EM Clerkship

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 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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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 Perform Tube Thoracostomy Final Diagnosis Pneumothorax Secondary to Penetrating Chest Trauma Tips and Tricks Be careful, lack of visual cues during oral cases can mislead you! Additional Reading * Thoracic Trauma (EM Clerkship)* NBME Trauma Review (EM Clerkship)

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 Without Contrast* Consult Neurosurgery for Subarachnoid Hemorrhage* Reverse Warfarin Coagulopathy* Administer Antihypertensives Final Diagnosis Acute Subarachnoid Hemorrhage on Anticoagulation Tips and Tricks Always ask the patient if they have allergies prior to administering ANYTHING. Additional Reading * Basics of Subarachnoid Hemorrhage (EM Clerkship)* How to Reverse Warfarin (AHA)

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 both IM and (subsequently) IV* Glucagon 1mg IV Final Diagnosis Refractory Anaphylaxis Due to Beta Blockers Tips and Tricks You still need to obtain a quick history and exam even if you know the diagnosis in the first few seconds of the case Additional Reading * Basic approach to anaphylaxis (EM Clerkship)* Tranexamic acid as first-line emergency treatment for episodes of bradykinin-mediated angioedema induced by ACE inhibitors. (PubMed)* Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. (PubMed)

I → Episode Summary

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* Give Pyridoxine (Vitamin B6) Final Diagnosis Isoniazid Toxicity Tips and Tricks When the patient is unable to provide history, attempt to obtain the information from external sources Additional Reading * Isoniazid toxicity overview (Life in the Fast Lane)* Basic approach to seizures (EM Clerkship)* Basic approach to status epilepticus (EM Clerkship)* Ketamine for refractory status epilepticus (PubMed) Corrections Ketamine not Keppra as potential induction agent for status epilepticus (32:40)

CORRECTION: Ketamine not Keppra as potential induction agent for status epilepticus (32:40)

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 in hip fracture, missed dialysis, and severe hyperkalemia Tips and Tricks Patient’s will frequently have more than one final diagnosis. Do not prematurely close an the initial, obvious, diagnosis. A man can have as many diseases as he damn well pleases! Hickam’s dictum Additional Reading * Basic approach to hyperkalemia (EM Clerkship)* EKG manifestations of hyperkalaemia (LITFL)

Round 8 (Fall)

Special Thanks to Mohamed Soliman for contributing this episode!

Special Thanks to Mohamed Soliman for contributing this episode!

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 Intra-Ocular Pressure After Initiating Treatment Dangerous Actions * Giving NSAIDS (The Patient Had This on Allergy List)* Performing a Lateral Canthotomy Final Diagnosis Acute Angle Closure Glaucoma Tips and Tricks Do not be surprised or scared when an examiner has a monotone voice and flat affect Additional Reading * Management of acute angle closure glaucoma (PubMed)* Basic approach to eye complaints (EM Clerkship)