beloved specialty in part TWO of this two-part series.
Aug 15, 2022
Round 1 (MW) – Shortness of Breath
You are working your FIRST SHIFT EVER at Clerkship General hospital when a 60 year old female presents with shortness of breath. Initial Vitals: HR: 92 RR: 28 BP: 120/80 O2%: 89% Temp: 101.2F Critical Actions: Obtain full set of vital signs Diagnose PNA and COPD exacerbation Administer appropriate antibiotics Treat symptoms with steroids and […]
Aug 01, 2022
Should I go into EM? – Part 1
The future of emergency medicine seems bleak. Listen to Zack’s perspective on the future of our beloved specialty in part one of this two-part series.
Jul 19, 2022
Round 35 (Pediatric Trauma)
You are working at *rural* Clerkship General when you receive a radio call from EMS – 7yo male from a severe bus accident with a large scalp laceration, unable to control the hemorrhage. Initial Vitals HR: 136 RR: 22 BP: 80/35 O2%: 100% Temp: 98F Critical Actions: Perform ATLS Algorithm Control Hemorrhage Transfuse pRBCs Replete […]
Jul 01, 2022
Bradycardia (Deep Dive R34)
Asymptomatic Bradycardia – usually don’t treat Symptomatic Stable Bradycardia – atropine, further workup Symptomatic Unstable Bradycardia – SIMULTANEOUS treatment with medications and electricity Meds: Trial of atropine, then either epinephrine, dopeamine, or isoproterenol Electricity: Transcutaneous Pace –> TVP DDX of Bradycardia – BRADIE Blocks (av blocks) Reduced vital signs (hypoxemia, hypothermia, hypoglycemia) Acs (acute coronary […]
Jun 15, 2022
ERAS 2 of 2 – How to fill out the CV section
What is most important to programs from ERAS? SLOEs, clinical grades on EM rotations and residency interviews. How do you look good on interviews? Have a thorough ERAS application that gives interviewers lots to ask about! On ERAS, there are four sections in the curriculum vitae portion: Education – honorary societies, medical school awards, other […]
Jun 09, 2022
ERAS 1 of 2 – The 8 parts of the application
ERAS Pt 1: The 8 Parts of the ApplicationThere are 8 parts to the application: Personal and Biographic Information – mostly self-explanatory Curriculum Vitae (Resume) – keep an updated CV throughout medical school to makethis easy to fill out, be concise but specific Personal Statement – start early Letters of Recommendation – should ideally have […]
Jun 03, 2022
Round 34 (Shortness of Breath / Bradycardia)
You are working at Clerkship General when you are called to see a 70 yo male who is presenting with shortness of breath. Initial Vitals Temp 98.0 HR 36 RR 28 BP 80/35 O2 82% Critical Actions Interpret ECG Correctly (3rd degree AV block) Order a troponin Perform and Describe transcutaneous pacing Perform and Describe […]
Jun 01, 2022
Ventilator Alarms (Deep Dive R33)
DOPES D-Displacement – endotracheal tube dislodges from trachea, or falls into right mainstem bronchus O-Obstruction – Mucous plugging, bronchospasm, patient biting tube P –Pneumothorax – Look out for pneumothorax, it can be subtle E – Equipment – Disconnected/unpowered equipment, ensure everything is powered on and connected appropriately S – Stacking – common in asthma/COPD due […]
May 15, 2022
Personal Statement Pt 2 – Brainstorming Ideas
Brainstorming ideas – how to make it personal What makes me unique? 2. What are some specific experiences I’ve had in my life that have either made me want to do EM or given me the skills that will prepare me well for training in EM? 3. If a family member or a friend were […]
May 02, 2022
Personal Statement Pt 1 – Dos and Donts
Welcome to EM Clerkship Maddie Watts! The personal statement should be *personal* and should *make a statement*. Start early Use solid organizational structure Address the big three questions – who? what? why? Check for grammar mistakes Explain any red flags Further Reading: EMRA / CORD Advising Guide NRMP Program Director Survey ALiEM Match Advice Series
May 02, 2022
Round 33 (Respiratory Distress)
You are working at Clerkship General when you are called to the resuscitation bay for a 55yo M presenting in respiratory distress. Initial Vitals Temp 99.9 HR 110 RR 22 BP 122/82 O2 82% on BiPAP 10/5 100%FiO2 Critical Actions Correctly interpret CXR #1 (multifocal PNA) Correctly interpret CXR #2 (bilateral PNTX) Treat with Oseltamivir […]
May 01, 2022
Toxic Plants (Deep Dive R32)
Cardiac Glycoside containing plants : Foxglove, Lilly of the Valley, Oleander, Squill Contain cardiac glycosides, which act as a negative chronotrope as well as a positive inotrope. Patients present with nausea, vomiting, visual changes, bradycardia/arrhythmia, and may develop hyperkalemia – a poor prognostic factor Treatment is Digibind/DigiFAB – look out for the side effects of […]
Apr 15, 2022
Round 32 (Pediatric Vomiting)
You are working at Clerkship General when you see your next patient : a 3 year old male accompanied by his father with chief complaint of vomiting.  Initial Vitals Temp 98.6 HR 50 RR 20 BP 95/55 O2 100% Critical Actions Identify the history of ingestion Check a blood glucose Call Poison Control Treat with […]
Apr 01, 2022
Opioid Use Disorder (Deep Dive R31)
Opioid overdose is the number one leading cause of death in adults under the age of 50. Many ED Physicians fail to recognize that offering MAT (medication assisted therapy) to victims of opiate overdose is one of the most effective interventions we can offer in medicine. 1 in 2 using high-dose buprenorphine (≥ 16 mg) […]
Mar 15, 2022
Round 31 (Altered Mental Status)
Critical Actions: Administer Naloxone Minimize Unnecessary Testing Discuss options for Rehab Offer opioid replacement therapy Provide Social Support Further Reading: Buprenorphine – EMDocs Naloxone – EMDocs Initiating Opioid Treatment in the ED – ACEP
Mar 01, 2022
Atrial Fibrillation (Deep Dive R30)
AFib with Rapid Ventricular Rate (RVR) – Rate >110 Primary AFib – Patients symptoms or their hemodynamic instability is due to the AFib itself. Treatment is by rate or rhythm control. Secondary AFib – Patients AFib rate or their hemodynamic instability is due to an underlying secondary process (eg thyrotoxicosis, PE, sepsis, drugs, etc). Treatment […]
Feb 15, 2022
Round 30 (Chest Pain)
You are working a shift at Clerkship General Hospital when you go see your next patient, a 70 year old male presenting with chest pain. Initial Vitals Temp 98.7 HR 140 RR 20 BP 125/85 O2 99% Critical Actions Obtain EKG Treat AFib RVR via rate control (and not cardioversion) Diagnose Acute Arterial Occlusion Treat […]
Feb 01, 2022
tPA (Deep Dive R29)
tPA usage is controversial. Listen to find out why. Read more to form your own opinions. Episode Sources: After Re-Analysis, No Trials Show Efficacy of tPA in Acute Ischemic Stroke Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department Why we can’t trust clinical guidelines […]
Jan 15, 2022
Round 29 (Weakness)
Initial Assessment: Obtain Vitals and blood glucose level Time of onset (important for tPA/TNK vs thrombectomy) Neurologic and Cardiac Examination / NIHSS do not delay head CT to complete NIHSS, can always finish after CT Assess contraindications for tPA Workup: Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck CXR and UA (infections can cause recrudescence […]
Jan 01, 2022
Trauma (Deep Dive R28)
ATLS – Advanced Traumatic Life Support Primary Survey Airway Breathing Circulation Disability Exposure Secondary Survey Head to Toe Examination Look for injury patterns and important injuries, such as Battle Sign (post auricular ecchymosis) Raccoon Eyes (infraorbital ecchymosis) Hemotympanum Nasal Septal Hematoma Urethral Injuries Circumferential Burns Obtain a basic medical history Obtain XRs, FAST exam, CT […]
Dec 15, 2021
Round 28 (Burn)
You are working a shift at ABEM General when you receive a call from EMS over the radio for a patient involved in a house fire. Initial Vitals Temp 99.0 HR 150 RR 40 BP 90/50 O2 95% Critical Actions Administer 8L IVF in first 8 hours Administer supplemental oxygen for CO poisoning Administer TDAP […]
Dec 01, 2021
Pelvic Inflammatory Disease (Deep Dive R27)
50% of cases of Pelvic Inflammatory Disease (PID) is caused by common STIs (Gonorrhea, Chlamydia ) but up to 50% is caused by native vaginal flora/other organisms No SINGLE historic, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID Women with PID may be asymptomatic!! Presumptive treatment of PID […]
Nov 15, 2021
Round 27 (Back Pain, Dysuria, Knee Pain)
You are working a shift at ABEM General when three patients check in simultaneously at the start of your shift at 6AM. Initial Vitals#1 (Ms. Taylor, 65F with Back Pain) Temp 98.8 HR 120 RR 22 BP 210/110 O2 97% Critical Actions#1 (Ms. Taylor, 65F withBack Pain) Obtain Medication/Social Hx (Ciprofloxacin use, Cocaine use) Diagnose […]
Nov 05, 2021
Cardiac Tamponade (Deep Dive R26)
Cardiac Tamponade Cardiac Tamponade – A physiological state caused by a pericardial effusion in which the pressure in the pericardial sac is higher than the pressure inside the right sided chambers of the heart, leading to impaired filling, decreased cardiac output, and hemodynamic collapse. Pericardial Effusions – Can be caused by infections, rheumatologic diseases, malignancy, […]
Oct 15, 2021
Round 26 (Stridor, Vomiting, Shock)
Case Introduction You are working a shift at your local free-standing emergency room when a family of three checks in to be seen (a father and his two sons). Initial Vitals#1 (Chris, 18mo with stridor) Temp 100.4F HR 120 RR 40 O2 93% Critical Actions#1 (Chris, 18mo with stridor) Check pulse oximetry (hidden) Administer PO […]
Oct 01, 2021
Hyponatremia (Deep Dive R25)
Hyponatremia in the ED Four questions to ask yourself: Is the patient symptomatic from their hyponatremia (confusion, nausea/vomiting, ams, seizures, etc)? If not, outpatient followup (unless super low) Is the patient having severe neurologic symptoms from their hyponatremia? (seizures, AMS) If yes, treat with hypertonic saline (3%) Is the patient going to be admitted from […]
Sep 15, 2021
Round 25 (Seizure)
CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you are called to the waiting room by the charge nurse for a seizing patient. Initial Vitals Temp 99.0F HR 97 RR 16 BP 120/80 O2 90% Critical Actions Perform airway maneuvers to clear obstruction Administer IV Benzodiazepines […]
Sep 01, 2021
Acetaminophen Overdose (Deep Dive R24)
Acetaminophen Overdose & Toxicology Pearls History: Figure out how much was taken, what time the ingestion occurred, and if any other toxins were ingested Physical Exam: Perform a regular physical exam, and in addition, perform the toxicologic physical exam! Check pupil size Assess neuromuscular status for rigidity/clonus Perform the “toxicologist handshake” Listen to bowel sounds […]
Aug 16, 2021
Round 24 (Altered Mental Status)
CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you receive a radio call from EMS who are bringing in a young female who was found unresponsive. Initial Vitals Temp 98.0F HR 97 RR 16 BP 120/80 O2 98% Critical Actions Obtain collateral history from EMS/friends Administer […]
Aug 01, 2021
Asymptomatic Hypertension (Deep Dive R23)
Asymptomatic Hypertension Make SURE the patient isn’t having symptoms of end organ dysfunction, which could make this hypertensive emergency (confusion, severe headache, blurry vision, weakness, chest pain, shortness of breath, seizures during pregnancy, etc). ACEP clinical policy states, that in the patient with true asymptomatic hypertension who presents to the emergency department, no routine testing […]
Jul 15, 2021
Round 23 (High Blood Pressure)
CAUTION: THESE NOTES CONTAIN SPOILERS!! Case Introduction You are working a shift at EM Clerkship General when you are handed the next chart, a 60 year old male presenting with high blood pressure. Initial Vitals Temp 98.0F HR 90 RR 18 BP 220/120 O2 98% Critical Actions Perform thorough neurological exam (and find papilledema) Diagnose […]
Jul 01, 2021
Neonatal Resuscitation (Deep Dive R22)
Neonatal Resuscitation *THIS IS A BASIC FRAMEWORK AND IS NOT COMPREHENSIVE* EVALUATE Is the newborn crying/breathing spontaneously? Does the newborn have good tone? Is the newborn a term infant? If YES, hand baby to mom for direct skin-to-skin. If NO, proceed to step 2. INTERVENE STIMULATE – dry vigorously WARM – place cap on head, […]
Jun 15, 2021
Round 22 (Cardiac Arrest)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkship General when the triage nurse runs and grabs both you and your attending for a patient in triage who has active CPR in progress. Initial Vitals Temp 98.0F HR 0 RR 0 BP unmeasurable O2 70% Critical Actions Identify pregnancy […]
Jun 01, 2021
Torsades de Pointes (Deep Dive R21)
Torsades de Pointes (TdP) A type of polymorphic ventricular tachycardia that is inherently unstable and often quickly degrades into ventricular fibrillation. It usually occurs in the setting of a prolonged QT interval, which can either be genetic or acquired. Treatment Defibrillation – per ACLS, ventricular tachycardia with a pulse should receive synchronized cardioversion. But in […]
May 15, 2021
Round 21 (Drowning)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkship General when EMS calls you on the radio… “Hey doc we’re bringing a young female who drowned in a pool ETA 1 minute”. Initial Vitals Temp 95.0F HR 55 RR 5-6 BP 110/82 O2 90% Critical Actions Evaluate for traumatic […]
May 01, 2021
Kawasaki Disease (Deep Dive R20)
Kawasaki Disease A small vessel vasculitis that affects children, usually <5 years old. Symptoms – remember the CRASH AND BURN mnemonic! Conjunctivitis Rash – nonspecific morbilliform or maculopapular rash, usually on torso Adenopathy – usually unilateral cervical lymphadenopathy Strawberry Tongue – erythema, swelling, or cracking of lips/mucous membranes Hands – swelling, erythema, or desquamation of […]
Apr 15, 2021
Round 20 (Dehydration)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when the next chart is handed to you – a four year old male named Tommy with chief complaint of dehydration. Initial Vitals Temp 100.4F HR 132 RR 22 BP 98/64 O2 98% Critical Actions Identify key historical findings […]
Apr 01, 2021
Beta Blocker Overdose (Deep Dive R19)
“The Brady Bunch” – Beta-Blockers, Calcium Channel Blockers, Digoxin, Clonidine Treatment of Beta Blocker OD Activated Charcoal – Only if ingestion time was <1 hour ago, and only if patient is protecting their airway (or intubated).   2. Glucagon – the best answer for the exam, unlikely to work in real life 3. Epinephrine Drip […]
Mar 15, 2021
Round 19 (Bradycardia)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when you are called to the resuscitation bay to see an elderly patient with unstable vitals brought in by EMS. Initial Vitals Temp 98.0F HR 43 RR 18 BP 60/40 O2 98% Critical Actions Diagnose the etiology for the […]
Mar 01, 2021
Deep Dive - Round 18
Four definitions you must know: SIRS – Must have at least 2 of 4 SIRS criteria (listed below): Fever (>38C) or Hypothermia (<36C) WBC >12k or <4k ; OR Bandemia >10% Tachycardia > 90 Tachypnea > 20 SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc) SEVERE SEPSIS […]
Feb 16, 2021
Round 18 (Fatigue)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a 20yo female accompanied by her mother checks into the ER with chief complaint of fatigue. Initial Vitals Temp 101.2F HR 122 RR 22 BP 110/90 O2 98% Critical Actions Obtain travel history in patient presenting with fever […]
Feb 01, 2021
Round 17 (Postpartum Fever)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a sepsis alert is paged overhead for a young female  who appears diaphoretic and confused. Initial Vitals Temp 102.7F HR 145 RR 32 BP 141/85 O2 93% Critical Actions Workup and treat for sepsis upfront (Cultures, Lactate, IVF, […]
Jan 01, 2021
Round 16 (Allergic Reaction)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise beautiful Friday afternoon when a mother brings her 16 year old son to the ED with chief complaint of allergic reaction.   Initial Vitals Temp 98.7 HR 155 RR 28 BP 125/85 O2 99% Critical Actions Interpret ECG Interview […]
Dec 01, 2020
Round 15 (Syncope)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at Clerkship General when a 51 year old female is brought in after a syncopal episode. Initial Vitals Temp 100.2 HR 132 RR 28 BP 105/69 O2 85% Critical Actions Give supplemental Oxygen Diagnose Pulmonary Embolism Administer Heparin Assess contraindications for tPA Administer […]
Nov 01, 2020
Round 14 (Shortness of Breath)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise quiet night when a young male is brought into your ED in obvious respiratory distress. Initial Vitals Temp 98.6 HR 99 RR 34 BP 105/69 O2 95% Critical Actions Give Albuterol + Ipratropium + Steroids Obtain Chest Xray Give […]
Oct 01, 2020
Round 13 (Dizziness)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working at your local hospital when the next chart gets put in your rack. You groan. The chief complaint is dizziness.. Initial Vitals Temp 98.6 HR 109 RR 20 BP 105/69 O2 100% Critical Actions Diagnose Upper GI Bleed Initiate IV Proton Pump Inhibitor Obtain Type […]
Sep 01, 2020
The website it updated! Please check it out and email me with any technical issues or other comments/concerns. Enjoy your shift!
Aug 01, 2020
Round 12 (Difficulty Breathing)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A young gentlemen runs out to triage yelling “I can’t breath!” and collapses to the floor in front of the nurse… Initial Vitals Temp 98.8 HR 145 RR 45 BP 60/30 O2 85% Critical Actions Give Supplemental Oxygen Identify Pneumothorax Prior to Imaging Correctly Perform Needle Thoracostomy Correctly […]
Jul 01, 2020
Round 11 (Headache)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are having a busy day in the department when you are paged overhead to the resuscitation bay for an ill appearing patient with a headache… Initial Vitals Temp 98.9 HR 99 RR 18 BP 180/110 O2 94% Critical Actions Verbalize a Full Neurologic Examination Obtain CT Scan […]
Jun 01, 2020
Round 10 (Allergic Reaction)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A 45 year old female is exposed to peanut butter and shrimp pizza and begins to have an apparent allergic reaction… Initial Vitals Temp 98.8 HR 130 RR 35 BP 70/40 O2 92% Critical Actions Verbalize Airway Evaluation Complete a FOCUSED History and Exam Normal Saline Bolus Epinephrine […]
May 01, 2020
Round 9 (Seizure)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse brings back a young adult male from the lobby who is having a seizure… Initial Vitals Temp 98.8 HR 90 RR 10 BP 120/80 O2 92% Critical Actions Verbalize ABCs on a Critical Patient Obtain Immediate Blood Glucose Level Give Benzodiazepine Initiate Workup of New-Onset Seizures […]
Mar 01, 2020
Round 8 (Fall)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction EMS brings in an elderly man who has fallen… Initial Vitals Temp 98.6 HR 58 RR 16 BP 105/60 99% Critical Actions Treat the patient’s pain Consult orthopedics for a hip fracture Obtain an EKG Treat Severe Hyperkalemia Consult nephrology for dialysis Final Diagnosis Ground level fall resulting […]
Feb 01, 2020
Round 7 (Headache)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction Just a routine day at your hospital, your next patient has a chief complaint of headache… Initial Vitals Temp 98.8 HR 88 RR 16 BP 130/80 O2 99% Critical Actions Identify Acute Angle Closure Glaucoma Initiate Appropriate Treatment for Acute Angle Closure Glaucoma Emergent Consult to Ophthalmology Recheck […]
Jan 01, 2020
Round 6 (Back Pain)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A notorious, disheveled frequent flyer presents to your emergency department for her back pain and is asking for more Dilaudid… Initial Vitals Temp 99.0 HR 99 RR 18 BP 118/78 O2 99% Critical Actions Ask about Red Flags for Spinal Infection Perform a Thorough Spinal Exam Obtain MRI […]
Dec 01, 2019
Round 5 (Geriatric Fall)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse is asking you to evaluate a 70 year old male who has been placed in a hall bed after hitting the back of his head. She wants to know if you would like to call a trauma alert… Initial Vitals Temp 103.7 (Hidden by Examiner) HR […]
Nov 01, 2019
Round 4 (Flank Pain)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse tells you that you have a new patient and is requesting a verbal order for nausea medicine. She advises you that the patient is the CEO of your hospital… Initial Vitals Temp 98.9 HR 99 RR 18 BP 120/80 O2 98% Critical Actions Perform Genitourinary Exam […]
Oct 01, 2019
Round 3 (Chest Pain)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction An ill appearing patient has been rushed back from the lobby, clutching his chest, you are needed immediately at the bedside… Initial Vitals Temp 99.1 HR 95 RR 20 BP 120/80 O2 98% Critical Actions Obtain Early EKG Notify Cardiology of Inferior STEMI Bring Crash Cart to Bedside […]
Sep 22, 2019
Round 2 (Seizure)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction EMS brings in a postictal 34 year old female after she has a seizure. She is complaining of a headache… Initial Vitals Temp 98.9 HR 110 RR 10 BP 175/115 O2 95% Critical Actions Articulate Full Neurologic Exam Early Blood Glucose Identification of Pregnancy Administer Magnesium Treat the […]
Sep 16, 2019
Round 1 (Altered Mental Status)
CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are called to the resuscitation bay for a poorly responsive patient that has been brought in by EMS. Initial Vitals Temp 98.8 HR 78 RR 4 BP 124/78 O2 98% Critical Actions Obtain Early Blood Glucose Administer Dextrose Obtain Salicylate and Acetaminophen Levels Admit for Further Observation […]
Sep 08, 2019
ABEM-style cases presented on EM Clerkship are not my actual ABEM exam cases, and they are not derived from my actual exam cases. I will never be discussing my specific exam details with anybody, including on this podcast. The cases were created independently, by me, for the purpose of medical education and improving patient care. […]
Aug 25, 2019
ACS, Acidosis, AAA and Other Miscellaneous Causes of Abdominal Pain
There are HUNDREDS of other non-GI/GU causes of abdominal pain… Acute coronary syndrome (ACS) Test with EKG and troponin Treat with aspirin and heparin Acidosis Diabetic Ketoacidosis (DKA) Respiratory Acidosis (COPD) Salicylate Toxicity (Remember MUDPILES) Abdominal Aortic Aneurysm (AAA) Older people with abdominal/flank/back pain or syncope Testing CT Scan Abdomen with contrast (Good) CTA Abdomen […]
Aug 11, 2019
Testicular Torsion and Prostatitis
Testicular Torsion History Pain in the testicles Referred pain in the flank or lower abdomen Usually sudden and severe Usually WITHOUT urinary symptoms Exam Asymmetric testicular lie High riding testicle Tenderness and swelling of the testicle itself Cremasteric reflex Testing Testicular Ultrasound Treatment Immediate call to urology when suspected Manual detorsion (“Open the Book”) Prostatitis […]
Aug 04, 2019
PID and Ovarian Torsion
Women have two additional diseases that must be added to the differential diagnosis of their abdominal pain. PID and ovarian torsion. Pelvic Inflammatory Disease (and Tube-Ovarian Abscess) Deep pelvic infections high in the reproductive tract frequently caused by sexually transmitted infection but can be caused by other infections (especially anaerobic infections) as well History Symptoms […]
Jul 28, 2019
Urinary Tract Infections
How to Read a Urinalysis Signs of Inflammation Leukocyte Esterace WBCs Multiple conditions cause inflammation on a urinalysis. Anything that causes nearby inflammation (appendicitis, pelvic infections, diverticulitis) or slows urine output (dehydration, renal disease) can commonly elevate these markers. Signs of bacterial presence (not present in ~25% of proven urinary tract infections!!!) Nitrites Bacteria Asymptomatic […]
Jul 21, 2019
Ectopic Pregnancy
All women of childbearing age who present with abdominal pain need a pregnancy test a core teaching of EMergency medicine Ectopic pregnancy is the leading cause of maternal death in the first trimester History Abdominal pain present in 90% of cases Amenorrhea present in 70% of cases Vaginal bleeding present in 50% of cases The […]
Jul 14, 2019
Bowel Perforation and Volvulus
Bowel Perforations History Perforation takes time, frequently symptoms were either ignored or not noticed as can occurring in… Elderly, diabetic, or immunosuppressed patients (frequently have minimal symptoms) Pediatric patients (unable to or scared to mention symptoms) Exam Commonly have “peritoneal signs” Guarding Rebound Tenderness Rigidity Testing CT Scan X-Ray? (not your primary test, but a […]
Jun 30, 2019
Mesenteric Ischemia and Small Bowel Obstruction
Mesenteric Ischemia Celiac truck supplies blood to the stomach and duodenum SMA supplies blood to the rest of the small bowel and proximal colon IMA supplies blood to the distal colon and rectum Arterial flow can be blocked because of emboli (atrial fibrillation) Venous flow can be blocked because of thrombosis (hypercoagulable states) Effective flow […]
Jun 23, 2019
Biliary Diseases and Pancreatitis
Biliary Diseases Biliary Colic- A gallstone DOES NOT GET STUCK, but it slowly rolls out of the gallbladder, through the cystic duct, then the common bile duct and pancreatic duct. This results in several hours of crampy “colicky” pain as the stone passes. Cholecystitis- A gallstone gets stuck IN THE NECK OF THE GALLBLADDER OR […]
Jun 09, 2019
Appendicitis and Diverticulitis
Appendicitis History Vague nonspecific abdominal cramping and nausea (Nonspecific Phase) gradually progresses to localized pain (Localized Phase). The pain most commonly localizes in the RIGHT LOWER QUADRANT near McBurney’s Point. Exam Focal tenderness in the right lower quadrant McBurney’s Point: 1/3 the distance traveled from anterior superior iliac spine (ASIS) to the navel. Psoas Sign: […]
Jun 02, 2019
Abdominal Pain Presentations (Exam, Plan, and Disposition)
EM Clerkship’s 10 Step Patient Presentation Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint) At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors) Red Flags/Pertinent Positives and Negatives Vital Signs Focused Physical Exam of the Complaint Suspected Diagnosis Can’t Miss Diagnosis Testing Plan Treatment Plan (If Asked) Anticipated Disposition Vital Signs “Vitals […]
May 26, 2019
Abdominal Pain Presentations (History)
EM Clerkship’s 10 Step Patient Presentation Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint) At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors) Red Flags/Pertinent Positives and Negatives Vital Signs Focused Physical Exam of the Complaint Suspected Diagnosis Can’t Miss Diagnosis Testing Plan Treatment Plan (If Asked) Anticipated Disposition Demographics (Age, Gender, […]
May 19, 2019
How to Crush Your SLOE (Tips 26-30)
Tip #26 Update your attending when the nurse is having difficulty with your patient’s IV or drawing blood. Tip #27 Get the urine sample from your patient (there is no greater delay in patient flow than waiting on urine) Tip #28 Round on your patients and repeat your initial scripting. “It’s Zack the medical student […]
Apr 14, 2019
How to Crush Your SLOE (Tips 21-25)
Tip #21 Review and note if the patient has any IMPORTANT old records. Any ED visit within the last month for a similar complaint (aka “Bouncebacks” and frequent fliers) Any echocardiogram or catheterization reports for a patient with cardiac symptoms H&P and discharge summary for recent hospitalizations Any large imaging studies (CT, MRI, etc) that […]
Apr 07, 2019
How to Crush Your SLOE (Tips 16-20)
Tip #16 Recheck the patient’s heart rate and respiratory rate (and put in your presentation that you did so) Heart rate frequently falsely elevated when being triaged Respiratory rate frequently falsely normal when being triaged Tip #17 Fully examine the specific complaint. Some common misses include… Neurologic complaints (headache, paresthesias, dizziness, asymptomatic hypertension, seizures, visual […]
Mar 31, 2019
How to Crush Your SLOE (Tips 11-15)
Tip #11 Give 4 descriptors/adjectives for each complaint Location Quality Duration Modifying Factors Severity Context Timing Associated Symptoms Tip #12 Get the ACTUAL story. Why did the patient come NOW? Did something change or worsen? Did family force them to come? Do they have a family history of something similar? Tip #13 Present the pertinent […]
Mar 24, 2019
How to Crush Your SLOE (Tips 6-10)
Tip #6 Make your patient remember your name. Introduce yourself clearly Show the patient your badge Use a nickname if your name is difficult for people to remember/understand Repeat your name again and again Tip #7 Keep the patient informed about… Diagnosis Anticipated ED course/timeline Delays Tip #8 Keep your patient comfortable. Get them blankets […]
Mar 10, 2019
How to Crush Your SLOE (Tips 1-5)
Tip #1 Introduce yourself. Attending? “Hello, my name is Zack, I’m one of the medical students” Resident? “Hello, my name is Zack, I’m one of the medical students” Nurse? “Hello, my name is Zack, I’m one of the medical students” Janitor? “Hello, my name is Zack, I’m one of the medical students” Tip #2 Be […]
Mar 03, 2019
Airway Part 4- What to Do If Intubation Fails
Verbalize the out loud prior to performing rapid sequence intubation. The Bougie Ideal for situations when you’re view is suboptimal Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique). Video Laryngoscopy (Glidescope) Laryngoscope with […]
Feb 03, 2019
Airway Part 3- Rapid Sequence Intubation
The most important thing to do when preparing for RSI is to PREOXYGENATE the patient. Step 1: Choose Your Equipment Miller or Mac blade? Miller blade is straight (like the ‘L’ in miller) Frequently used in kids Mac blade is curved (like the ‘c’ in mac) (Generally, this is the best choice to use on […]
Jan 27, 2019
Airway Part 2- Bag Valve Mask Adjuncts
How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful? Pharyngeal Airways These tools bypass the posterior portion of the tongue to help with BVM ventilation Nasopharyngeal Airway (NP) Measure from earlobe to tip of nose TEST QUESTION: Don’t use in a […]
Jan 20, 2019
Common Fungal Infections
Most Life Threatening Fungal Infection Mucormycosis Black facial discharge Cranial nerve dysfunction Facial swelling Eschar formation When to Suspect a Fungal Infection Immunocompromised (HIV, Diabetes, Organ Transplants, etc) Not getting better on typical antibiotics Other Fungal Infections Aspergillus Aspergilloma Bronchopulmonary Aspergillosis Invasive Aspergillosis Coccidiomycosis Southwestern United States Histoplasmosis North Central United States Blastomycosis Southeast United […]
Jan 13, 2019
Psychiatric Complaints
The Two Objectives During Every Psychiatric-Type Complaint Medical Clearance Psychiatric Risk Assessment Medical Clearance Required by EMTALA to perform a “screening exam” regardless of complaint Most psychiatric facilities have poor diagnostic/treatment capabilities for non-psychiatric conditions and will want patient to be “medically cleared” Sometimes they will require specific tests to be performed, blood pressure to […]
Dec 23, 2018
NBME Shelf Review (Part 11) – OBGYN
Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age! It changes the differential diagnosis It changes the medications you can give It changes the tests you can order Vaginal Bleeding Pearls Non-pregnant vaginal bleeding Order a pelvic ultrasound (for structural causes) Order a CBC and coagulation panel (for anemia and coagulopathy) […]
Dec 09, 2018
NBME Shelf Review (Part 10) – Miscellaneous
Stroke Most appropriate initial tests Blood Glucose Hypoglycemia is a common stroke mimic CT Head without contrast Rules out HEMORRHAGIC strokes Subarachnoid Hemorrhage Classic description “Worst headache of life” “Sudden and maximal in onset” “Thunderclap” Testing CT Head without contrast (If negative CT) Lumbar puncture Xanthochromia (yellowish fluid) Treatment Nimodipine (Given orally) Prevents vasospasm Causes […]
Dec 02, 2018
NBME Shelf Review (Part 9) – Cardiopulmonary
Pulmonary Embolism Three types of pulmonary embolism “Massive” Hypotension or severe bradycardia Treat with tPA or thrombectomy “Submassive” Normotensive but with Right Heart Strain S1Q3T3 on EKG Elevated BNP Elevated troponin Dilation of RV on ultrasound Treat with heparin/lovenox and admit “Low Risk” Treat with anticoagulation Outpatient vs inpatient treatment Testing CTA of the Chest […]
Nov 25, 2018
NBME Shelf Review (Part 8) – Abdominal Pain
Acute Mesenteric Ischemia History of atrial fibrillation “Pain out of proportion to exam” Bowel Obstruction History Abdominal pain Bloating/Distention Vomiting Decrease stool/flatus Exam Abdominal tenderness and distention If guarding/rigidity/rebound tenderness (aka peritonitis) Consider perforated bowel Testing Obtain CT abdomen with IV contrast Treatment Fluids NPO NG Tube Acute Diverticulitis NOTE: DiverticulOSIS is what causes GI […]
Nov 18, 2018
NBME Shelf Review (Part 7) – Abdominal Pain
Hernia 3 classifications for hernia Reducible Able to be reduced (placed back into the abdomen) at bedside Incarcerated Cannot be reduced but not severely tender or erythematous Can occasionally cause bowel obstructions Strangulated Cannot be reduced but LOSING BLOOD SUPPLY Extremely tender and abnormal exam Needs emergent surgical consult Esophageal Varices Classic presentation Hematemesis/Melena Chronic […]
Nov 11, 2018
NBME Shelf Review (Part 6) – Common Arrhythmias
“Unstable” Arrhythmias Arrhythmias that cause Hypotension Pulmonary Edema Chest Pain Altered Mental Status Supraventricular Tachycardia (SVT) Stable Vagal maneuver Adenosine Beta blocker or calcium channel blocker Unstable SYNCHRONIZED cardioversion Monomorphic Ventricular Tachycardia (VT) Stable Amiodarone Procainamide Lidocaine Unstable SYNCHRONIZED cardioversion Pulseless Defibrillation Polymorphic Ventricular Tachycardia (aka Torsades de Pointes) Known complication of prolonged QTc Side […]
Nov 04, 2018
NBME Shelf Review (Part 5) – Ophthalmology and Toxicology
Corneal Abrasion Stain the eye with fluorescein and use woods lamp Look for fixed staining (“uptake”) on the cornea Acute Angle Closure Glaucoma Symptoms Eye Pain Headache Check for intraocular pressure greater than 20 Commonly precipitants OTC cough/cold medicine (anticholinergic effect) Dark environment (such as movie theater) Treatment Timolol Pilocarpine Acetazolamide Apraclonidine Giant Cell Arteritis […]
Oct 28, 2018
NBME Shelf Review (Part 4) – Environmental
General Bite Wound Management Irrigate thoroughly Update tetanus LOW RISK bites get sutured High risk bites to cosmetic areas (face) get sutured AND antibiotics High risk bites to non-cosmetic areas are left open AND get antibiotics Rabies Give vaccine if… ANY suspicion for bat bite (bat in room, cave, etc) Bite by wild animal that […]
Oct 21, 2018
NBME Shelf Review (Part 3) – Pediatrics
Febrile Seizures Simple (All features must be present) Age 6 months – 5 years Febrile Lasts less than 15 minutes Only one seizure in 24 hour period No focal neuro deficits on exam Generalized seizure (must have LOC) Treat with acetaminophen and reassurance Complex Does not meet ALL of the criteria for a simple febrile […]
Oct 14, 2018
NBME Shelf Review (Part 2) – Trauma
Penetrating Abdominal Trauma Anything below the 4th intercostal space (nipple) is potentially an abdominal injury Gunshot wounds to the abdomen Needs immediate exploratory laparotomy Stab wounds to the abdomen Needs immediate exploratory laparotomy IF… Hemodynamically unstable Peritonitis on exam (rebound, rigidity, guarding) Organs hanging out of abdomen Blunt Abdominal Trauma If the patient is unstable […]
Oct 07, 2018
NBME Shelf Review (Part 1) – General Concepts
General Approach to a Test Question Read the last sentence of the question Read the answer choices THEN read the vignette Common Scenarios with Quick Answers Hypotensive patients Give a fluid bolus Altered mental status Check a blood glucose Hypoglycemia Orange juice if can swallow safely D50 if patient cannot swallow and mildly altered IM […]
Sep 30, 2018
When to Stop CPR
Why is this Important? It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal. Hospitals need to steward their resources to distribute equitable care between its patients When is it Appropriate to Stop CPR on a Pulseless Patient? Patient shows signs of irreversible death Rigor mortis Decapitation Rotting/decaying […]
Sep 09, 2018
Abdominal Aortic Aneurysm
Kidney Stones are a Diagnosis of Exclusion!!! History Risk factors Age >60 Tobacco use Classic presentations Stable with sudden flank/back/abdominal pain or syncope Unstable with pallor, hypotension, and ill appearance Exam Pulsatile abdominal mass Unstable vitals Testing Plan Labs TYPE AND SCREEN CBC Electrolytes Coagulation studies Lactic acid Imaging Bedside ultrasound (optimal) Aorta protocol Look […]
Sep 02, 2018
Testicular Torsion
Kidney Stones are a Diagnosis of Exclusion!!! Introduction Testicular torsion is a time sensitive diagnosis (risk of infertility, etc) Commonly mimics kidney stones History Sudden onset pain Epididymitis tends to be slower in onset Flank/lower abdomen/scrotal pain Frequently causes vomiting Uncommon in geriatric patients Exam Perform a GU exam and look for Unequal/horizontal “lie” Testicular […]
Aug 26, 2018
Flank Pain and Kidney Stones
Kidney Stones are a Diagnosis of Exclusion!!! Step 1: Consider the Differential Diagnosis for Flank Pain Appendicitis Abdominal Aortic Aneurysm Ectopic Pregnancy Testicular/Ovarian Torsion Kidney Stone Step 2: Diagnose the Kidney Stone Option 1- Renal Ultrasound Findings consistent with kidney stone diagnosis Hydronephrosis Lack of ureteral jets (in bladder) Kidney stones (poor sensitivity for this) […]
Aug 19, 2018
Ventilator Basics
Step 1: Start Patient on Volume Assist-Control Ventilation The most basic mode of ventilation Provides a FIXED VOLUME at a FIXED RATE If the patient over-breaths… The ventilator will give another FULL breath Can cause breath stacking and be uncomfortable in patients who are poorly sedated This is not a problem in the ED because […]
Jul 08, 2018
Rabies Prophylaxis
Introduction What is rabies? A very rare and aggressive encephalitis Global impact with exception of UK/Australia Animals whose bites/scratches may require prophylaxis Bats Dogs, Cats, Ferrits Other carnivorous animals Foxes, Coyotes, Skunks, Raccoons Post exposure prophylaxis Both Rabies vaccine and immunoglobulin When Do You Give Rabies Prophylaxis? Step 1: Bitten or scratched by domesticated pet? […]
Jun 24, 2018
Occupational Exposures
The only chief complaint that you are guaranteed to eventually have to manage in a colleague Respiratory Exposures Meningococcus​ (meningococcemia, meningitis, etc) Give prophylaxis (ceftriaxone) if… Intubated a pt without a mask Suctioned a pt without a mask Performed mouth to mouth resuscitation Tuberculosis​  CDC recommends testing if exposed Treat if positive CDC recommends prophylaxis in.. […]
Jun 17, 2018
Breast Complaints
All breast complaints are cancer until proven otherwise!!! History Increased risk of breast cancer Family history of breast cancer (especially 1st degree) Delayed childbearing (no children until after 30) Age >50 Associated with menstrual cycle Exam Asymmetric appearance of breasts Palpable mass Red Flags Non-mobile Overlying skin changes Lymphadenopathy Located in upper/outer quadrant of breast […]
Jun 10, 2018
Neonatal Conjunctivitis
The 3 Worst Causes of Neonatal Conjunctivitis Gonorrhea Causes corneal ulcers and sepsis Red flags 1st week of life Copious purulent drainage Diagnose with cultures Treatment Cefotaxime (3rd generation cephalosporin) Admit Chlamydia Occurs in 1st month of life Treat with PO erythromycin HSV Can disseminate to the brain Red flags Mother tested positive (or had […]
Jun 03, 2018
Subarachnoid Hemorrhage
History Sudden and maximal in onset Compared to previous headaches Family history of aneurysm Associated Symptoms Photophobia Visual Changes Neck Stiffness Exam Full neuro examination Cranial nerves Visual fields Speech Cerebellar (finger-nose) Motor Sensation Gait Testing Plan Non-contrast head CT Excellent sensitivity <6 hours from onset Lumbar puncture >100 RBCs in tube 4 Can be […]
May 20, 2018
Blood in the Diaper
The 4 Most Common Causes of Blood in Diaper Urinary crystals Will be guaiac negative Common in first few weeks of life Vaginal bleeding Common in newborn females as they withdraw from maternal estrogen Maternal blood Swallowed during birthing process Breastfeeding with cracked/bleeding nipples Anal fissures Common and will improve on its own Basic Approach […]
May 13, 2018
Nutritional Emergencies
Consider In High Risk Patients Alcoholics GI disorders Eating disorders Starvation/poor diet Extremes of age Thiamine (B1) deficiency Causes damage to neurons and cardiac myocytes Manifestations Dry beriberi Neuropathy Paresthesias Wernicke’s encephalopathy Ophthalmoplegia Ataxia Altered mental status Korsakoff syndrome Ophthalmoplegia, ataxia, altered mental status PLUS Confabulation Memory loss Wet beriberi Heart failure from cardiac damage […]
May 06, 2018
Complications of Myocardial Infarction
Mnemonic: DARTH VADER Death Arrhythmia ACS patients need to be placed on cardiac monitor Frequently degenerate into non-perfusing rhythms Rupture of Ventricle Occur within a few days of myocardial infarction Rapid decompensation Bedside ultrasound will show pericardial effusion and tamponade Tamponade Multiple etiologies Rupture of ventricle (see above) Pericarditis Becks Triad Jugular vein distension Muffled […]
Apr 29, 2018
tPA Basics
My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated. Introduction tPA is one […]
Apr 15, 2018
Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information. Introduction Sepsis is bad and needs to be treated aggressively Confusion around multiple conflicting guidelines and requirements Surviving Sepsis Campaign recommendations CMS requirements Sepsis-3 SOFA/SIRS/qSOFA Institutional protocols Sepsis-3 Proposed Recommendations Screen for sepsis by applying […]
Apr 01, 2018
Neonatal Jaundice
Physiology RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin Conjugated (direct) bilirubin -> Eliminated in stool Causes of Hyperbilirubinemia Increased RBC turnover Sepsis Rh incompatibility RBC disorders Maternal diabetes Scalp hematoma Decreased/slow conjugation by the liver Peaks around day 5 of life Congenital liver disorders Gilbert/Crigler Najjar […]
Mar 25, 2018
Clinical Presentation Incidental finding on routing CBC Petechiae/purpura Mucosal bleeding Epistaxis Gingival bleeding Hematuria Vaginal bleeding 5 Major Causes of Thrombocytopenia Thrombotic Thrombocytopenic Purpura (TTP) Clinical presentation (pentad) Thrombocytopenia Fever Microangiopathic hemolytic anemia “schistocytes” Neurologic abnormalities Renal dysfunction Physiology Low ADAMTS13 results in impaired vWF breakdown Widespread “platelet plugs” Treatment Plasma exchange Hemolytic Uremic Syndrome […]
Mar 11, 2018
Nausea and Vomiting
The hardest part about this chief complaint is expanding your differential beyond gastritis!!! Step 1: Expand Your Differential Diagnosis Early appendicitis Bowel obstructions Myocardial infarction Elevated ICP Diabetic Ketoacidosis Step 2: Give a Testing Plan High yield tests to consider EKG – older adults Pregnancy test – women of child bearing age Electrolytes – most […]
Mar 04, 2018
Complications of Cirrhosis
Organ Failure Complications Hepatorenal syndrome (renal failure) Decreased urine output Labs show elevated creatinine Admit to hospital (high mortality) Hepatic encephalopathy (brain failure) Introduction Liver clears ammonia from body In advanced liver failure, ammonia increases Symptoms Altered mental status/confusion Asterixis Treatment Lactulose Binds ammonia and is excreted Rifaximin Eliminates bacteria responsible for producing ammonia Portal […]
Feb 25, 2018
Peds T- Tummy and Non-Accidental Trauma
Non-Accidental Trauma Estimated 10% of pediatric patients are victims of abuse Sexual abuse Physical abuse Neglect Common red flags Changing story Story that doesn’t make since Delays in seeking care Unusual bruising locations Torso Ears Neck Common tests if non-accidental trauma suspected Skeletal survey x-rays Head CT Especially if altered mental status Abdominal CT Especially […]
Feb 18, 2018
Peds I- Inborn Errors of Metabolism and Endocrinology
Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!! Inborn Errors of Metabolism (IEM) Almost always result in one of the following three clinical abnormalities Buildup of toxins Ammonia To test for this, obtain an ammonia level Buildup of acids Methylmalonic acidemia To test for this, obtain electrolyte […]
Feb 11, 2018
Peds H- Heart Failure and Congenital Heart Disorders
Common Chief Complaints Cyanosis Difficulty feeding Failure to thrive Cyanotic Heart Lesions Truncus arteriosus Aorta and pulmonary artery are fused Single vessel comes from both ventricles Transposition of great vessels Aorta comes off RIGHT ventricle Pulmonary artery comes off LEFT ventricle Tricuspid atresia Blood unable to get from right atrium to right ventricle Tetrology of […]
Feb 04, 2018
Peds S- Sepsis and Serious Bacterial Infections
Pediatric “Sepsis” Consider in any toxic appearing child/neonate Especially with fever (or hypothermia) Treatment Early antibiotics Fluid bolus “Serious Bacterial Infections” (SBI) Consider in any baby with fever Three classic categories Age <30 days Introduction Weak immune system No immunizations Very high risk for serious bacterial infections Require a significant amount of testing Urinalysis with […]
Jan 28, 2018
Peds H- Hyperglycemia and Hypoglycemia
Introduction In pediatric patients, have a low threshold to check blood sugar Undiagnosed diabetics commonly identified in ED during first episode of DKA HYPOglycemia is very common in multiple conditions, especially in ill children Hyperglycemia DKA is different in kids They get cerebral edema Increased intracranial pressure with rapid fluid administration Common symptoms Headache Altered […]
Jan 21, 2018
Peds O- Oxygen, Airway, and Respiratory Disorders
Applying oxygen is one of the first steps in treating any crashing child!!! Airway Emergencies Foreign body (FB) Patient presentation Stridor Choking episode Testing CXR May directly show foreign body May show secondary effects of a foreign body Hyperinflated/collapsed lobes of the lung Patient needs bronchoscopy if suspicion is high Peritonsillar abscess Visible in the […]
Jan 14, 2018
How to Save a Dying Baby
When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!! Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies Foreign body Peritonsillar abscess Bacterial tracheitis Epiglottitis Retropharyngeal Abscess Bronchiolitis Asthma Croup Pneumonia Cystic Fibrosis Hyper/Hypoglycemia- Check Blood Glucose Hypoglycemia DKA Sepsis- Consider Sepsis and Serious Bacterial Infections Pediatric sepsis […]
Jan 07, 2018
Bleeding Disorders
These are most important in trauma patients!!! Platelet Disorders Symptoms of SUPERFICIAL bleeding Mucosal bleeding GI bleeding Recurrent epistaxis Thrombocytopenia When the platelets ARE LOW Refer to THIS episode Von-Willebrand disease When the platelets CAN’T BIND Treatment Desmopressin (DDAVP) Causes increase in amount of von-willebrand factor (vWF) available Also causes free water retention Treatment of […]
Dec 31, 2017
How to Read an EKG
Always remember…1, 2, 3, get an old EKG!!! Step 1: Identify the Rate and Rhythm Is it sinus rhythm? P wave before every QRS Is it one of the tachycardias? (Refer to THIS episode) Is it one of the bradycardias? (Refer to THIS episode) Step 2: Look for Signs of Ischemia Most consistent way is […]
Dec 03, 2017
Pediatrics Exam
Mnemonic: ABCDEF Appearance The ‘A’ in the pediatric assessment triangle Interactive vs distant Good tone vs floppy Calm and happy vs inconsolable Breathing The ‘B’ in the pediatric assessment triangle Signs of respiratory distress Nasal flaring Retractions Abnormal respiratory sounds Color/Circulation The ‘C’ in the pediatric assessment triangle Pink = good Abnormalities Pallor Cyanosis Mottling […]
Nov 26, 2017
Pediatrics History
Always ask about pediatric patient’s ‘P-I-S-S’ status!!! Core Function Questions (P-I-S-S Status) Peeing Evaluates for dehydration Number of wet diapers per day? Same number as usual? Intake Rule of 3s Estimates how much milk/formula an average infant should be taking 3oz of milk or formula every 3 hours Sleeping Is the patient sleeping MORE than […]
Nov 19, 2017
Fever in a Returning Traveler
If a returning traveler has a fever, think malaria malaria malaria!!! Step 1: Ask your patient if they have traveled within the last year If yes… You should at least CONSIDER malaria Step 2: If patient says yes, take a travel history When did they go Where did they stay Where they exposed to anything […]
Nov 12, 2017
If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!! 3 Big (Non-Viral) Causes of Diarrhea The Icky ‘I’s Ischemia Frequently require surgery consult Infection Frequently require antibiotics Inflammatory bowel disease Frequently require GI consult, steroids, or salicylates 5 Red Flags Is it bloody? Consider […]
Nov 05, 2017
Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!! Three Stages of Appendicitis Stage 1: ~12 hours of “gastroenteritis” like symptoms Stage 2: Direct somatic irritation This is when pain over McBurney’s develops! Stage 3: Perforation Patient is now sick and septic Approach to Appendicitis Step 1: Consider getting labs […]
Oct 22, 2017
Eye Complaints
Common Complaints Red Eye Decreased Vision Trauma to the Eye Approach to a Vision Complaint Step 1: Assess visual acuity Visual acuity is the “vital sign of the eye” Snellen eye chart is best If patient unable to see chart… Count fingers? Able to see light? Step 2: Examine the conjunctiva/cornea with fluorescein How to […]
Oct 15, 2017
Differential Diagnosis Mnemonic: HE DIES Hypothyroidism Elevated intracranial pressure (ICP) Cushings reflex Bradycardia Increased blood pressure Irregular breathing Drugs Beta blockers Calcium channel blockers Digoxin Ischemia Electrolytes Especially potassium!!! Sick Sinus Syndrome Approach to Bradycardia Step 1: Get an EKG Ischemia? Heart block? 1st degree = PR interval >200ms (5 small boxes) 2nd degree type […]
Oct 08, 2017
Airway and Epi! Airway and Epi! Airway and Epi! Introduction Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen” The antigen causes extensive mast cell and basophil cross-linking/activation Common antigens Foods Drugs Insect venoms Basic Approach Step 1: Diagnose anaphylaxis Consider anaphylaxis if the patient has TWO body systems involved Dermatologic […]
Oct 01, 2017
Basic Approach Step 1: Is this SINUS tachycardia? P before every QRS? Treat the underlying condition Step 2: Is this a NARROW and REGULAR rhythm? SVT Treat with vagal maneuvers or adenosine Another new trend is treating with calcium channel blockers!! ORTHOdromic Wolf Parkinson White Treat with adenosine Atrial flutter with fixed block Treat with […]
Sep 10, 2017
Status Epilepticus
Introduction Simple seizure Seizure ends in <5 minutes AND Patient wakes up before next seizure No meds required Status epilepticus Seizure lasts >5 minutes OR Patient has a 2nd seizure before waking up from 1st Initiate status epilepticus pathway Approach to Status Epilepticus Step 1: Give a benzodiazepine Lorazepam (IV) Diazepam (IV or PR) Midazolam […]
Sep 03, 2017
Basic Approach Step 1: Describe the seizure Did patient have an aura? Was there loss of consciousness? What did the movements look like? Did they have postictal phase? Did they have a trauma as well? Step 2: Ask about TIME (mnemonic) Tongue biting Usually occurs on the lateral sides of tongue Incontinence Medication changes/adjustments Ethanol […]
Aug 27, 2017
Cardiac Arrest (ACLS)
Hard, fast, unrelenting chest compressions are the core of ACLS!!! Step 1: Check the Patient’s Pulse If the patient does not have a pulse, start CPR Hard, fast, unrelenting compressions Intubated patients Continuous Compressions Non-intubated adults 30 compressions then 2 breaths… Repeat Non-intubated pediatrics 15 compressions then 2 breaths… Repeat Step 2: Determine if the […]
Aug 20, 2017
RUQ Abdominal Pain
There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain. Cholelithiasis and Biliary Colic Cholelithiasis = Gallstones in the gallbladder Frequently seen on CT scan or RUQ ultrasound Present in 15% of the population Biliary colic = Intermittent episodes of pain if stone passes Classically colicky/crampy/spasmy pain in RUQ Frequently radiates […]
Aug 13, 2017
Gunshot Wounds (Arms and Legs)
Evaluate 5 important structures when evaluating gunshot wounds in an extremity. Blood Vessel Injuries 3 Categories Hard-Signers Mnemonic: HARD Bruit Hypotension Arterial/pulsatile bleeding Rapidly expanding hematoma Deficits (pulse) Audible BRUIT/thrill These patients likely need OR Soft-Signers Significant vascular oozing/bleeding Large hematoma These patients need to be screened with ABI (ankle brachial index) ABI <0.9 or […]
Jul 30, 2017
Asthma and COPD
5 core treatments and 5 MORE treatments 5 Core Treatments Albuterol Beta agonist Bronchodilator Core treatment for asthma Ipratropium Anti-muscarinic Relax muscles around the airways Works synergistically with albuterol Steroids Decrease inflammation in the airways Prednisone (PO) Methylprednisone (IV) BiPAP (COPD) Decreases work of breathing Decreases rates of intubation Decreases mortality Antibiotics (COPD) Infection common […]
Jul 23, 2017
GI Bleed
Basic Categories Upper GI Bleed Symptoms Coffee ground emesis Melena Black tarry stool Digested blood Common causes Peptic ulcer disease Varices Lower GI Bleed Symptoms Bright red blood per rectum (BRBPR) Maroon/bloody stools Common causes Diverticulosis Colon cancer Angiodysplasia AV Malformations History Ask about risk factors for upper GI bleed Peptic ulcer risk factors NSAIDS […]
Jul 16, 2017
How to Transfuse Blood
Type and Rh What information it provides Blood type (A, B, AB, O) Rh status (Rh positive or negative) When to order Pregnant patients with vaginal bleeding Need if Rh negative (prevents hemolytic disease of newborn) Type and Screen What information it provides Blood type (A, B, AB, O) Rh status (Rh positive or negative) […]
Jul 09, 2017
Pulmonary Embolism
Introduction Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries Can cause pulmonary infarction (which mimics pneumonia on chest x-ray) Basic Approach to the Diagnosis of PE Step 1: Consider PE in any patient with signs or symptoms consistent with […]
Jul 02, 2017
There are 3 main “categories” of hemoptysis… Mild, “Streaky” Hemoptysis Most common diagnosis Bronchitis Testing plan Chest xray Rules out alternative causes of hemoptysis Pneumonia Cancer Pulmonary Embolism Vasculitis Scary but Stable Hemoptysis Patient is coughing up frank blood Testing plan CTA of the chest CBC PTT/PT/INR Electrolytes Need renal function if giving IV contrast […]
Jun 18, 2017
Salicylate Overdose
Salicylate toxicity is the great toxicologic mimicker!!! Step 1: When to Suspect Salicylate Overdose Signs of CNS stimulation Tachypnea Hyperthermia Altered mental status Signs of GI irritation Nausea/Vomiting Abdominal pain Common “mimicker” Sepsis Acute abdomen Step 2: Testing Plan Electrolyte panel Anion gap metabolic acidosis Sodium – Chloride – Bicarb Normal anion gap (AG) is […]
Jun 11, 2017
Acetaminophen Overdose
Acetaminophen is the most important overdose in toxicology Step 1: Check a Serum Acetaminophen Level Common situations where testing is ordered Suicidal ideation Severe depression Overdose Step 2: Consult the Rumack-Matthew nomogram Only works for acute/single ingestions of acetaminophen Loses reliability if patient is on drugs that affect bowel motility If the time of ingestion […]
Jun 04, 2017
Non-Pregnant Vaginal Bleeding
Common Causes Structural Cancer Post-menopausal bleeding is cancer until proven otherwise Fibroids Adenomyosis Polyps Coagulopathy Present in approximately 20% of non-pregnant vaginal bleeding Most common = Von Willebrand Disease Hormonal causes Dysfunctional uterine bleeding Basic Approach to Non-Pregnant Vaginal Bleeding Step 1: Pelvic exam The utility of this is debated It is best to sound […]
May 14, 2017
1st Trimester Vaginal Bleeding
The pregnancy test is the most important test in females of reproductive age! Five Important Tests in 1st Trimester Vaginal Bleeding CBC Hemoglobin/Hematocrit Mild anemia in pregnancy is physiologic and normal Thrombocytopenia Type and Screen Required for blood transfusion Determines if patient needs RhoGAM Rho(D) immune globulin Binds fetal Rh antigens from a fetus so […]
Apr 30, 2017
Common Causes of Constipation Lifestyle Low fiber diet Minimal water intake Poor exercise Medications Especially opiates Endocrine/electrolytes Hypothyroidism Hypercalcemia Bowel obstruction Delayed colonoscopy Unintentional weight loss Previous abdominal surgeries Rectal problems Anal fissures Fecal impaction Masses How to Treat Constipation Fiber (ex. Metamucil, Citrucel) Adds structure to the stool Water (polyethylene glycol/miralax) Hydrates the stool […]
Apr 23, 2017
Diabetic Ketoacidosis (DKA)
The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!! Signs and Symptoms Vomiting Abdominal pain Polydipsia Polyuria Step 1: Test for DIABETIC-KETO-ACIDOSIS Diabetes Blood sugar Typically notably elevated (>250 mg/dL) Can be normal in certain circumstances Ketones Easiest test is a urinalysis Serum ketones also can be obtained Acidosis Blood gas (arterial […]
Apr 02, 2017
Laceration Repair
Step 1: Pain Control Local anesthesia Most common agent is lidocaine (frequently already in laceration repair kits) Inject through wound edges (not through epidermis) This decreases pain Alternative is digital/regional nerve block Step 2: Irrigation Laceration repair is not a sterile procedure Copious irrigation is the best method to decrease chance of wound infection Faucet/sink […]
Mar 12, 2017
Laceration Evaluation
Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!! To Close or Not To Close? Closing a wound with sutures, etc = Healing by “primary intention” INCREASES risk of infection but DECREASES scar Leaving a wound open = Healing by “secondary intention” DECREASES risk of infection but INCREASES scar Step […]
Mar 05, 2017
Sore Throat
You must know the FOUR emergent causes of sore throat! Step 1: Apply the Centor Criteria Determines if patients is at risk for Group A strep (“strep throat”) 4 Criteria Fever No cough Tonsiller exudates Lymphadenopathy Interpretation If patient has ALL of the criteria Treat for strep throat If patient has NONE of the criteria […]
Feb 26, 2017
Procedural Sedation
Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship Common Scenarios Cardioversion Orthopedic reductions Painful procedures Three Step Approach to Procedural Sedation Step 1: Risk stratify the patient Mallampati score (aka “How visible is the uvula?”) Level 1: Can visualize THE WHOLE uvula Level 2: Can […]
Feb 19, 2017
Back Pain
Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses Aortic Dissection and Abdominal Aortic Aneurysm (AAA) Age >50 Hypertension “Ripping” or “Tearing” pain Absent pulses in lower extremities Spinal Infections Fever Immunocompromized HIV Diabetes mellitus Transplant patients Spinal cord compression (especially cauda equina) Urinary retention Consider obtaining post-void residual Saddle anesthesia Fecal incontinence/decreased rectal […]
Feb 05, 2017
Dental Pain
Minor complaint. Huge SLOE points! Step 1: Identify Which Tooth is Causing Pain Bonus points if you number teeth correctly! Number 1-32 Tooth #1 is top right Tooth #32 is bottom right Refer to dental chart for reference Step 2: Correct Terminology When Making Diagnosis Pulpitis Pain in the tooth itself Reversible Triggered by hot/cold […]
Jan 15, 2017
Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo? Step 1: How Does Patient Describe the Vertigo? Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is) Central vertigo Mild Vague Peripheral vertigo Severe Sudden Step 2: What Are the Associated Symptoms? Central vertigo frequently associated with “The […]
Jan 08, 2017
Hyperkalemia = EKG… EKG changes = Calcium… Step 1: Recheck the Potassium Most common cause of hyperkalemia is PSEUDOhyperkalemia Caused by too aggressive/fast of a blood draw Causes RBCs to break open and falsely increase serum potassium Step 2: Get an EKG Earliest EKG change Peaked T waves Late EKG changes Flattened P wave Prolonged […]
Jan 01, 2017
How to Interpret a Chest X-Ray
A-B-C-D-E-F-G Two Types of X-Rays Anterior-Posterior (“AP”) Classic “portable” xray The beam shoots from in front of the patient (anterior) TO The plate sitting behind the patient (posterior) Posterior-Anterior (“PA”) Requires trip to radiology Results in a better picture The beam shoots from behind the patient (posterior) TO The plate sitting in front of the […]
Dec 11, 2016
Trauma in Pregnancy
Mom is Scared. You are Scared. Don’t Be Scared. General Principles Evaluate for intimate partner violence in all poorly explained traumas during pregnancy Get the scans you would order in a non-pregnant patient, even CTs! Shield the uterus if necessary Basic Approach to Trauma in Pregnancy Step 1: Place mother in left lateral decubitus position […]
Dec 06, 2016
Genitourinary Trauma
Four important injuries. Four different imaging studies to obtain. Step 1: Obtain Pelvic X-Ray Commonly performed at bedside as part of initial trauma evaluation A pelvic injury significantly increases risk of GU injury Step 2: Examine the Perineum Common signs of GU injury Blood at urethral meatus Bruising of the perineum Step 3: Obtain Urinalysis […]
Nov 13, 2016
Abdominal Trauma
Step 1: Does This Patient Need Surgery NOW? Obvious penetrating injury to abdomen Peritonitis Hypotensive Step 2: FAST Scan Performed with bedside ultrasound machine Blood/intra-peritoneal fluid is hypoechoic (black) in appearance Four views required Right upper quadrant Probe marker points towards patient’s head “Morrisons Pouch” Potential space between liver and right kidney Left upper quadrant […]
Nov 06, 2016
Cardiac Trauma
Cardiac tamponade. Aortic Dissection. Blunt cardiac injury. Cardiac Tamponade Blood fills pericardial sac Increasing pressure on myocardium -> Decreased preload Decreased preload -> Hypotension -> Death Clinical exam shows Beck’s Triad Hypotension Muffled heart sounds Jugular venous distension (JVD) Diagnosed during FAST exam (subxiphoid view) Treat with pericardiocentesis Bedside thoracotomy if patient loses pulse Aortic […]
Oct 30, 2016
Thoracic Trauma
Step 1: Perform ATLS Primary Survey (B- Breathing) Signs of respiratory distress/injury Shortness of breath Hypoxemia Tracheal deviation Diminished breath sounds Step 2: Consider Performing Bedside Tube Thoracostomy Insert at 5th intercostal space just anterior to mid-axillary line Step 3: Imaging Start with portable bedside chest x-ray Pneumothorax can also be diagnosed by thoracic ultrasound […]
Oct 16, 2016
Neck Trauma
The hardest question… Should you get a CTA? Blunt Trauma of Neck Obtain CTA if… Patient has neurologic deficit Numbness Weakness Visual changes Patient sustained forceful impact to the neck Patient has fracture Basilar skull Facial bones Cervical spine Penetrating Trauma of the Neck Go to OR if patient is unstable Go to OR if […]
Oct 09, 2016
C-Spine Trauma
Step 1: Protect the Spine Apply cervical collar Step 2: Apply NEXUS Criteria Use the “SPINE” mnemonic Spinal midline tenderness Painful distracting injury Intoxication Neurologic deficit Encephalopathy Step 3: If Patient Has None of the NEXUS Criteria… You Are Done! Step 4: If Patient Has Positive NEXUS Criteria… Obtain CT scan of the cervical scan […]
Oct 02, 2016
Facial Trauma
There are 6 major areas/injuries to the face. Basic Approach to Facial Injury Step 1: Airway Indications for intubation after trauma Burns to the airway Rapidly expanding hematoma GCS <8 Step 2: CT Maxillofacial Without Contrast Step 3: Supportive Care Stop bleeding Apply pressure Control epistaxis Caution advised with packing if patient has basilar skull […]
Sep 25, 2016
Head Trauma
CT scan without contrast is your test of choice. Step 1: Consider Your Differential Diagnoses Five high-yield head trauma diagnoses Skull fracture External skull fracture Basilar skull fracture Epidural hematoma Subdural hematoma Traumatic subarachnoid hemorrhage (SAH) Concussion Step 2: Important Add-ons When Taking History Specific mechanism of injury Loss of consciousness Blood thinners/antiplatelet agents Step […]
Sep 11, 2016
Abdominal Pain Basics
Elderly people die from abdominal pain Step 1: Risk Stratify Certain patient groups have VERY high mortality when having abdominal pain Geriatrics Immunocompromised Diabetics Step 2: Consider Genitourinary Causes Be especially cautious with lower abdominal/flank pain Mention that you performed or considered performing GU exam during presentation! Common GU causes of abdominal pain Testicular/ovarian torsion […]
Aug 28, 2016
Get your attending! Step 1: Obtain Last Known Well Stroke treatments including tPA and thrombectomy both require last known well <3-4.5 hours for tPA <24 hours mechanical thrombectomy Step 2: Finger Stick Blood Glucose Hypoglycemia is classic mimic of CVA Results can be obtained immediately Step 3: STAT Head CT Without Contrast Poor sensitivity for […]
Aug 21, 2016
Shortness of Breath
You need an organized, anatomical approach. Step 1: Consider Differential Diagnosis Upper airway Angioedema Foreign body Abscess Lower airway COPD Asthma Alveoli Pneumonia Pulmonary edema Blood Anemia Acidosis DKA Sepsis (lactic acid) Toxins (salicylic acid) Blood vessels Pulmonary embolism Aortic dissection Heart Myocardial infarction Acute heart failure Cardiac tamponade Step 2: Examine Anatomically Upper airway […]
Aug 14, 2016
6 EKG Findings. 6 Risk Factors. 6 Mimics. Step 1: Get an EKG This is the only “required” test for a patient with syncope Other common tests CBC Evaluate for anemia hCG If patient might be pregnant Step 2: Look For 6 High Risk EKG Patterns Mnemonic: QT-BRIDE QT prolongation Especially QTc >500 Brugada pattern […]
Aug 07, 2016
Common Pain Medications
Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone. Oral Acetaminophen (Tylenol) Give every 4-6 hours Regular strength – 325mg Extra strength – 500mg Maximum Daily Dose – 3000mg Oral Ibuprofen (Advil) NSAID Give every 4-6 hours Regular strength – 200mg Therapeutic Ceiling – 400mg Oral Hydrocodone-Acetaminophen (Vicodin, Norco) Give ever 4-6 hours Common doses – 5-325mg, 7.5-325mg, […]
Jul 24, 2016
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 […]
Jul 17, 2016
Altered Mental Status
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: […]
Jul 11, 2016
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 […]
Jul 04, 2016
BRUE (Pediatrics)
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 […]
Jun 20, 2016
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 […]
Jun 06, 2016
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 […]
May 30, 2016
Preeclampsia (Critical Diagnosis)
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 […]
May 23, 2016
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 […]
May 16, 2016
Tummy Ache
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 […]
May 03, 2016
Circulation (Shock)
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 […]
Apr 26, 2016
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 […]
Apr 19, 2016
“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 […]
Apr 11, 2016
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 […]
Apr 03, 2016
Chest Pain
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 […]
Mar 27, 2016
Patient Presentations
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 […]
Mar 27, 2016
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 […]
Mar 20, 2016