The EM Clerkship Podcast: Recent Episodes
Zachary Olson
Learn about Maddie’s experience in New Zealand as well as unique aspects of New Zealand medical practice. Disclaimer: This is based on personal experience. If you’d like to learn more, some resources are listed below. https://www.mcnz.org.nz/about-us/glossary https://pharmac.govt.nz/about/what-we-do/how-pharmac-works https://www.acc.co.nz https://www.luc.edu/media/lucedu/law/centers/healthlaw/pdfs/advancedirective/pdfs/8/robin.pdf https://nzformulary.org
You are working at Clerkship General when the triage nurse walks back and gets you. “Hey doc, we just put a hypoxic infant in bed 7”. Initial Vitals: HR: 168 RR: 44 BP: 81/40 O2: 81% (Room Air) Critical Actions:
You are working at Clerkship General on New Year’s Day when you see a nurse running from triage. He is carrying an unresponsive child to the resuscitation bay. Initial Vitals: HR: 43 BP: 47/20 Temp: 66F RR: 4 O2: 95% (BVM) Critical Actions:
You are working at Clerkship General when you hear an EMS call on the base command radio. “Clerkship General. We are bringing you a minimally responsive 79 year-old female found lying on the floor inside her apartment. ETA 5 minutes” Initial Vitals: HR: 143 BP: 160/105 Temp: 106.3F RR: 22 O2: 99% Room Air Critical […]
Introduction: You are working at Clerkship General when the next chart is handed to you. It’s a 35-year-old female with a chief complaint of dizziness and fatigue. She is here accompanied by her husband. Initial Vitals: HR: 118 BP: 150/91 Temp: 100.4F RR: 20 O2: 99% Room Air Critical Actions:
You are working at Clerkship General when you hear a woman screaming from triage… It’s baby time! Initial Vitals: HR: 120 RR: Shallow O2: 58% Critical Actions:
You are working at Clerkship General when the nurse comes up to you and says, “Hey doc, EMS dropped off this guy named Randy from the memory care unit at the nursing home down the street. He’s in the hall bed outside of room 7. EMS says he’s here for confusion, we will get him […]
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:
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 Treatment – IVIG and monitor respiratory status
Guillian Barre Syndrome : A progressive, autoimmune acute inflammatory demyelinating polyneuropathy leading to weakness, neuropathic pain, sensory changes, and can cause respiratory failure. Critical Actions:
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 […]
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:
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 […]
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:
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: References: Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time […]
Phase One: CNS Phase Two: Cardiopulmonary Phase Three: Renal Diagnosis: Treatment: 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:
Hypertensive Emergencies of Pregnancy PreEclampsia, Eclampsia, HELLP syndrome Diagnosis: BP >140/90 plus end organ dysfunction Treatment
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:
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 Treatment of PE
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: […]
Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion
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:
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:
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:
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:
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: Other atypical ischemic EKG findings: 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:
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: Dangerous Actions: […]
Indications for LP: CNS infection, SAH, Guillian Barree, IIH Contraindications for LP: Space occupying lesion with mass effect ; severe thrombocytopenia and coagulopathy; cellulitis over LP site or concern for epidural abscess ; traumatic injury to spine Complications for LP: Post LP Headache, spinal hematoma, brainstem herniation Technique for LP: Positioning is everything. Use US […]
You are working at Clerkship General when the charge nurse comes and grabs you… “Hey doc, we need you in room 2, this kid looks sick…” Initial Vitals: BP: 68/40 HR: 128 RR: 22 O2: 99% (Room Air) Temp: 103.5F Critical Actions: Check Out: Pearson Ravitz Webinar – “Disability Insurance 101 for Residents” https://us06web.zoom.us/webinar/register/1416806357023/WN_ziYRNc0kT8yAyOOJZ-Xk2g
You are working at Clerkship General on an overnight shift when the next chart is handed to you. It’s a 35 year old male with a chief complaint of groin pain. Initial Vitals: BP: 150/90 HR: 107 RR: 20 O2: 99% (Room Air) Temp: 98.0F Critical Actions:
Obtain IV Access – get two large bore IVs (18g or larger) Resuscitate – un-crossmatched blood at first, don’t forget type and screen! Medicate – Give Pantoprazole always, Octreotide and Ceftriaxone if hx liver disease, reverse anticoagulation if indicated Imaging – Upright CXR to assess for perforation, CTA if concerned for lower GIB Consult – […]
You are working at Clerkship General when the charge nurse grabs you – “hey we got a real sick one, a 57yo Male who I just put in the resuscitation bay, he is vomiting blood”. Initial Vitals:BP: 77/34 HR: 135 RR: 24 O2%: 95% Temp: 98.8F Critical Actions: Further Reading: EMDocs – GI Bleed
In this long-form episode we will discuss opioid use disorder, the leading cause of death in young adults in the United States. What you do matters! References
This episode will answer 3 big pre-Match Day questions: 1. How do I go about making my rank list? 2. What about post-interview communication both from and to programs? 3. How does this whole thing called the Match actually work? Resources: https://www.emra.org/books/msadvisingguide/preparing-and-submitting-your-rank-list/
Aortic Dissection – when there is a tear in the intima layer of the aorta and the blood dissects the intima away from the media creating a false lumen in the aorta Further Reading: Core EM – Aortic Dissection LITFL – Aortic Dissection
You are working at Clerkship General when the base command phone rings – “Hey doc just wanted to give you a heads up on this stroke alert we’re bringing you – we have a 70yo M with sudden onset left arm numbness and weakness, last known well 2 hours ago, we’ll be there in about […]
You are working at Clerkship General Hospital when EMS calls in a female with opioid overdose, but she won’t stop complaining of leg pain… Initial Vitals: Temp: 98 BP: 120/80 HR: 89 RR: 20 O2 Sat: 100% Critical Actions:
Diabetic Ketoacidosis – hyperglycemia, ketosis, and anion gap metabolic acidosis Don’t forget about euglycemic DKA (especially in setting of SGLT2 inhibitor) or mimics such as alcoholic ketoacidosis Treatment of the ketoacidosis Insulin (usually a drip or bolus + drip) – only once K>3.5 Volume Resuscitation (NS initially, change to LR) Bicarb drip (poor evidence, only […]
You are working a shift at Clerkship General when the charge nurse comes and grabs you to see a 24yo male who appears to be in respiratory distress. Critical Actions: Diagnose DKA Replete potassium Start insulin AFTER potassium repletion EITHER place central line for faster K repletion OR initiate bipap to allow time for potassium […]
Before interview day, do your research on programs and interviews and reflect on the way in which you want to portray yourself. On interview day, have a cheat sheet with notes about your conversations, questions, and pro-cons. Remember to stay calm, take a pause if you need to, and above all be authentic to who […]
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 […]
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 […]
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: […]
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
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
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.
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 […]
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.
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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
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 […]
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 […]
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 […]
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) […]
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
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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 […]
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, […]
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 […]
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 […]
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 […]
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 […]
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 […]
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, […]
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 […]
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 […]
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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 injury (and/or place C-Collar) Intubate the patient Identify Long QT Syndrome on ECG Treat Pulseless Polymorphic VTach with defibrillation and IV magnesium Treat Polymorphic VTach (pulse present) with overdrive pacing (transcutaneous pacing or isoproterenol)
Further Reading
Torsades de Pointes – EMCrit
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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 bradycardia (BB overdose) Administer Atropine Administer Glucagon Administer Epinephrine drip Attempt transcutaneous/transvenous pacing* Administer high-dose Insulin therapy
Final Diagnosis
Beta Blocker Overdose
Tips and Tricks
- Keep in mind the broad differential for severe bradycardia – ischemia, ingestion, electrolyte abnormalities, intrinsic arrhythmia/heart block, hypothyroidism, hypothermia, hypoglycemia, hypoxia, increased intracranial pressure, neurogenic shock.
Further Reading
High Dose Insulin Therapy (EMCRIT)
Low and Slow Poisoning (EMCASES)
Four definitions you must know:
- SIRS – Must have at least 2 of 4 SIRS criteria (listed below): Fever (>38C) or Hypothermia (12k or 10% Tachycardia > 90 Tachypnea > 20 SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc) SEVERE SEPSIS – Must have Sepsis + ONE of the following criteria indicative of end organ dysfunction: Hypotension (MAP 2.0 Platelets < 100k INR > 1.5 Bilirubin > 2 SEPTIC SHOCK – Must have severe sepsis PLUS one of the following Hypotension DESPITE adequate fluid resuscitation (usually 30cc/kg bolus) Lactate > 4.0 DESPITE adequate fluid resuscitation (usually 30cc/kg bolus)
GENERAL GUIDELINES (exact management depends on clinical scenario):
- If patient meets SIRS criteria you work the patient up for sepsis / severe sepsis: Lactate, Blood Cultures, Urinalysis/Culture, Chest XRay CBC, BMP, Coags, LFTs If patient meets SEPSIS criteria, you add in broad spectrum antibiotics +/- intravenous fluids If patient meets SEVERE SEPSIS criteria, you give a 30cc/kg fluid bolus,* If patient meets SEPTIC SHOCK criteria and is HYPOTENSIVE, you start vasopressors (norepinephrine usually)
MDCalc – Sepsis
Sepsis-2 and Sepsis-3 Guidelines Summarized
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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 of unknown source Perform sepsis workup and treatment in patient with at least 2 SIRS criteria Order thick/thin peripheral blood smear Consult ID Admit patient
Final Diagnosis
Malaria
Tips and Tricks
- Always obtain detailed history in patient presenting with fever without obvious source (travel history for infectious agents, IV Drug history for endocarditis, etc)* Utilize CDC.org to determine which infections are endemic to each country that your patient traveled in
Further Reading
Malaria (EMDocs)
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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, Abx) Order TSH with Free T4 Administer non-selective Beta Blocker (Propanolol) Administer Inhibitor of Thyroid Hormone Synthesis (Methimazole or PTU) Administer Steroids, +/- Iodine (must be given after inhibitor)
Final Diagnosis
Post Partum Thyroid Storm
Tips and Tricks
- Be aware of common post-partum pathologies (PP depression, hyper/hypothyroidism, cardiomyopathy, infections, eclampsia, etc) Have a DDX for Fever other than infectious (especially if refractory to acetaminophen) Administer treatment in correct order (BB first, inhibitor second, Iodine at least 1 hour after inhibitor, steroids)
Further Reading
Thyroid Storm (EMCrit)
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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 patient alone (and identify trigger) Perform vagal maneuver Administer Adenosine* Discharge patient
Final Diagnosis
Supraventricular Tachycardia
Tips and Tricks
- Interview pediatric patients without family members in the patient's room Escort family out of patient room during invasive procedures Ask about / rule out potential triggers (caffeine use, drugs, ischemia, electrolyte abnormalities, etc)
Further Reading
The REVERT Trial (RebelEM)
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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 tPA
Final Diagnosis
Massive Pulmonary Embolism
Tips and Tricks
- Reassess vital signs after interventions Obtain collateral history from EMS and family Make sure your diagnosis fits the patient's symptoms! (EG don't diagnose pneumonia based on a consolidation on CXR if the patient doesn't clinically have pneumonia)
Further Reading
Submassive and Massive PE (EMCrit)
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 Magnesium Place patient on BiPAP Give IV Beta Agonist (Epinephrine)
Final Diagnosis
Status Asthmaticus
Tips and Tricks
Frequently perform verbal reassessments on patients with the examiner (vitals, patient appearance, pain, etc)
Additional Reading
- The Crashing Asthmatic (REBEL EM)
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 and Screen Admit Patient to the Hospital Identify Medications That Increase Risk of Ulcer (If Prompted)
Final Diagnosis
Upper GI Bleed due to Peptic Ulcer
Tips and Tricks
If you get stuck in a case and don't know what to do next. Identify all abnormal findings that you have been provided
Additional Reading
- Why You Should Never Ask "What Do You Mean By Dizzy?" (PubMed)
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