Author: Zack (Page 6 of 9)

Thrombocytopenia

March 11, 2018 / Zack

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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 exchange
Hemolytic Uremic Syndrome (HUS)
- Clinical presentation
  - Pediatric patient with bloody diarrhea
  - Renal dysfunction
  - Thrombocytopenia
- Treatment
  - Supportive care
Heparin Induced Thrombocytopenia (HIT)
- Clinical presentation
  - Recent heparin administration
  - Acute thrombocytopenia (<150) or 50% decrease in platelets
- Treatment
  - Stop heparin and choose different anticoagulant
Disseminated Intravascular Coagulation (DIC)
- Clinical presentation
  - Patient septic, severe trauma, or otherwise critically ill/injured
  - Multiple abnormal labs
    - Increased PT/PTT
    - Increased D-dimer
    - Increased fibrinogen degradation products
- Treat underlying trigger
Immune/Idiopathic Thrombocytopenic Purpura (ITP)
Common condition
- Relatively benign
Treatment
- Steroids
- Occasionally platelet transfusion
Other causes
- HIV
- Hepatitis
- Heavy alcohol use

Additional Reading

Thrombocytopenia: An ED Approach (emDOCs)

Nausea and Vomiting

March 4, 2018 / Zack

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The hardest part about this chief complaint is expanding your differential beyond gastritis!!!

Step 1: Expand Your Differential Diagnosis

Early appendicitis
Bowel obstructions
Myocardial infarction
Elevated ICP
Diabetic Ketoacidosis

Step 2: Give a Testing Plan

High yield tests to consider
- EKG – older adults
- Pregnancy test – women of child bearing age
- Electrolytes – most patients
Other tests to consider
- CBC
- LFTs/Lipase
- Urinalysis

Step 3: Give a Treatment Plan

IV fluids (1L normal saline)
Antiemetics
- Ondansetron (Zofran)
- Promethazine (Phenergan)
- Prochlorperazine (Compazine)

Step 4: PO Challenge

Prior to discharge patient needs to keep fluids down
- Bonus points if you update your attending on this

Step 5: Repeat Abdominal Exam

Perform this prior to discharging patient

Additional Reading

Antiemetic Pearls (EM Cases)

Complications of Cirrhosis

February 25, 2018 / Zack

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Organ Failure Complications

Hepatorenal syndrome (renal failure)
- Decreased urine output
- Labs show elevated creatinine
- Admit to hospital (high mortality)
Hepatic encephalopathy (brain failure)
- Introduction
  - Liver clears ammonia from body
  - In advanced liver failure, ammonia increases
- Symptoms
  - Altered mental status/confusion
  - Asterixis
- Treatment
  - Lactulose
    - Binds ammonia and is excreted
  - Rifaximin
    - Eliminates bacteria responsible for producing ammonia

Portal Hypertension Complications

Gastric/esophageal varices
- Symptoms
  - Altered mental status
    - Hepatic encephalopathy triggered by reabsorbed GI blood
  - Melena
    - Black stools from digested GI blood
- Treatment
  - Proton pump inhibitor (PPI)
    - Pantoprazole
  - Octreotide
  - Antibiotics
  - Classic procedure
    - Blakemore tube (balloon tamponade)
Ascites with spontaneous bacterial peritonitis (SBP)
- Symptoms
  - Abdominal pain/tenderness
  - Ascites
  - Fever
- Testing plan
  - Diagnostic paracentesis
    - >250 neutrophils
    - High protein
    - Low glucose
- Treatment
  - Antibiotics
  - Albumin

Liver Failure Complications

Coagulopathy
- Diagnose with abnormal coagulation studies
  - PT with INR
- Patients can be BOTH hyper and hypocoagulable

Additional Reading

How to Perform Paracentesis (Medscape)

Peds T- Tummy and Non-Accidental Trauma

February 18, 2018 / Zack

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Non-Accidental Trauma

Estimated 10% of pediatric patients are victims of abuse
- Sexual abuse
- Physical abuse
- Neglect
Common red flags
- Changing story
- Story that doesn’t make since
- Delays in seeking care
- Unusual bruising locations
  - Torso
  - Ears
  - Neck
Common tests if non-accidental trauma suspected
- Skeletal survey x-rays
- Head CT
  - Especially if altered mental status
- Abdominal CT
  - Especially if abdominal trauma
Report to child protective services (CPS)

Tummy Ache

Necrotizing enterocolitis
- Classic presentation
  - Premature baby
  - 1st month of life
  - Ill appearing
- Classic finding on x-ray
  - “Pneumatosis intestinalis”
Volvulus
- Classic presentation
  - 1st month of life but previously healthy
  - Distended abdomen
  - Bilious vomiting
- Testing
  - Abdominal Xray
  - Upper GI Series (ideal test)
Toxic megacolon
- Complication of Hirchsprung Disease
- Seen on x-ray
Intussusception
- Telescoping bowel resulting in ischemia
- Classic presentation
  - 2 months – 2 years old
  - Intermittent abdominal pain followed by lethargy
- Diagnose with abdominal ultrasound
Pyloric stenosis
- Classic presentation
  - Projectile vomiting
  - Normal appetite/hungry
  - Palpable “olive” in epigastrium
- Testing
  - Electrolyte panel
    - Hypokalemia
    - Hypochloremia
    - Alkalosis
  - Abdominal ultraound

Additional Reading

Pediatric Abdominal Pain (EM Clerkship)

Peds I- Inborn Errors of Metabolism and Endocrinology

February 11, 2018 / Zack

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Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!!

Inborn Errors of Metabolism (IEM)

Almost always result in one of the following three clinical abnormalities
- Buildup of toxins
  - Ammonia
    - To test for this, obtain an ammonia level
- Buildup of acids
  - Methylmalonic acidemia
    - To test for this, obtain electrolyte panel and look for decrease CO2
- Shortage of glucose
  - Glycogen storage disorders
    - To test for this, obtain a blood glucose level

Congenital Adrenal Hyperplasia (CAH)

Decreased 21-hydroxylase enzyme
Physiologic abnormalities
- Decreased aldosterone
  - Low sodium (hyponatremia)
  - High potassium (hyperkalemia)
- Decreased cortisol
  - Low glucose level
  - Hyperpigmentation
- INCREASED sex hormone (androgens)
  - Fused labia
  - Partial male genitalia

Additional Reading

Congenital Adrenal Hyperplasia (Wikipedia)

Peds H- Heart Failure and Congenital Heart Disorders

February 4, 2018 / Zack

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Common Chief Complaints

Cyanosis
Difficulty feeding
Failure to thrive

Cyanotic Heart Lesions

Truncus arteriosus
- Aorta and pulmonary artery are fused
- Single vessel comes from both ventricles
Transposition of great vessels
- Aorta comes off RIGHT ventricle
- Pulmonary artery comes off LEFT ventricle
Tricuspid atresia
- Blood unable to get from right atrium to right ventricle
Tetrology of fallot
- Overriding aorta
- Ventricular septal defect
- Right ventricular outflow tract obstruction
- Hypertrophy of right ventricle
Total anomalous pulmonary venous return
- Pulmonary vein empties into the right ventricle

Ductal Dependent Lesions

Classically presents in first 30 days of life
Treatment = Prostaglandins
Common lesions
- Hypoplastic left heart
- Aortic stenosis
- Coarctation of the aorta

Congestive Heart Failure

Common Presentation
- Difficulty feeding
- Organomegaly
- Cardiomegaly on CXR
Treatment
- Furosemide
- Vasopressors
Admit

Additional Reading

Congenital Heart Disease Emergencies (EM Cases)
Ductal Dependent Congenital Heart Defects (CodeHealth)

Peds S- Sepsis and Serious Bacterial Infections

January 28, 2018 / Zack

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Pediatric “Sepsis”

Consider in any toxic appearing child/neonate
- Especially with fever (or hypothermia)
Treatment
- Early antibiotics
- Fluid bolus

“Serious Bacterial Infections” (SBI)

Consider in any baby with fever
Three classic categories
- Age <30 days
  - Introduction
    - Weak immune system
    - No immunizations
    - Very high risk for serious bacterial infections
  - Require a significant amount of testing
    - Urinalysis with Urine Culture
    - Blood Cultures
    - Lumbar Puncture with CSF Cultures
    - Chest X-Ray
  - Require admission and antibiotics
- Age 30-60 days
  - ILL appearing
    - Treat same as fever in <30 day patient
  - WELL appearing
    - Testing and treatment differ by institution
    - Multiple criteria established to help in this age range
      - Rochester criteria
      - Philadelphia criteria
      - PECARN criteria
    - Choose one and use consistently
- Age >60 days
  - (Assumes immunizations are up to date)
  - Workup is more targeted
    - Blood cultures, Urine cultures, Chest X-Rays still common

Additional Reading

Rochester Criteria Febrile Infants (MDCalc)
PECARN Rule for Low Risk Febrile Infants (MDCalc)

Peds H- Hyperglycemia and Hypoglycemia

January 21, 2018 / Zack

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Introduction

In pediatric patients, have a low threshold to check blood sugar
Undiagnosed diabetics commonly identified in ED during first episode of DKA
HYPOglycemia is very common in multiple conditions, especially in ill children

Hyperglycemia

DKA is different in kids
- They get cerebral edema
  - Increased intracranial pressure with rapid fluid administration
- Common symptoms
  - Headache
  - Altered mental status
  - Neurologic deficits
  - Cushings triad
    - Hypertension
    - Bradycardia
    - Irregular breathing
- Treatment = mannitol

Hypoglycemia

Multiple causes
- Sepsis
- Inborn errors of metabolism
- Endocrine disorders
Replace glucose using “Rule of 50s”
- Dextrose % x Volume = 50
  - Neonates: 5ml/kg of D10
  - Pediatrics: 2ml/kg of D25
  - Teens/Adults: 1ml/kg of D50
- 1 “amp” of D50 = 25g of sugar = 50ml

Additional Reading

Rule of 50s (PEMBlog)
Pediatric DKA (EM Cases)

Peds O- Oxygen, Airway, and Respiratory Disorders

January 14, 2018 / Zack

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Applying oxygen is one of the first steps in treating any crashing child!!!

Airway Emergencies

Foreign body (FB)
- Patient presentation
  - Stridor
  - Choking episode
- Testing
  - CXR
    - May directly show foreign body
    - May show secondary effects of a foreign body
      - Hyperinflated/collapsed lobes of the lung
- Patient needs bronchoscopy if suspicion is high
Peritonsillar abscess
- Visible in the pharynx
Bacterial tracheitis
- HIDDEN IN the airway
Epiglottitis
- HIDDEN ABOVE the airway
Retropharyngeal abscess
- HIDDEN BEHIND behind the airway
Common presentations of airway emergencies
- Voice changes
- Drooling
- Stiff neck
Testing
- Most are seen on neck X-Ray
- Peritonsillar abscess is clinical diagnosis
Treatment
- Manage the airway
- IV Antibiotics
- Peritonsillar abscess needs drainage

Breathing Emergencies

Bronchiolitis = Badly breathing booger babies
- Upper respiratory infection caused by virus
- Signs of severe illness requiring admission
  - Grunting
  - Nasal flaring
  - Retractions
  - Hypoxemia
  - Unable to tolerate PO
- Treatment
  - Deep suctioning
  - Can consider albuterol trial
  - Oxygen supplementation as needed
- Generally avoid
  - Chest X-rays
  - Steroids
  - Antibiotics
Asthma
- Treatment
  - First line
    - Albuterol/ipratropium
    - Steroids
  - Additional options as needed
    - Magnesium
    - Ketamine
    - IV epinepherine
Croup
- Presentation
  - Barky cough
  - Stridor
- Treatment
  - Steroids
  - Consider racemic epinephrine
Pneumonia
- Diagnosed by x-ray
- Treat with antibiotics
Cystic fibrosis
- Albuterol/ipratropium
- Nebulized saline
- Antibiotics

Additional Reading

Approach to Asthma (EM Clerkship)
More Than a Sore Throat (emDOCs)

How to Save a Dying Baby

January 7, 2018 / Zack

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When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!!

Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies

Foreign body
Peritonsillar abscess
Bacterial tracheitis
Epiglottitis
Retropharyngeal Abscess
Bronchiolitis
Asthma
Croup
Pneumonia
Cystic Fibrosis

Hyper/Hypoglycemia- Check Blood Glucose

Hypoglycemia
DKA

Sepsis- Consider Sepsis and Serious Bacterial Infections

Pediatric sepsis
Fever <30 days of age
Fever 30-60 days of age
Fever >60 days of age

Heart- Consider Congenital Heart Abnormalities

Truncus arteriosis
Transposition of great vessels
Tricuspid atresia
Tetrology of fallot
Total anomalous pulmonary venous return
Ductal dependent lesions
Congestive heart failure

Inborn Errors of Metabolism/Endocrinology

Congenital adrenal hyperplasia

Tummy/Trauma- Consider Abdominal Processes and Non Accidental Trauma

Non-accidental trauma
Necrotizing enterocolitis
Volvulus
Toxic megacolon
Intussusception
Pyloric stenosis

And never forget… If you feel flustered… GRAB THE BROSLOW!!!

Additional Reading

Peds Oxygen, Airway, and Respiratory Disorders (EM Clerkship)
Peds Hyper/Hypoglycemia (EM Clerkship)
Peds Sepsis and Serious Bacterial Infections (EM Clerkship)
Peds Heart Failure and Congenital Heart Disorders (EM Clerkship)
Peds Inborn Error of Metabolism and Endocrinology (EM Clerkship)
Peds Trauma and Tummy Ache (EM Clerkship)

Bleeding Disorders

December 31, 2017 / Zack

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These are most important in trauma patients!!!

Platelet Disorders

Symptoms of SUPERFICIAL bleeding
- Mucosal bleeding
- GI bleeding
- Recurrent epistaxis
Thrombocytopenia
- When the platelets ARE LOW
  - Refer to THIS episode
Von-Willebrand disease
- When the platelets CAN’T BIND
- Treatment
  - Desmopressin (DDAVP)
    - Causes increase in amount of von-willebrand factor (vWF) available
    - Also causes free water retention
      - Treatment of diabetes insipidus
  - Replace vWF
    - Transfuse factor VIII
      - Contains vWF (factor VIII binds vWF)
    - Transfuse cryoprecipitate

The Hemophilias

Symptoms of DEEP bleeding
- Hemarthrosis
- Hematomas
- Intracranial Bleeding
Factor IX deficiency (Christmas disease)
- Treat by replacing factor IX
  - Rate the “severity” of the bleeding on a scale of 1-100
    - Dosing equals the severity score in milligrams
      - For example
      - 25 = 25mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)
      - 50 = 50mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)
      - 75 = 75mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)
      - 100 = 100mg/kg factor = deadly bleeding = (intracranial hemorrhage)
Factor VIII deficiency (Hemophilia A)
- Treat by replacing factor VIII
  - Dosing similar to factor IX but you take severity score and divide by 2
    - For example
    - 25 = 12mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)
    - 50 = 25mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)
    - 75 = 37mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)
    - 100 = 50mg/kg factor = deadly bleeding = (intracranial hemorrhage)

Additional Reading

Approach to Thrombocytopenia (EM Clerkship)
Treatment of Hemophilia (Hemophilia.org)

How to Read an EKG

December 3, 2017 / Zack

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Always remember…1, 2, 3, get an old EKG!!!

Step 1: Identify the Rate and Rhythm

Is it sinus rhythm?
- P wave before every QRS
Is it one of the tachycardias? (Refer to THIS episode)
Is it one of the bradycardias? (Refer to THIS episode)

Step 2: Look for Signs of Ischemia

Most consistent way is to examine by anatomic region of the heart
- II, III, and aVF are “inferior” leads
- I, aVL, V5, V6 are “lateral” leads
- V1 and V2 are “septal” leads
- V3 and V4 are “anterior” leads
Check for Q waves
Check for ST segment elevation or depression
- Compare the J point with baseline (TP segment)
Check for peaked T waves and T wave inversions
- T wave inversions in V1 and aVR are normal

Step 3: Look at Intervals

PR interval
- Wolf-Parkinson White Syndrome
- 1st degree heart block
QRS interval
- Left bundle branch block
- Right bundle branch block
- Sodium channel blockade
QT interval
- Long QT syndrome
- Hypokalemia
- Risk of torsades de pointes

Step 4: Get an Old EKG

If you find anything abnormal looking, compare to an old EKG

Bonus: Scarbossa Criteria

Identifies ischemia in patients with a left bundle branch block
- 1 lead with concordant ST elevation
- 1 lead with concordant ST depression (V1-V3)
- Severely discordant ST elevation (>25% preceding S wave)

Additional Reading

Basic Approach to Tachycardias (EM Clerkship)
Basic Approach to Bradycardias (EM Clerkship)
EKGs for the Emergency Physician (Amazon)

Pediatrics Exam

November 26, 2017 / Zack

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Mnemonic: ABCDEF

Appearance

The ‘A’ in the pediatric assessment triangle
- Interactive vs distant
- Good tone vs floppy
- Calm and happy vs inconsolable

Breathing

The ‘B’ in the pediatric assessment triangle
- Signs of respiratory distress
  - Nasal flaring
  - Retractions
  - Abnormal respiratory sounds

Color/Circulation

The ‘C’ in the pediatric assessment triangle
Pink = good
Abnormalities
- Pallor
- Cyanosis
- Mottling

Distraction

Almost impossible to do a good peds exam in a crying kid
- Easiest ways to keep kids distracted
  - Let parents hold/play with them
  - Toys
  - Stethoscope
  - Funny sounds/noises

ENT

Many times the kids don’t localize the symptoms
May present with vomiting, fever, irritability, etc
If difficulty examining pharynx, consider triggering a gag reflex

Fully Undress

Look for bruising, rash, blisters
Signs of non-accidental trauma
GU exam (especially in boys, check the testes!)

Additional Reading

Peds Respiratory Disorders (EM Clerkship)
Pediatric Assessment Triangle (Wikipedia)

Pediatrics History

November 19, 2017 / Zack

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Always ask about pediatric patient’s ‘P-I-S-S’ status!!!

Core Function Questions (P-I-S-S Status)

Peeing
- Evaluates for dehydration
  - Number of wet diapers per day?
  - Same number as usual?
Intake
- Rule of 3s
  - Estimates how much milk/formula an average infant should be taking
  - 3oz of milk or formula every 3 hours
Sleeping
- Is the patient sleeping MORE than usual?
- LESS than usual?
Stooling
- Normal stool
  - Changes from dark meconium to tans/yellows

Pediatric Medical History

Prebirth
- Did the patient have prenatal care?
- Any issues with the pregnancy?
- Was mom GBS positive?
Peribirth
- What gestational age was patient born at?
- Vaginal delivery or c-section?
- How long did baby have to stay in hospital after delivery?
Postbirth
- Diagnosed medical/surgical problems
- Immunization status

Additional Reading

The Truth About Baby Poop (WebMD)

Fever in a Returning Traveler

November 12, 2017 / Zack

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If a returning traveler has a fever, think malaria malaria malaria!!!

Step 1: Ask your patient if they have traveled within the last year

If yes… You should at least CONSIDER malaria

Step 2: If patient says yes, take a travel history

When did they go
Where did they stay
Where they exposed to anything concerning
- Mosquitos
- Animals
- Weird foods
- Sexual partners
- Sick people
Where they in developed/tourist areas or “off the trail”

Step 3: Ask about prophylaxis

Did they see a doctor before leaving?
Did they take any immunizations or medicines prior to departure?
Did they continue prophylaxis as instructed?

Step 4: Go to the CDC website

Look up the country of concern
Will help establish your differential

Step 5: Test for malaria

If you are concerned that patient has malaria…
Order thick and thin blood smear

Additional Reading

CDC Yellow Book (CDC Website)

Diarrhea

November 5, 2017 / Zack

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If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!!

3 Big (Non-Viral) Causes of Diarrhea

The Icky ‘I’s
- Ischemia
  - Frequently require surgery consult
- Infection
  - Frequently require antibiotics
- Inflammatory bowel disease
  - Frequently require GI consult, steroids, or salicylates

5 Red Flags

Is it bloody?
- Consider performing a guaiac test
- Bloody diarrhea usually isn’t “just a virus”
Is it severely painful?
- (Viral gastroenteritis may cause gas cramping but shouldn’t be tender or severely painful)
- Bonus red flag!!!
  - POST-PRANDIAL pain
  - Consider mesenteric ischemia
Recent antibiotics or hospitalization?
- Consider C. difficile
  - Treat with PO vancomycin
Recent travel?
- ~80% travelers diarrhea is bacterial
  - Treat with ciprofloxacin
    - Note: See FDA black box for fluoroquinolones prior to prescribing
Do you have history of atrial fibrillation?
- Increases risk for mesenteric ischemia and ischemic colitis

Consider Testing if Patient is Ill or has Red Flags

CBC
Electrolytes
Stool studies
- Stool WBCs
- Stool culture
- C-diff
- Ova/Parasite
CT abdomen/pelvis with IV contrast

Common Antidiarrheals

Loperamide (Imodium)
Bismuth (Pepto-Bismol)
Dphenoxylate (Lomotile)

Additional Reading

Fluoroquinolone Black Box Update (FDA)

Appendicitis

October 22, 2017 / Zack

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Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!!

Three Stages of Appendicitis

Stage 1: ~12 hours of “gastroenteritis” like symptoms
Stage 2: Direct somatic irritation
- This is when pain over McBurney’s develops!
Stage 3: Perforation
- Patient is now sick and septic

Approach to Appendicitis

Step 1: Consider getting labs
- Always remember “The white blood cell count is the last refuge of the intellectually destitute”
- The WBC count has both low sensitivity and low specificity for acute appendicitis
Step 2: Get a detailed history
- When did the pain start?
  - How many HOURS into their syndrome are they (remember stages of appendicitis)
  - Is the pain migrating?
- Objective fever?
- Did the pain start before the vomiting started?
- Does the patient have decreased appetite?
Step 3: Perform a physical exam
- Pain over McBurney’s point
  - Right lower quadrant
  - 1/3 the distance from the ASIS to the umbilicus
- Peritoneal signs (Rigidity, Rebound, Guarding)
- Psoas sign
  - Lie patient on left side with legs extended
  - Extend their hip behind them
  - Pain = Suspected retroperitoneal inflammation
- Obturator sign
  - Have patient lie on back with hip/knee flexed at 90 degrees
  - Internally rotate hip (move ankle away from body)
  - Pain = Suspected obturator internus inflammation
Step 4: Imaging
- Most adults
  - CT scan +/- IV contrast
- Pregnant women
  - MRI abdomen
- Pediatric patients
  - RLQ ultrasound
Step 5: Disposition
- Perform a repeat abdominal exam
- Even if CT is negative, consider followup in ED in 12-24 hours

Additional Reading

McBurney’s Point (Wikipedia)
Psoas Sign (Wikipedia)
Obturator Sign (Wikipedia)

Eye Complaints

October 15, 2017 / Zack

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Common Complaints

Red Eye
Decreased Vision
Trauma to the Eye

Approach to a Vision Complaint

Step 1: Assess visual acuity
- Visual acuity is the “vital sign of the eye”
- Snellen eye chart is best
- If patient unable to see chart…
  - Count fingers?
  - Able to see light?
Step 2: Examine the conjunctiva/cornea with fluorescein
- How to apply fluorescein
  - Recline patient 45 degrees
  - Pull down on lower eyelid to create pocket
  - Place anesthetic eye drops in pocket (ex. tetracaine)
  - Wet the fluorescein strip with eye drops and apply to pocket
  - Have the patient blink to distribute the dye
- Look under woods lamp for bright “uptake” areas that don’t move with blinking
  - These represent abrasions, ulcers, etc
- This step is also a good opportunity to evert the eyelids and examine for foreign bodies if appropriate
Step 3: Examine the anterior chamber with slit lamp
- “Cell and flare” (example HERE)
- Representative of iritis, uveitis
- This is also a good opportunity to examine any other abnormal areas of the eye under magnification!!!
Step 4: Check intraocular pressure
- Pressure >20mmHg (especially when unequal) is concerning for acute angle closure glaucoma
- Multiple tools to measure pressure on market, ask somebody to show you how to use
Step 5: If appropriate, use ultrasound to evaluate posterior eye
- Multiple things can be diagnosed with ultrasound of the eye
  - Retinal detachment
  - Optic neuritis
  - Papilledema
  - Foreign bodies

Additional Reading

Introduction to Slit Lamp (YouTube)
Cell and Flair (TimRoot.com)

Bradycardia

October 8, 2017 / Zack

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Differential Diagnosis

Mnemonic: HE DIES
- Hypothyroidism
- Elevated intracranial pressure (ICP)
  - Cushings reflex
    - Bradycardia
    - Increased blood pressure
    - Irregular breathing
- Drugs
  - Beta blockers
  - Calcium channel blockers
  - Digoxin
- Ischemia
- Electrolytes
  - Especially potassium!!!
- Sick Sinus Syndrome

Approach to Bradycardia

Step 1: Get an EKG
- Ischemia?
- Heart block?
  - 1st degree = PR interval >200ms (5 small boxes)
  - 2nd degree type 1 = PR gradually prolongs until dropped beat
  - 2nd degree type 2 = Intermittent dropped beats
  - 3rd degree = None of the atrial beats result in a ventricular beat
- Evidence of hyperkalemia?
Step 2: Determine if patient is SYMPTOMATIC
- Hypotension
- Chest Pain
- Syncope
- Lightheadedness
- Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications
Step 3: If patient is having symptoms… Give atropine!
- Typical dose is 0.5mg IV atropine
Step 4: If patient still having symptoms… Give epinephrine!
Step 5: If patient still having symptoms… Cardiac pacing!
- If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology
- Transcutaneous pacing
  - Sometimes difficult to get mechanical capture
- Transvenous pacing
  - Place through the right internal jugular vein

Additional Reading

How to Read an EKG (EM Clerkship)
Transcutaneous Pacing Procedure (EM Clerkship)

Anaphylaxis

October 1, 2017 / Zack

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Airway and Epi! Airway and Epi! Airway and Epi!

Introduction

Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen”
The antigen causes extensive mast cell and basophil cross-linking/activation
Common antigens
- Foods
- Drugs
- Insect venoms

Basic Approach

Step 1: Diagnose anaphylaxis
- Consider anaphylaxis if the patient has TWO body systems involved
- Dermatologic symptoms
  - Flushing
  - Rash
  - Urticaria
- Pulmonary symptoms
  - Shortness of breath
  - Wheezing
- Cardiovascular symptoms
  - Hypotension
  - Lightheadedness
- Gastrointestinal symptoms
  - Nausea/Vomiting
  - Diarrhea
Step 2: Give epinepherine
- A major pitfall in the treatment of anaphylaxis is delay of epinephrine!!!
- Normal adult “EpiPen” contains 0.3mg epinephrine
- Normal dosing of IM epinephrine is 0.01mg/kg
Step 3: Consider intubation
- The second biggest pitfall in the treatment of anaphylaxis is delaying intubation until it’s extremely difficult to intubate!!!
Step 4: Give adjunct medications
- H1 blocker
  - Diphenhydramine
- H2 blocker
  - Ranitidine
- Steroids
  - Prednisone, dexamethasone, etc
Step 5: Send the patient home with an EpiPen prescription
- Education them on this
- Articulate this part of the plan to your attending
Bonus
- Refractory anaphylaxis
- Beta-blockers?
  - Treat with glucagon

Additional Reading

Round 10 – Allergic Reaction (EM Clerkship)
How to Use an EpiPen (YouTube)

Author: Zack (Page 6 of 9)

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