Author: Zack (Page 4 of 9)

How to Crush Your SLOE (Tips 11-15)

March 24, 2019 /

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Tip #11

Give 4 descriptors/adjectives for each complaint

  • Location
  • Quality
  • Duration
  • Modifying Factors
  • Severity
  • Context
  • Timing
  • Associated Symptoms
Tip #12

Get the ACTUAL story. Why did the patient come NOW?

  • Did something change or worsen?
  • Did family force them to come?
  • Do they have a family history of something similar?
Tip #13

Present the pertinent RED FLAGS for each complaint (some examples)…

  • Headache
    • Sudden and Severe
    • Fever
    • Neck Stiffness
    • Neurologic Complaints
  • Back Pain
    • Saddle Anesthesia
    • Bowel/Bladder Incontinence
    • Fever
    • Trauma
  • Chest Pain
    • Exertional
    • Family history of MI at same age
    • PE risk factors
    • Sudden and Maximal/Tearing
Tip #14

Get their doctor’s names

  • Primary care provider
  • Pertinent specialists
Tip #15

Don’t get bogged down giving too much medical history during your presentation. Simply write down the important facts for reference and present a few notable items in your opening sentence.

How to Crush Your SLOE (Tips 6-10)

March 10, 2019 /

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Tip #6

Make your patient remember your name.

  • Introduce yourself clearly
  • Show the patient your badge
  • Use a nickname if your name is difficult for people to remember/understand
  • Repeat your name again and again

Tip #7

Keep the patient informed about…

  • Diagnosis
  • Anticipated ED course/timeline
  • Delays

Tip #8

Keep your patient comfortable.

  • Get them blankets
  • Show them how to use the remote/call light
  • Adjust the bed
  • Turn down the lights
  • Get them something to drink

Tip #9

Move fast.

  • Spend no more than 10 minutes with the patient
  • Immediately grab your attending if the patient is ill appearing

Tip #10

Use a translator.

  • Learn how to use a medical translator in your department (phone vs consult vs video consult)
  • INDEPENDENTLY use a translator to obtain your history when appropriate

How to Crush Your SLOE (Tips 1-5)

March 3, 2019 /

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Tip #1

Introduce yourself.

  • Attending? “Hello, my name is Zack, I’m one of the medical students”
  • Resident? “Hello, my name is Zack, I’m one of the medical students”
  • Nurse? “Hello, my name is Zack, I’m one of the medical students”
  • Janitor? “Hello, my name is Zack, I’m one of the medical students”
Tip #2

Be humble but confident.

  • Humility- Students know very little about the practice of medicine, the smartest med students actually realize that.
  • Confidence- You have to be able to act confident, be decisive in your presentations, and make decisions. The best way to achieve this is to remember that you have (hopefully) been working hard and studying consistently.
Tip #3

Stay focused.

  • Your humor, hobbies, activities, dress, and “cool” personality, don’t impress anybody in the emergency department.
  • The best students tend to be friendly, focused, hardworking, and generally quiet (yay introverts!)
  • Emergency medicine tends to be a very pragmatic, no b.s, specialty. Let your performance speak for itself.
Tip #4

Do the majority of your learning BEFORE your rotation starts.

Your audition rotation should not be when you are downloading podcasts, studying pretest, or going through practice questions. Your learning should be completed well in advance so you can focus your energy on clinical performance).

Tip #5

HELP around the department.

  • Help patient change into gown
  • Get urine samples
  • Keep patients updated
  • Go back and ask missing information

Airway Part 4- What to Do If Intubation Fails

February 3, 2019 /

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Verbalize the out loud prior to performing rapid sequence intubation.

The Bougie
  • Ideal for situations when you’re view is suboptimal
  • Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique).
Video Laryngoscopy (Glidescope)
  • Laryngoscope with a camera at the tip which displays on a screen at bedside
  • Ideal for situations when both view and direct access to the cords is suboptimal (c-collar, poor mallampati). Some physicians use this as their primary technique.
  • Use it like a camera that you advance into position so you can see the cords. Maneuver the endotracheal tube by watching indirectly on the screen.
Flexible Endoscopy
  • It is a flexible stylet that you can control and has a camera at the tip.
  • Advances through the cords like a bougie and the (preloaded) endotracheal tube advances over it.
  • Can intubate through both the nose or mouth with this
LMA (laryngeal mask airway)
  • Placed blindly and sits above the cords, forming a seal.
  • Not a “definitive” airway, but can oxygenate and ventilate the patient when in a difficult situation.
Cricothyrotomy
  • Immediately perform this step in “can’t intubate can’t oxygenate” situations
  • The 3-step EMCrit method is best in my opinion (see link below)
    • “Scalpel, Finger, Bougie”
Additional Reading
  • Overview of the bougie with videos (LITFL)
  • The 3-step cricothyrotomy (EMCrit)

Airway Part 3- Rapid Sequence Intubation

January 27, 2019 /

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The most important thing to do when preparing for RSI is to PREOXYGENATE the patient.

Step 1: Choose Your Equipment
  • Miller or Mac blade?
    • Miller blade is straight (like the ‘L’ in miller)
      • Frequently used in kids
    • Mac blade is curved (like the ‘c’ in mac)
      • (Generally, this is the best choice to use on your clerkship and most common in the ED)
  • Tube Size?
    • 7.5 cuffed tube for a small adult
    • 8.0 cuffed tube for a big adult
Step 2: Choose your Meds
  • You need both a sedative and a paralytic to perform RSI
  • Paralytic options are succinylcholine or rocuronium
    • Succinylcholine is best if you need something short acting
      • For example, when frequent neurologic checks are required
    • Rocuronium is best because it’s easy to remember (1mg/kg)
      • “Rocuronium Rocks”
  • Sedative options include ketamine, propofol, and midazolam.
    • My favorite is ETOMIDATE.
      • It is hemodynamically neutral.
      • Dosing is 0.3mg/kg
Step 3: Prepare Your Equipment
  • Suction
  • Bag Valve Mask
  • Backup airway (ex. LMA)
  • Cardiac monitor
  • Capnography for tube placement
Step 4: DO IT
  • Push the sedative
  • Push the paralytic
  • Put the blade in your LEFT hand
  • Open mouth with right hand
  • Slowly advance (holding top of blade against tongue) until you see cords
    • The cords will be hiding under the white, cartilaginous, tongue-like epiglottis

NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great.

Step 5: Advance the Tube and then CLOSING STATEMENT
  • Generally, you want depth to equal 3x the size of the tube
  • Closing statement
    • “Please attach capnography to confirm tube placement”
    • “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)”

CONGRATULATIONS!! THEY ARE INTUBATED!!

Airway Part 2- Bag Valve Mask Adjuncts

January 20, 2019 /

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How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful?

Pharyngeal Airways
  • These tools bypass the posterior portion of the tongue to help with BVM ventilation
  • Nasopharyngeal Airway (NP)
    • Measure from earlobe to tip of nose
    • TEST QUESTION: Don’t use in a patient with possible skull fracture
  • Oropharyngeal Airway (OP)
    • Measure from earlobe to corner of mouth
Laryngeal Mask Airway (LMA)
  • Essentially a modified BVM to place inside the mouth
  • It fits OVER the larynx (cords, epiglottis, etc)
Retroglottic Airways
  • “King”
  • “Combitube”
Additional Reading

Common Fungal Infections

January 13, 2019 /

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Most Life Threatening Fungal Infection
  • Mucormycosis
    • Black facial discharge
    • Cranial nerve dysfunction
    • Facial swelling
    • Eschar formation
When to Suspect a Fungal Infection
  • Immunocompromised (HIV, Diabetes, Organ Transplants, etc)
  • Not getting better on typical antibiotics
Other Fungal Infections
  • Aspergillus
    • Aspergilloma
    • Bronchopulmonary Aspergillosis
    • Invasive Aspergillosis
  • Coccidiomycosis
    • Southwestern United States
  • Histoplasmosis
    • North Central United States
  • Blastomycosis
    • Southeast United States
Additional Reading
  • Fungal infection archive and data sheets (CDC)

Psychiatric Complaints

December 23, 2018 /

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The Two Objectives During Every Psychiatric-Type Complaint
  • Medical Clearance
  • Psychiatric Risk Assessment
Medical Clearance
  • Required by EMTALA to perform a “screening exam” regardless of complaint
  • Most psychiatric facilities have poor diagnostic/treatment capabilities for non-psychiatric conditions and will want patient to be “medically cleared”
    • Sometimes they will require specific tests to be performed, blood pressure to be treated, etc
    • My “medical clearance” order set includes
      • Electrolytes
      • CBC
      • Serum Alcohol
      • Urine Drug Screen (UDS)
      • Pregnancy (if appropriate)
      • Tylenol/Salicylate Levels (especially if suicidal)
  • Psychiatric patients frequently have other non-psychiatric emergencies
    • Overdoses (salicylate, acetaminophen, etc)
    • Trauma (alcoholics with subdural hematoma from falls)
    • Encephalopathy (hypoglycemia, encephalitis)
Psychiatric Risk Assessment
  • Will this patient truly put themself or others at risk if sent home due to mental health?
  • Do you need to involuntarily hold patient?
  • Are they having passive thoughts of being dead or true INTENT and PLAN to harm themself?
  • Did they name a specific person/group of people that they intend to harm?
Additional Reading

NBME Shelf Review (Part 11) – OBGYN

December 9, 2018 /

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Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age!
  • It changes the differential diagnosis
  • It changes the medications you can give
  • It changes the tests you can order
Vaginal Bleeding Pearls
  • Non-pregnant vaginal bleeding
    • Order a pelvic ultrasound (for structural causes)
    • Order a CBC and coagulation panel (for anemia and coagulopathy)
  • Pregnant vaginal bleeding
    • If sick…
      • Think ectopic pregnancy (early pregnancy)
      • Think uterine rupture (late established pregnancy)
      • Think placental abruption (recent trauma or cocaine)
    • Don’t forget to order a type and screen
      • Rh- mothers will need RhoGam
    • If patient is unstable and you can’t wait for blood type…
      • Transfuse type O negative blood
  • Postpartum vaginal bleeding
    • Most common cause is retained products of conception
      • Order an ultrasound
    • Consider endometritis if patient also has fever
      • Treat with clindamycin and gentamycin
Vaginal Discharge Pearls
  • Cervical motion tenderness?
    • Pelvic Inflammatory Disease (PID)
  • Thin, grey, and smells like fish?
    • Bacterial vaginosis (BV)
      • Treat with metronidazole
      • Warn patient not to mix metronidazole with alcohol
  • Thick like cottage cheese?
    • Vulvovaginal candidiasis
      • Diagnosis with KOH prep
        • Look for yeast and pseudohyphae
      • Treat with fluconazole
  • Thin Yellow/Green and “frothy”?
    • Trichomoniasis
      • Diagnose with wet prep
      • Look for mobile organisms
      • Treat with metronidazole
      • Partners should be checked and treated too
Ovarian Torsion

Severe and sudden pain

  • Can be intermittent
  • Diagnose with Pelvic ultrasound with Doppler
  • PITFALL: Frequently has normal arterial flow (dual blood supply to ovary)
Additional Reading

NBME Shelf Review (Part 10) – Miscellaneous

December 2, 2018 /

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Stroke
  • Most appropriate initial tests
    • Blood Glucose
      • Hypoglycemia is a common stroke mimic
    • CT Head without contrast
      • Rules out HEMORRHAGIC strokes
Subarachnoid Hemorrhage
  • Classic description
    • “Worst headache of life”
    • “Sudden and maximal in onset”
    • “Thunderclap”
  • Testing
    • CT Head without contrast
    • (If negative CT) Lumbar puncture
      • Xanthochromia (yellowish fluid)
  • Treatment
    • Nimodipine (Given orally)
      • Prevents vasospasm
Causes of Stroke in Young People
  • Cervical artery dissection
  • Vasospasm
  • Vasculitis
  • Sickle Cell Disease
Meningitis
  • Treatment
    • Vancomycin, Ceftriaxone
    • Add ampicillin (covers listeria) in very young/old
    • Rifampin prophylaxis for close contacts (if patient has petechial rash)
      • Neisseria Meningitidis
HSV Encephalitis
  • Classic symptoms
    • Fevers
    • Headache
    • Altered Mental Status
    • Seizures
  • Treat with acyclovir
Altered Mental Status
  • The two most common causes on your test
    • Hypoglycemia
    • Infections (Especially in elderly)
      • Aka Delirium
Fat embolism
  • Trauma PLUS petechial rash
  • Common with long bone fracture
Schaphoid Fracture
  • Exam shows tenderness over anatomic “snuffbox”
  • Notorious for being missed on X-ray
    • High risk of osteonecrosis
  • If suspicious, place patient in thumb spica splint regardless of X-ray findings
    • Outpatient followup 1-2 weeks for repeat xray
Pericarditis
  • Patient complains of chest pain that is…
    • Sharp
    • Positional
    • Worse when laying flat
  • Friction rub on exam
  • EKG Findings
    • Diffuse ST segment elevation
    • Diffuse PR depression
  • Treat with NSAIDS
Kawasaki’s Disease
  • Mnemonic: CRASH and Burn
    • Conjunctivitis
    • Rash
    • Adenopathy
    • Strawberry Tongue
    • Hands/Feet Swelling
    • Burn = Fever for 5 days
  • Treat with aspirin

Burns

  • Parkland formula
    • Weight (kg) x BSA (%) x 4 = Volume of fluid needed in first 24 hours
    • Give half over first 8 hours
  • Rule of 9s
    • Estimates % Body surface area burned

Vascular Injury

  • Hard Signs
    • If present patient needs OR
    • Mnemonic: ABCDE
      • Active pulsatile hemorrhage
      • Bruit
      • Cerebral ischemia
      • Diminished Distal pulses
      • Expanding Hematoma
Infectious Disease Pearls
  • Gram positive cocci in CLUSTERS
    • Staphylococcus Aureus
  • Gram positive cocci in CHAINS
    • Streptococcus Pneumoniae
Additional Reading

NBME Shelf Review (Part 9) – Cardiopulmonary

November 25, 2018 /

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Pulmonary Embolism
  • Three types of pulmonary embolism
    • “Massive”
      • Hypotension or severe bradycardia
        • Treat with tPA or thrombectomy
    • “Submassive”
      • Normotensive but with Right Heart Strain
      • S1Q3T3 on EKG
      • Elevated BNP
      • Elevated troponin
      • Dilation of RV on ultrasound
        • Treat with heparin/lovenox and admit
    • “Low Risk”
      • Treat with anticoagulation
      • Outpatient vs inpatient treatment
  • Testing
    • CTA of the Chest
      • If severe contrast allergy or other contraindication
        • Ventilation/Perfusion (V/Q) Scan
Inferior STEMI
  • EKG shows ST elevation in 2, 3, aVF
  • Can involve AV node (bradycardia)
    • Avoid beta blockers
    • Treat with atropine
  • Can involve RV (preload dependent)
    • Avoid nitroglycerine
    • Treat with fluids
Common to Nitroglycerine
  • Hypotension
  • Current sildenafil usage
Aortic Dissection
  • Type A (ascending) Dissection
    • Surgical emergency
  • Type B (descending) Dissection
    • Medical management
  • Testing
    • CTA of the chest
    • Chest X-Ray SOMETIMES shows a widened mediastinum
  • Treatment
    • Esmolol (decrease heart rate)
    • Labetelol (decrease blood pressure)
  • PEARL: Aortic dissection can cause STEMI
Heart Failure
  • Treatment
    • Diuresis
    • Nitroglycerin
    • BiPAP
  • If patient needs fluids
    • Decrease size of fluid bolus
COPD
  • Treatments
    • Albuterol/Ipratropium
    • Antibiotics
    • Steroids
    • BiPAP
Pneumonia
  • If alcoholic/homeless/dementia/parkinson’s
    • Treat for aspiration (anaerobes)
  • If recent hospitalization/ventilator
    • Treat for pseudomonas and MRSA
  • If pneumonia PLUS atypical symptoms
    • Treat for legionella
  • If recent influenza
    • Treat for MRSA
Additional Reading

NBME Shelf Review (Part 8) – Abdominal Pain

November 18, 2018 /

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Acute Mesenteric Ischemia
  • History of atrial fibrillation
  • “Pain out of proportion to exam”
Bowel Obstruction
  • History
    • Abdominal pain
    • Bloating/Distention
    • Vomiting
    • Decrease stool/flatus
  • Exam
    • Abdominal tenderness and distention
    • If guarding/rigidity/rebound tenderness (aka peritonitis)
      • Consider perforated bowel
  • Testing
    • Obtain CT abdomen with IV contrast
  • Treatment
    • Fluids
    • NPO
    • NG Tube
Acute Diverticulitis
  • NOTE: DiverticulOSIS is what causes GI bleeding
  • History/Exam
    • Fever
    • Left lower quadrant pain/tenderness
  • Testing/Treatment
    • CT abdomen with IV contrast
    • Liquid diet
    • Antibiotics
  • Complications
    • Abscess
    • Stricture
    • Fistula
    • Perforation
    • Obstructions

Abdominal Aortic Aneurysm

  • If suspected, perform bedside ultrasound of the abdomen
    • Aortic diameter >3 cm
Spontaneous Bacterial Peritonitis
  • Diagnose by performing a paracentesis
    • Look for >250 white blood cells
  • Treat with ceftriaxone

Kidney Stones

  • CT without contrast
  • If the stone is <5mm
    • Treat with analgesics and tamsulosin
  • If the stone is >5mm
    • Consult urology
Common Indications for Emergency Dialysis
  • Mnemonic: AEIOU
    • Acidosis (pH <7.1)
    • Electrolytes (K > 6.5)
    • Intoxication
      • Lithium
      • Ethylene Glycol
      • Methanol
      • Aspirin
    • Overload of volume resistant to diuresis
    • Uremia that is symptomatic
      • Altered mental status
      • Pericarditis
Ectopic Pregnancy
  • Testing
    • BhCG QUANTITATIVE
    • Type and screen for Rh Status
    • Pelvic ultrasound
      • IUP = Gestational sac PLUS a Yolk sac
      • Beware “heterotopic” pregnancy in fertility treatment patients (IVF)
    • Treatment
      • If no IUP visualized, ectopic pregnancy is a possibility, and management depends on hCG
        • If <1500
          • Consider sending stable patients home and repeat hCG in 48 hours
        • If >1500
          • Ectopic until proven otherwise, consult OBGYN
      • Rh- needs RhoGAM
        • Prevents complications in future pregnancies
Additional Reading

NBME Shelf Review (Part 7) – Abdominal Pain

November 11, 2018 /

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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 hypotensive
    • Octreotide
    • Ceftriaxone
    • Transfuse blood as needed
      • If hemoglobin <7 transfuse
      • If patient actively bleeding and level <8 transfuse
  • Consult GI for endoscopy
Hepatic Encephalopathy
  • Common findings
    • Altered mental status
    • Asterixis
    • Elevated ammonia level
  • Treat with lactulose or rifamixin
Peptic Ulcer Disease
  • History
    • Hematemesis or Melena
    • Epigastric abdominal pain
    • Chronic NSAIDS or steroids
  • Treatment
    • PPI (such as pantoprazole)
      • Works better than an H2 blocker
Cholecystitis
  • RUQ ultrasound
    • Thickened gallbladder wall
    • Distended gallbladder
    • Pericholecystic fluid
    • Obvious impacted stone
  • HIDA scan
    • Inject radioactive material
    • Absorbed by hepatocytes
    • Secreted into biliary tree into small intestine
      • If gallbladder not visualized
        • Cystic duct obstruction
      • If common bile duct cannot be visualized
        • Choledocolithiasis
Ascending Cholangitis
  • Charcots Triad
    • Fever
    • RUQ Pain
    • Jaundice
  • Patient requires ERCP (gastroenterology consult)
  • Give antibiotics
Acute Pancreatitis
  • Diagnosis
    • Classic description
      • Epigastric pain radiating to back
      • Severe vomiting
    • Lipase
      • >3x upper limit of normal is diagnostic
    • CT scan to look for complications of pancreatitis
Additional Reading

NBME Shelf Review (Part 6) – Common Arrhythmias

November 4, 2018 /

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“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 complication of prolonged QTc
    • Side effect of multiple medications
      • Antipsychotics
      • Methadone
      • Ondansetron
  • Give Magnesium Sulfate
High yield EKG patterns
  • Long QTc
  • Wolf Parkinson White (WPW)
  • Brugada Pattern
Atrial Fibrillation
  • Stable
    • Patient presents immediately after onset (<24-48 hours)
      • Synchronized cardioversion
      • Rhythm control medications
        • Amiodarone
        • Procainamide
        • Flecanide
  • Patient does not present immediately (or unknown onset)
    • Rate control
      • Beta blockers
        • Metoprolol
      • Calcium channel blocker
        • Diltiazem
    • Anticoagulation (heparin)
  • Unstable
    • Synchronized cardioversion
  • Atrial fibrillation with extremely fast rate (200+) is common in WPW
  • Atrial fibrillation with slow rate is common with Digoxin toxicity
Bradycardia
  • AV Blocks
    • 1st Degree
    • 2nd degree (type 1)
    • 2nd degree (type 2)
    • 3rd degree
  • If symptomatic and stable…
    • Atropine
  • If they become unstable…
    • Transcutaneous or transvenous pacing
Additional Reading

NBME Shelf Review (Part 5) – Ophthalmology and Toxicology

October 28, 2018 /

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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 Arteries
    • Jaw claudication
    • Elevated ESR (“sed rate”)
  • Treat with steroids
Anterior Uveitis
  • Painful red eye
  • Cell and flair on slit lamp examination
UV Keratitis (“snow blindness”)
  • Common in skiers/snowboarders
  • Diagnose with fluorescein and use woods lamp
    • Punctate lesions on the cornea
Common Poisons/Antidotes
  • Digoxin toxicity
    • Digibind
  • Acetaminophen toxicity
    • N-Acetylcysteine (NAC)
  • Ethylene glycol or methanol toxicity
    • Fomepizole
  • Jimson weed (anticholinergic toxicity)
    • Physostigmine
  • Organophosphate toxicity
    • Atropine
      • Treat until airway secretions have stopped
    • Pralidoxime
  • Opiate toxicity
    • Naloxone
  • Benzodiazepine
    • Flumazenil (falling out of favor)
  • Cocaine toxicity
    • DON’T give beta blockers
      • Unopposed alpha effect
      • Very little data to support this but commonly believed
  • Iron toxicity
    • Deferoxamine
  • Salicylate overdose
    • Sodium bicarbonate
    • Dialysis
  • Tricyclic antidepressent
    • Sodium bicarbonate
  • Beta blocker overdose
    • Glucagon
    • Calcium channel blocker overdose
    • Glucagon
    • IV Calcium
    • High dose euglycemic insulin therapy
  • Sulfonylurea overdose
    • Octreotide
    • Dextrose
  • Heparin reversal
    • Protamine sulfate
  • Cyanide toxicity (common in house fires)
    • Hydroxocobalamin
    • Sodium Nitrite
  • Carbon monoxide toxicity
    • Oxygen oxygen oxygen
    • Hyperbaric oxygen
      • BEWARE: pulse oximetry will be normal
  • Valproic acid toxicity
    • L-carnitine
Additional Reading

NBME Shelf Review (Part 4) – Environmental

October 21, 2018 /

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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
    • Diaphoresis
    • Myalgias
    • Muscle spasms/cramping
  • Supportive care
Pit Viper Bite
  • Causes Coagulopathy/DIC
  • Swelling around bite site
  • Treat with CroFab antivenin
Brown Recluse Bite
  • Painless bite
  • Ulceration/necrosis around bite site
Altitude Illnesses
  • Acute Mountain Sickness (AMS)
    • Headache
    • Nausea and vomiting
    • Treat with acetazolamide or decent
  • High Altitude Pulmonary Edema (HAPE)
    • Shortness of breath
    • Treat with supplemental oxygen and immediate decent
    • Consider nifedipine or sildefenil
  • High Altitude Cerebral Edema
    • Ataxia
    • Confusion
    • Cushings reflex
      • Bradycardia
      • Hypertension
      • Cheyne-Stokes respirations
    • Treat with supplemental oxygen and immediate decent
    • Consider dexamethasone
Digit Amputation
  • Wrap in saline soaked gauze
  • Put in plastic bag
  • Place on ice
  • Send to surgeon
Tooth avulsion
  • Reimplant tooth in socket
  • Place in glass of milk
Frostbite
  • Remove wet clothing
  • Rewarm at body temperature
Additional Reading

NBME Shelf Review (Part 3) – Pediatrics

October 14, 2018 /

Podcast: Play in new window | Download

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
    • Common causes
      • Meckles diverticulum
      • Henoch-Schonlein purpura
    • Diagnose with abdominal ultrasound
      • Look for target sign
    • Treat with air enema
  • Malrotation with Volvulus
    • Classic symptoms
      • Bilious emesis
      • Projectile
      • CONSTANT severe abdominal pain
      • Peritonitic abdominal exam
    • Common tests (if stable)
      • Upper GI Series
        • Corkscrew sign
        • Coffee-bean sign
  • Necrotizing Enterocolitis
    • Classic symptoms
      • Premature neonate
      • Bloody stool
    • X-Ray shows pneumotosis intestinalis
      • (Air in the bowel wall)
  • Hirschsprungs Disease
    • Delayed passage of meconium
    • Diagnosis
      • Contrast enema (not typically done in ED)
        • Look for distal transition point
      • Rectal suction biopsy (DEFINITELY not done in the ED)
        • Gold standard for diagnosis
Bronchiolitis
  • Commonly caused by RSV
  • Initial fever and URI
    • Progresses to respiratory distress
Croup (laryngotrachealbronchitis)
  • Commonly caused by parainfluenza
  • Initial fever and URI
    • Progresses to stridor
    • Barky cough
  • Neck xray will show “steeple sign” (subglottic narrowing)
  • Treatment
    • Steroids
    • Nebulized epinephrine
Epiglottitis
  • Commonly caused by Haemophilus influenzae 
  • Classic symptoms
    • Fever
    • Sore throat
    • Drooling
    • Muffled voice
  • Treatment
    • Keep the child calm
    • Intubation in a controlled environment
    • Antibiotics
Additional Reading

NBME Shelf Review (Part 2) – Trauma

October 7, 2018 /

Podcast: Play in new window | Download

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 with contrast
Basilar Skull Fracture
  • Bilateral post-auricular ecchymosis (Battle’s Sign)
  • Raccoon eyes
  • Hemotympanum
  • Otorrhea/Rhinorrhea
Tension Pneumothorax
  • Classic findings
    • Hypotension
    • Obstructive shock
    • Absent breath sounds
    • Jugular vein distension (JVD)
  • Treatment
    • Needle decompression
      • 2nd intercostal space
      • Mid-clavicular line
    • Tube thoracostomy
Hemothorax
  • Hypotension
    • Hemorrhagic shock
  • Absent breath sounds
  • NO jugular vein distension
Cardiac Tamponade
  • Beck’s Triad
    • Hypotension
      • Obstructive shock
    • Jugular vein distension
    • Muffled heart sounds
  • Perform bedside ultrasound
    • Diastolic collapse of right ventricle (RV)
  • EKG
    • Electrical alterans
Traumatic Aortic Rupture
  • Rapid deceleration injuries
  • Tears at ligamentum arteriosum
  • Widened mediastinum on chest X-Ray
Pulmonary Contusion
  • Blunt chest trauma
  • Respiratory distress
    • NO paradoxical chest movement with breathing
  • Chest X-Ray
    • Shows non-lobar infiltrates
    • Located near location of injury
Additional Reading

NBME Shelf Review (Part 1) – General Concepts

September 30, 2018 /

Podcast: Play in new window | Download

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 childbearing age
    • Get a pregnancy test
  • If you need to give contrast for a CT scan (example CTA for pulmonary embolism)
    • Need renal function
Hyperkalemia
  • Common scenarios
    • Crush injury
    • Severe burns
    • End stage renal disease
    • Especially if missed dialysis
    • Leukemia on chemotherapy
  • Remember: Don’t give succinylcholine to a patient with hyperkalemia
  • Common EKG findings on test
    • Hyperacute T waves
    • Sinusoidal waves
  • Treatment
    • Stabilizes cardiac cell membranes
      • Calcium
    • Shifts potassium into the cells
      • Insulin/Glucose
      • Albuterol
      • Sodium Bicarbonate
    • Removes potassium
      • Furosemide
      • Dialysis
      • Kayexalate
Hypokalemia
  • EKG findings
    • Flattened T waves
    • QTC prolongation
    • U waves
  • At risk for ventricular arrhythmias
  • Treatment
    • Oral potassium replacement
    • IV potassium replacement
    • Consider magnesium replacement
Hyponatremia
  • Hypertonic saline IF
    • Comatose
    • Actively seizing
  • Otherwise treat with normal saline
  • Pseuohyponatremia
    • Correct the sodium if patient has severe hyperglycemia
    • Add 1.6 to sodium for every 100 glucose above normal limit
Hypercalcemia
  • Symptoms
    • “Stones, bones, groans, psychiatric overtones”
  • Treatment
    • IV fluids (promotes excretion) FIRST
    • Then calcitonin/bisphosphates
Torsade de Pointes
  • Common in patients with prolonged QTc
    • Hypokalemia
    • Hypocalcemia
  • Treat with magnesium
Additional Reading

When to Stop CPR

September 9, 2018 /

Podcast: Play in new window | Download

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 in a rural EMS system
      • Non-EMS witnessed arrest
      • No return of spontaneous circulation prior to transport
      • Only non-shockable rhythms present
    • Early identification of patients with out-of-hospital cardiac arrest with no chance of survival and consideration for organ donation
      • Non-EM witnessed arrest
      • Non-shockable INITIAL rhythm
      • No ROSC despite 3 doses of epinepherine
  • Duration of pre-hospital CPR and favorable neurologic outcomes for pediatric out-of-hospital cardiac arrests. A nationwide, population based cohort study
    • Less than 1% chance of recovery after 46 minutes of resuscitation
Additional Reading
  • Jordan MR, O’keefe MF, Weiss D, Cubberley CW, Maclean CD, Wolfson DL. Implementation of the universal BLS termination of resuscitation rule in a rural EMS system. Resuscitation. 2017;118:75-81.
  • Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016;165(11):770-778.
  • Goto Y, Funada A, Goto Y. Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study. Circulation. 2016;134(25):2046-2059.
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