Author: Mike Estephan (Page 1 of 4)

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Critical Actions:

1. Treat the Patient’s Pain
2. Perform a detailed neurologic exam (including reflexes)
3. Perform LP
4. Administer IVIG
5. Check NIF or FVC and intubate prior to transfer

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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 crus first)

Paperclip Eyelid Retractors

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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 seizure with Todd’s paralysis.  

Management/treatment – thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (<185/110 if treating, <220/120 if no treatment). 

Remember that time is brain, so move fast! 

AAEM tPA Infographic

AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

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• Common during the first year of life as well as during puberty
• Presents with nausea/vomiting, abdominal pain, and/or testicular pain
• ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)
• Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex
• Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound
• Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US
• Attempt manual detorsion if there will be a significant delay to surgery

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Phase One: CNS

• Ataxia, Slurred Speech, Confusion, N/V, Seizures

Phase Two: Cardiopulmonary

• CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS

Phase Three: Renal

• Flank pain, Hematuria, Oliguria, Renal Failure

Diagnosis:

• HIGH INDEX OF SUSPICION
• Ethylene Glycol Serum Level
• Elevated Osmolar Gap
• Serial Anion Gap Measurements

Treatment:

• Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid
• Hemodialysis
• Consider Bicarb drip, pyridoxine, and thiamine

Further Reading:

EMCrit Toxic Alcohols

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Hypertensive Emergencies of Pregnancy

PreEclampsia, Eclampsia, HELLP syndrome

Diagnosis: BP >140/90 plus end organ dysfunction

• Acute Kidney Injury
• Proteinuria
• Thrombocytopenia
• Transaminitis
• Hemolysis
• Pulmonary Edema
• Cerebral Edema / Hemorrhage
• Headache refractory to tylenol
• Visual Changes
• RUQ Pain not attributable to another diagnosis

Treatment

• Loading Dose: IV Magnesium 4-6g over 20-30 min OR 5g IM in each buttock
• Maintenance Dose: 1g/hr IV
• Antihypertensives (goal 20% reduction): Labetalol, Nicardipine, Hydralazine
• Delivery of fetus and placenta

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Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion

• Hypovolemic Shock
  • Hemorrhage
  • Volume Loss (vomiting/diarrhea, dehydration)
• Cardiogenic Shock
  • ACS, Myocarditis, CHF, Valve failure, Endocarditis, etc
• Obstructive Shock
  • Massive PE, Tension Pneumothorax, Cardiac Tamponade
• Distributive Shock
  • SIRS (Septic Shock, Pancreatitis, Severe Burns)
  • Anaphylactic Shock
  • Neurogenic Shock
  • Adrenal Crisis

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The 6 STEMI Equivalents:

1. Posterior MI
   • ST Depression V2/V3 (or STE in V7-V9)
2. Right Ventricular MI
   • STE V1 associated with inferior MI ; or STE V4R-V6R
3. Wellens Syndrome
   • Type A: Biphasic T-waves V2/3
   • Type B: Deep Symmetric T-wave Inversion V2/V3
4. De Winter’s T Wave
   • ST Depression with a large, symmetric, upright T wave
5. STE avR with diffuse ST-Depression
   • Usually a strain pattern due to underlying pathology, in correct clinical context can represent a left main or proximal LAD coronary occlusion
6. Modified Sgarbossa Criteria in LBBB
   • Concordant STE in any lead
   • Concordant ST Depression in V1-V3
   • Excessive Discordance (ST/S ratio >0.25)

Other atypical ischemic EKG findings:

1. Isolated TWI in avL – early sign of inferior MI
2. Hyperacute TWave
3. NTTV1 (New Tall T-wave in V1)

Further Reading (see photos in the article):

ECG Diagnosis of Life-Threatening STEMI Equivalent’s: Journal of the American College of Cardiology

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1. The MILDLY agitated patient : verbal de-escalation or PO benzo/antipsychotic
2. The MODERATELY agitated patient : IM benzo/antipsychotic
3. The SEVERELY agitated patient : IM Ketamine 5mg/kg

Consider removing the terminology “Agitated Delirium” from your vocabulary, as there is significant racial bias behind this term.

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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 if necessary.  Check for CSF early and often.  

When to CT before LP?: AMS; focal neuro deficit; new onset seizures, known CNS lesions; immunosuppression; papilledema 

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• Two Types of Priapism
  • Low Flow “Ischemic” (Most Common >95% of Cases)
    • Urologic Emergency
      • Results in Erectile Dysfunction
    • Painful
    • Common Etiologies
      • Idiopathic
      • Erectile Dysfunction Drugs (ex. sildenafil)
      • Sickle Cell Disease
      • Trazodone (“TrazoBONE”)
      • Cocaine/Meth
  • High Flow
    • Caused by Trauma and AV Fistulas
• Management
  • Analgesia
    • Dorsal Penile Nerve Block
  • Aspiration
    • Can intermittently irrigate with normal saline to dilute the clot
  • Injection
    • Phenylepherine
      • Recommend cardiac monitor

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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 – GI if unstable / if variceal bleeding

Disposition – based on amount of bleeding and hemodynamic stability

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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:

1. Place two large bore IVs
2. Transfuse emergency uncross matched blood
3. Administer IV Pantoprazole
4. Administer IV Ceftriaxone and IV Octreotide
5. Consult GI

Further Reading: EMDocs – GI Bleed

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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

1. Historical Features
   • Be VERY suspicious with ABRUPT onset of chest/back pain that reaches MAXIMAL SEVERITY immediately after onset of pain.
   • Chest pain or Back pain with a neurologic deficit
   • Pain “above and below the diaphragm”
2. Diagnosis
   • CT Angiography of chest abdomen and pelvis is gold standard
   • Can see widened mediastinum on CXR or dissection flap on POCUS
3. Treatment
   • Pain control first
   • Heart rate control second (goal <60bpm, use esmolol)
   • Blood pressure control third (goal 100-120SBP, use nicardipine/clevidipine)
   • CT Surgery consult (should go directly to OR with a Type A dissection)
   • Arterial Line placement

Further Reading:

Core EM – Aortic Dissection

LITFL – Aortic Dissection

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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 5 minutes”

Initial Vital Signs:

HR 120

BP 180/90

RR 22

O2 97%

Temp 97.7F

Critical Actions:

1. Check a blood glucose

2. Diagnose Aortic Dissection

3. Give Esmolol first, titrate to HR<60

4. Give Nicardipine/Clevidipine second, titrate for SBP 100-120

5.   Consult cardiothoracic surgery for type A dissection

Further Reading:

EMCrit – Aortic Dissection