EM Clerkship

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 or treatments are indicated. * You risk causing HARM to your patients by treating these asymptomatic patients. For example, if you push IV hydralazine for asymptomatic hypertension in a patient who chronically lives at a BP of 230/120 and their blood pressure drops precipitously, you may cause a stroke/watershed infarcts. * ACEP clinical policy also states that in a patient who has poor access to followup (eg homeless), you may consider routine testing or initiation of long term anti-hypertensive treatment. Further Reading: ACEP Clinical Policy – Asymptomatic Hypertension EM Docs – Hypertensive Emergency

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 Hypertensive Emergency* Start anti-hypertensive drip (usually Nicardipene)* Recheck patient’s blood pressure after intervention* Admit to ICU Further Reading Hypertensive Emergency (EMCrit)

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, place in warmer* OPEN AIRWAY – sniffing position, oral/nasal airway, suction if necessary* ASSESS HR (manually)* If HR>100, continue above interventions and move to PPV if not improving/if pulse ox low* If HR 60-100, attach to telemetry and pulse oximetry and begin PPV with room air at a rate of 60.* If HR<60, this is a CODE situation. Chest compressions and ventilations in a 3:1 ratio (“one and two and three and breath”), use PPV with 100% FiO2. Obtain access via UC or IO line, and intubate. Use epinephrine / fluid bolus if no improvement in 60 seconds. Check glucose, supplement with dextrose if necessary. PEARL: At one minute of life, we expect an SpO2 of 60%.  Every minute afterwards, we expect the SpO2 to increase by 5%, so by 5 minutes of life it should be around 80%.   Neonatal Resuscitation – Emergency Medicine Cases

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 by exam, POCUS, or history* Place patient in left lateral decubitus* Perform resuscitative hysterotomy* Resuscitate the neonate Further Reading Neonatal Resuscitation (EMCases) Resuscitative Hysterotomy (EMCases)

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 real life, the defibrillator often isn’t able to “sync” with TdP, forcing you to perform unsynchronized cardioversion (aka defibrillation).* IV Magnesium – treats and prevents TdP, even when magnesium levels are normal* Overdrive Pacing – by preventing bradycardia, we help prevent TdP (bradycardia prolongs the QT interval). * Electrical Overdrive Pacing – transcutaneous or transvenous pacemaker* Chemical Overdrive Pacing – beta agonist therapy (isoproterenol)* Lidocaine – anti-arrhythmic therapy that does not prolong QTc.* Fix underlying cause – congenital long QT syndrome, hypokalemia, hypocalcemia, medication induced (psych meds, anti-emetics, methadone, fluoroquinolones, many more) Defibrillation and IV Magnesium are used for patients who are ACTIVELY in TdP. Once you shock/mag them into a stable rhythm, you can use Overdrive Pacing / Lidocaine / Treat Underlying Cause to PREVENT them from going back into TdP.

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 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

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 the hands/feet BURN – 5 days of fever Diagnosis: * COMPLETE KAWASAKI – 5 days of fever and 4/5 of the CRASH symptoms * INCOMPLETE KAWASAKI – 5 days of fever and 2-3/5 of the CRASH symptoms, in the setting of elevated inflammatory markers (WBC, ESR, CRP) Treatment: IVIG and High Dose Aspirin Multisystem Inflammatory Syndrome in Children (MIS-C) A new disease entity seen in children defined by widespread systemic inflammation affecting multiple organ systems that presents weeks after infection by COVID-19. Symptoms: * Persistent Fever* Skin involvement – nonspecific rash, conjunctivitis, changes to mucous membranes* GI involvement – nonspecific abdominal pain, nausea, vomiting, diarrhea* Renal involvement – acute kidney injury with elevated creatinine* Cardiac involvement – elevated troponin/pro-BNP, reduced EF, cardiogenic shock* Neuro involvement – altered mental status Diagnosis and Treatment: Varies by hospital, but usually involves the presence of clinical symptoms along with a positive covid IgM/IgG, elevated inflammatory markers (WBC, ESR, CRP, Ferritin, DDimer), multisystem involvement (elevated troponin/proBNP, elevated creatinine, elevated LFTs, etc). These children need a stat ECHOcardiogram to rule out significant cardiac dysfunction.

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 (fever >= 5 days)* Identify abnormal physical exam findings (Conjunctivitis, Rash, Adenopathy, Strawberry Tongue)* Diagnose Kawasaki Disease Clinically* Administer Aspirin* Administer IVIG Final Diagnosis Kawasaki Disease Tips and Tricks * Remember the CRASH & BURN mnemonic* Always have a high index of suspicion for this diagnosis* Remember the diagnosis is CLINICAL! Further Reading EMDocs – Kawasaki Disease

“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 4. Calcium  5. High Dose Insulin Therapy

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 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 (<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 – Must have Sepsis + ONE of the following criteria indicative of end organ dysfunction:* Hypotension (MAP<65 or SBP<90)* Creatinine > 2.0 (with normal baseline renal function)* Lactate > 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

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 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)

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, 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)

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 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)

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 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)