Episodes

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 liver disease (hepatitis, alcoholics)* Treatment* Fluid bolus if hypotens...

“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 complica...

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 * Common features* Severe headache* Tenderness of the Temporal Arteri...

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 can’t be monitored* Bite by domestic animal that develops symptoms during observation Black widow spider * Painful bite* Symptoms* Abdominal pain* Dia...

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 seizure* Consider full workup including lumbar puncture Pediatric Abdominal Pain * Intussusception* Classic history* Severe emesis* INTERMITTENT severe abdominal pain...

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* Perform FAST exam* If the patient is stable* CT scan of the abdomen/pelvis wi...

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 glucagon if unresponsive* Patient with altered mental status and possible drug overdose* Give empiric naloxone * Female patients of childbeari...

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* Patient has dismal prognosis (3 studies discuss this)* Implementation of the universal BLS termination of resuscitation rule...

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 for aorta >3cm* RUSH protocol* Mnemonic: HI-MAP* Heart* IVC* Morriso...

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 tenderness* Swelling* Absent cremasteric reflex Testing Plan * Testicular/Scrotal Ul...

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)* Benefits* Can be performed at bedside* No radiation* Option 2- Non-contrast CT s...

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 patients are typically deeply sedated Step 2: Know your oxygenation and ventilation goals * Oxygenation (getting oxygen in)* Try to keep O2 saturation >92%* Ven...

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?* Immunization status of pet does not matter* Animal must be monitored* Give proph...

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..* Little children, HIV positive, immunosuppressed Cutaneous Exposures (Broken Skin, Mucous...

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 Differential Diagnoses * Red/inflamed/painful breast* Postpartum engorgement* Tre...

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 active lesions)* Vesicles on baby* Treatment* IV acyclovir* Admit Other Causes of Conjunctivitis * Viral/other bacteri...

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 difficult to interpret after a traumatic lumbar puncture* Xanthochromia Treatment Plan...

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 * Step 1: Check if guaiac positive* If negative, it’s not blood* Urinary crystals, food coloring, etc* Step 2: Consider vaginal...

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* Treatment* High dose thiam...

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 heart sounds* Hypotension* Diagnosed with bedside ultrasound* Trea...

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 of the core treatments for acute ischemic stroke* The history of tPA is filled with controversy* Mechanism* Activates plasmino...

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 qSOFA instead of SIRS criteria* qSOFA ...

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 Syndromes* Breast milk jaundice* Breas...

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 exc...