Episodes

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 Dissection/Rupture/Tear * Common with rapid deceleration in...

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 Step 4: Consider the 3 Critical Diagnoses * Tension pneumothorax* Pressure builds up ...

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 patient has HARD signs* HARD Bruit Mnemonic* Hemoptysis/Hematemesis/Hypotension* Arterial bleeding* Rapidly expanding hematoma* Deficit (neurologic/pulse)...

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 without contrast Step 5: Clear the C-Spine * If CT scan negative -> Have patient turn head 45 degrees to right and left* If patien...

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 fracture* Ice* Analgesics* Step 4: Antibiotics* Common indications* Fractures of a sinus* Open fractures* Step 5: Consider Consu...

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 3: Important Add-ons To Your Physical Exam * GCS Score (MDCalc)...

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 ischemic stroke* Primary use is identification of hemorrhagic stroke* Required prior to administration of tPA! Step 4: Perform NIHSS ...

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* Right heart strain* Tachycardia* S1Q3T3* Inverted T waves precordial leads* Ischemic changes* ST segment elevation/depression* T wave inversion* Delta waves* Seen in Wolf-Pa...

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, and 10-325mg IV/IM Ketorolac (Toradol) * NSAID* Common dosing – 15-30mg*...

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 3: Stop the Coagulation Cascade * Heparin 60 units/kg (MAX 4000 units) Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now * If you DON’T hav...

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 take it? Step 3: Toxicology Exam * Vital signs* Pupils* Skin Step 4: Medication List * Make note of all bottles with patient* Make EXTRA note if any pills see...

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 Risk BRUE? * Five low risk criteria* Age >2 months* Born at >32 weeks gestational age* First and only episode* No CPR by medical providers* No “Red Flags” Step 3: Do They Have Red...

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 has tachypnea, hypoxemia, or respiratory distress* Give O2* Examine for tension pneumoth...

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 flow OUT* Patient requires emergent detumescence* 50% chance of erectile dysfunction Step 1: Prepare (4c approach) * Collect* 19G needle* 2...

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* Proteinuria* CBC* Hemol...

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* Carbon monoxide toxicity* Glaucoma Step 2: How Does This Compare to Previous Headaches? * Finding t...

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 and Exam * Pediatric assessment triangle* Appearance* Breathing*...

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* Tension pneumothorax* Diagnosis: Clini...

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 breathing…* Intubation Additional Reading * Ventilator Basics (EM Clerkship)* Airway Part 1 – Immediate Actions (EM Clerkship)* Circulation (EM Clerkship)

“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 vomiting* Gurgling Step 2: Move the Tongue * Bedside maneuvers* Head tilt* Chin lift* Jaw thrust* Adjunct e...

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* “Posterior” epistaxis* Most severe/dangerous form Step 3: Spra...

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 shoulder* Vomiting* Worsens with exertion* Diaphoresis Step 3: Look for the “Queen” (Pulmonary Embolism) *...

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 billing reasons* Pertinent positives/negatives* Give approximately 5 most pertinent symptom...

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* The list goes on and on… Additional Reading * Emergency Medicine Advanced Clinical Sub...