Author: Zack (Page 8 of 9)

Procedural Sedation

February 19, 2017 / Zack

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Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

Cardioversion
Orthopedic reductions
Painful procedures

Three Step Approach to Procedural Sedation

Step 1: Risk stratify the patient
- Mallampati score (aka “How visible is the uvula?”)
  - Level 1: Can visualize THE WHOLE uvula
  - Level 2: Can visualize MOST of the uvula
  - Level 3: Can visualize SOME of the uvula
  - Level 4: Can NOT visualize the uvula
- ASA (aka “How healthy are they?”)
  - Level 1: Healthy
  - Level 2: Mild illness
    - Hypertension
    - Hyperlipidemia
    - Anemia
  - Level 3: Major illness
    - Diabetes
    - Coronary disease
    - COPD
    - Chronic renal disease
  - Level 4: Extremely unhealthy
    - Dialysis patient
    - Severe heart failure
    - Chronically debilitated
  - Level 5: Dying
    - Patient needs operation to live
      - Intracranial hemorrhage with midline shift
      - Ruptured aortic aneurysm
      - Ruptured papillary muscle with cariogenic shock
      - Dissecting aortic aneurysm
Step 2: Informed consent
- Patients sign a GENERAL CONSENT to treat when registering to the department
- Many emergency scenarios require physician to operate with IMPLIED CONSENT
- Many patients have an ADVANCED DIRECTIVE
- In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required
  - Varies by hospital
  - Typically required for procedural sedation in stable patients
Step 3: Gather supplies
- Nurse and nursing supplies
  - IV
  - Cardiac monitor
- Respiratory therapy and respiratory supplies
  - Capnography
  - Bag-valve mask
  - Airway box

Top 5 Procedural Sedation Medications

Midazolam (“Versed”) – 0.02 mg/kg IV
- Reduces anxiety prior to procedure
- Provides no analgesia
Fentanyl – 1 mcg/kg IV
- Reduces pain
- Useful for painful procedures
  - Incision and drainage
  - Simple reductions
Propofol – 0.5-1mg/kg IV
- General anesthetic
- Best given “low and slow”
- Short acting
- Causes respiratory depression and hypotension
Etomidate – 0.15 mg/kg IV
- General anesthetic
- Less hypotension than propofol
- Can cause myoclonus
Ketamine – 1-2mg/kg IV
- “Dissociative”
- Provides both amnesia AND analgesia
- Can cause emergence reactions
- Can cause laryngospasm and secretions

Additional Reading

Mallampati Score (Wikipedia)
ASA Physical Status Classification (Wikipedia)

Back Pain

February 5, 2017 / Zack

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Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses

Aortic Dissection and Abdominal Aortic Aneurysm (AAA)
- Age >50
- Hypertension
- “Ripping” or “Tearing” pain
- Absent pulses in lower extremities
Spinal Infections
- Fever
- Immunocompromized
  - HIV
  - Diabetes mellitus
  - Transplant patients
Spinal cord compression (especially cauda equina)
- Urinary retention
  - Consider obtaining post-void residual
- Saddle anesthesia
- Fecal incontinence/decreased rectal tone
Fracture
- Recent trauma
- Advanced age
Cancer
- History of cancer
- Night sweats
- Weight loss

Step 2: Testing Plan (If Patient Has Red Flags)

X-ray or CT scan if concerned for fracture
MRI if concerned for infection, cord compression, or cancer

Step 3: Symptom Management

NSAIDS
- Naproxen
- Ibuprofen
“Muscle relaxants”
- Cyclobenzaprine
Other agents
- Opiates
- Topical therapy
- Lidocaine patches

Step 4: Counseling

Remain active
Avoid heavy lifting
Red flags = immediate return to ED

Additional Reading

Round 6 – Back Pain (EM Clerkship)
Back Pain Red Flags (WikEM)

Dental Pain

January 15, 2017 / Zack

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Minor complaint. Huge SLOE points!

Step 1: Identify Which Tooth is Causing Pain

Bonus points if you number teeth correctly!
- Number 1-32
  - Tooth #1 is top right
  - Tooth #32 is bottom right
- Refer to dental chart for reference

Step 2: Correct Terminology When Making Diagnosis

Pulpitis
- Pain in the tooth itself
- Reversible
  - Triggered by hot/cold etc (then goes away)
- Irreversible
  - Does not resolve
Gingivitis
- Pain of the gingiva around the tooth
Periapical abscess
- Pain with percussion of tooth

Step 3: Give Pain Medicine

NSAIDS have been shown to work best
- Naproxen
- Ibuprofen
Opiates for breakthrough pain
- Hydrocodone-acetaminophen (Norco)
- Oxycodone-acetaminophen (Percocet)

Step 4: Consider Antibiotics

Pulpitis does not require antibiotics
Gingivitis/Periapical abscess frequently improve on antibiotics
- Penicillin VK

Step 5: Inferior Alveolar Nerve Block

Watch HERE

Additional Reading

Inferior Alveolar Nerve Block (YouTube)
Common Dental Emergencies (AFP)

Vertigo

January 8, 2017 / Zack

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Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo?

Step 1: How Does Patient Describe the Vertigo?

Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is)
Central vertigo
- Mild
- Vague
Peripheral vertigo
- Severe
- Sudden

Step 2: What Are the Associated Symptoms?

Central vertigo frequently associated with “The Dangerous D’s”
- Diplopia (double vision)
- Dysphagia (difficulty swallowing)
- Dysmetria (uncoordinated movement)
- Dysarthria (difficulty speaking)

Step 3: Does this Patient Have Risk Factors for Central Vertigo?

History of stroke
Atrial fibrillation
Diabetes
Recent trauma

Step 4: Do a Neuro Exam

Important exam findings for central vertigo
- Abnormal gait
- Abnormal finger-to-nose
- Nystagmus
Important exam findings for peripheral vertigo
- Dix-Hallpike

Step 5: Plan

If concerned for CENTAL vertigo
- MRI head/neck
If concerned for PERIPHERAL vertigo
- Treat with meclizine

Additional Reading

Posterior Circulation Strokes and Dizziness (emDOCs)

Hyperkalemia

January 1, 2017 / Zack

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Hyperkalemia = EKG… EKG changes = Calcium…

Step 1: Recheck the Potassium

Most common cause of hyperkalemia is PSEUDOhyperkalemia
- Caused by too aggressive/fast of a blood draw
  - Causes RBCs to break open and falsely increase serum potassium

Step 2: Get an EKG

Earliest EKG change
- Peaked T waves
Late EKG changes
- Flattened P wave
- Prolonged QRS
Critical/Emergent EKG changes
- Sine wave

Step 3: Protect the Heart

EKG Changes = Give Calcium
- Calcium gluconate (can be given IV)
- Stabilizes the myocardium against dysrhythmia

Step 4: Shift Potassium Into Cells

Insulin (plus D50)
Albuterol

Step 5: Remove Potassium from Body

Kayexalate
- Notorious for causing intestinal necrosis
- Falling out of favor
Furosemide

Additional Reading

Round 8 – Fall (EM Clerkship)
Emergency Management of Hyperkalemia (EM Cases)

How to Interpret a Chest X-Ray

December 11, 2016 / Zack

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A-B-C-D-E-F-G

Two Types of X-Rays

Anterior-Posterior (“AP”)
- Classic “portable” xray
  - The beam shoots from in front of the patient (anterior)
  - TO
  - The plate sitting behind the patient (posterior)
Posterior-Anterior (“PA”)
- Requires trip to radiology
- Results in a better picture
  - The beam shoots from behind the patient (posterior)
  - TO
  - The plate sitting in front of the patient (anterior)

Three Indicators of a High Quality Chest X-Ray

Well inflated lungs
Visualize spine through cardiac silhouette
Medial aspect of both clavicles lined up
- Evaluates for rotation

Chest X-Ray Interpretation Mnemonic

A-B-C-D-E-F-G
A = Airway
- Trachea midline (rule out tension pneumothorax)
B = Bones
- Rib/Clavicle/Shoulder fractures
C = Cardiac silhouette
- Should be no bigger than 50% of distance from chest wall to chest wall
  - Larger than this may represent cardiomyopathy
D = Diaphragm
- Costophrenic angles should be sharp
  - Blunted in pleural effusion
E = Equipment
- Central lines
- Endotracheal tubes
- Chest tubes
F = Lung Fields
- The most important step
- Look at lung markings/tissue to evaluate for…
  - Pneumothorax
  - Consolidation
  - Nodules
  - Pulmonary Edema
G = Great vessels
- Look for mediastinal widening (> 8cm)
  - Can be a sign of aortic injury
  - Looks falsely widened on AP/portable chest x-ray

Additional Reading

How to Read a Chest X-Ray (Medgeeks)
Learn to Read a Chest X-Ray in 5 Minutes (YouTube)

Trauma in Pregnancy

December 6, 2016 / Zack

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Mom is Scared. You are Scared. Don’t Be Scared.

General Principles

Evaluate for intimate partner violence in all poorly explained traumas during pregnancy
Get the scans you would order in a non-pregnant patient, even CTs!
- Shield the uterus if necessary

Basic Approach to Trauma in Pregnancy

Step 1: Place mother in left lateral decubitus position
- This removes the weight of the uterus OFF the inferior vena cava (IVC)
  - Can significantly improve patient’s hemodynamics
Step 2: Palpate the fundus
- If fundus is palpable at umbilicus, fetus is approximately 20 weeks
- Add 1 week of pregnancy for every 1cm above umbilicus
Step 3: Pelvic ultrasound
- Primary utility is to reassure mother that baby is OK
  - Calculate fetal heart rate
- Also identifies SOME placental abruptions and pelvic free fluid
Step 4: Obtain type and screen
- If mother is Rh NEGATIVE…
  - Give RhoGAM
  - Prevents Rh isoimmunization in mothers with Rh positive babies
Step 5: Consult OBGYN for fetal heart monitoring (tocodynamometry)
- Best test to rule out placental abruption and uterine irritability
- Only necessary if patient is >20 weeks gestational age

Additional Reading

Trauma Basics (EM Clerkship)
Trauma in Pregnancy (AAFP)

Genitourinary Trauma

November 13, 2016 / Zack

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Four important injuries. Four different imaging studies to obtain.

Step 1: Obtain Pelvic X-Ray

Commonly performed at bedside as part of initial trauma evaluation
A pelvic injury significantly increases risk of GU injury

Step 2: Examine the Perineum

Common signs of GU injury
- Blood at urethral meatus
- Bruising of the perineum

Step 3: Obtain Urinalysis

Gross hematuria is the red flag
- Can be identified at bedside
Importance of microscopic hematuria uncertain
- If you decided to send a formal urinalysis…
- Patient needs follow up on the hematuria until resolved

Step 4: Consider the FOUR Genitourinary Injuries

Kidney injury
- Evaluate with CT scan abdomen/pelvis with IV contrast
- Occur in approximately 10% abdominal trauma
  - Flank pain
  - Lower rib trauma
Ureteral injury
- Evaluate with delayed CT scan abdomen/pelvis with IV contrast
  - Call radiology to help choose right imaging protocol
- RARE injury
  - Sometimes seen with penetrating trauma or surgical injury
- Frequently needs surgical repair
Bladder injury
- Evaluate with retrograde cystogram
- Occurs when patient with distended bladder has direct impact to low abdomen
Urethral injury
- Evaluate with retrograde urethrogram (RUG)
- TWO subtypes
  - Posterior injury
    - Occur with pelvic fractures
  - Anterior injury
    - Occur with straddle-type injuries

Additional Reading

The Importance of the RUG (Taming the SRU)
Genitourinary Trauma (emDOCs)

Abdominal Trauma

November 6, 2016 / Zack

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Step 1: Does This Patient Need Surgery NOW?

Obvious penetrating injury to abdomen
Peritonitis
Hypotensive

Step 2: FAST Scan

Performed with bedside ultrasound machine
Blood/intra-peritoneal fluid is hypoechoic (black) in appearance
Four views required
- Right upper quadrant
  - Probe marker points towards patient’s head
  - “Morrisons Pouch”
    - Potential space between liver and right kidney
- Left upper quadrant
  - Probe marker towards patient’s head
  - Most difficult view to obtain
  - Potential space around spleen and between spleen and left kidney
- Suprapubic
  - Probe marker towards patient’s head
  - Looking for thin rim of fluid between bladder wall and bowel wall
- Subxiphoid
  - Hold probe flat and aim through liver towards heart
  - Looking for fluid around heart and evidence of cardiac tamponade

Step 3: Consider the Mechanism

Low risk
- Low speed MVAs
- Falling down only a few steps
High risk
- Falling off ladder/roof
- High velocity MVA/impact

Step 4: Perform Careful Abdominal Exam

Pain
Bruising/Seatbelt sign
Distension
Peritonitis
- Rigidity
- Rebound
- Guarding

Step 5: Obtain Imaging if High Risk Mechanism or Abnormal Exam

CT Abdomen/Pelvis with IV contrast
If normal CT scan but you still have clinical concern- ADMIT
- Serial abdominal exams
- CT notorious for missing small bowel and diaphragmatic injuries

Additional Reading

Trauma Basics (EM Clerkship)
FAST Examination (SAEM)

Cardiac Trauma

October 30, 2016 / Zack

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Cardiac tamponade. Aortic Dissection. Blunt cardiac injury.

Cardiac Tamponade

Blood fills pericardial sac
- Increasing pressure on myocardium -> Decreased preload
- Decreased preload -> Hypotension -> Death
Clinical exam shows Beck’s Triad
- Hypotension
- Muffled heart sounds
- Jugular venous distension (JVD)
Diagnosed during FAST exam (subxiphoid view)
Treat with pericardiocentesis
- Bedside thoracotomy if patient loses pulse

Aortic Dissection/Rupture/Tear

Common with rapid deceleration injuries
Most commonly occurs at ligamentum arteriosum
- Small ligament that attaches arch of aorta to pulmonary artery
- Remnant of the ductus arteriosus
Obtain CTA of the chest if…
- Widened mediastinum on chest x-ray
- Unequal pulses
- Concerning mechanism of injury
Requires emergent repair

Blunt Cardiac Injury

Contusion to the myocardium can cause arrhythmia/death
- Place patient on cardiac monitor
- Consider EKG/troponin
Commotio Cordis
- Blunt impact to chest resulting in ventricular fibrillation

Additional Reading

Blunt Cardiac Injury (American Association for the Surgery of Trauma)
FAST Exam (SAEM)

Thoracic Trauma

October 16, 2016 / Zack

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Step 1: Perform ATLS Primary Survey (B- Breathing)

Signs of respiratory distress/injury
- Shortness of breath
- Hypoxemia
- Tracheal deviation
- Diminished breath sounds

Step 2: Consider Performing Bedside Tube Thoracostomy

Insert at 5th intercostal space just anterior to mid-axillary line

Step 3: Imaging

Start with portable bedside chest x-ray
Pneumothorax can also be diagnosed by thoracic ultrasound

Step 4: Consider the 3 Critical Diagnoses

Tension pneumothorax
- Pressure builds up between chest wall and lung
- Eventually decreases cardiac preload -> Hypotension/Death
- Treatment
  - Needle decompression
  - Tube thoracostomy
Open pneumothorax
- Lung unable to expand during inspiration
- Treatment
  - 3-sided occlusive dressing over open (“sucking”) chest wound
  - Tube thoracostomy
Hemothorax
- Chest cavity fills with blood
- Eventual decreases cardiac preload -> Hypotension/Death
- Treat with tube thoracostomy

Step 5: Consider the 3 Other Common Diagnoses

Rib fractures
- Diagnose with chest x-ray
- Treatment
  - Pain control
  - Incentive spirometry
Small pneumothorax
- Worsens with positive pressure ventilation (intubation, BiPAP)
- Treatment
  - Supplemental oxygen
  - Supportive care
Pulmonary contusion
- Supportive care

Additional Reading

Round 12 – Difficulty Breathing (EM Clerkship)
Chest Tube Thoracotomy Demonstration (YouTube)

Neck Trauma

October 9, 2016 / Zack

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The hardest question… Should you get a CTA?

Blunt Trauma of Neck

Obtain CTA if…
- Patient has neurologic deficit
  - Numbness
  - Weakness
  - Visual changes
- Patient sustained forceful impact to the neck
- Patient has fracture
  - Basilar skull
  - Facial bones
  - Cervical spine

Penetrating Trauma of the Neck

Go to OR if patient is unstable
Go to OR if patient has HARD signs
- HARD Bruit Mnemonic
  - Hemoptysis/Hematemesis/Hypotension
  - Arterial bleeding
  - Rapidly expanding hematoma
  - Deficit (neurologic/pulse)
  - Bruit
Otherwise obtain CTA of the neck

Additional Reading

Neck Trauma: A Practice Update (emDOCs)

C-Spine Trauma

October 2, 2016 / Zack

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Step 1: Protect the Spine

Apply cervical collar

Step 2: Apply NEXUS Criteria

Use the “SPINE” mnemonic
- Spinal midline tenderness
- Painful distracting injury
- Intoxication
- Neurologic deficit
- Encephalopathy

Step 3: If Patient Has None of the NEXUS Criteria… You Are Done!

Step 4: If Patient Has Positive NEXUS Criteria…

Obtain CT scan of the cervical scan without contrast

Step 5: Clear the C-Spine

If CT scan negative -> Have patient turn head 45 degrees to right and left
- If patient has no limitation and no paresthesias or neurologic deficit…
  - Remove collar
- If still concerned for spinal injury despite normal CT
  - Keep collar on and have patient follow up in clinic for reexam

Unstable Cervical Spine Fractures

Mnemonic: Jefferson Bit Off a Hangmans Tit
- Jefferson fracture
- Bilateral facet dislocation
- Odontoid fracture
- Atlantooccipital dislocation
- Hangman’s fracture
- Teardrop fracture

Additional Reading

NEXUS Criterial for C-Spine Imaging (MDCalc)
Unstable Spine Fractures (WikEM)

Facial Trauma

September 25, 2016 / Zack

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There are 6 major areas/injuries to the face.

Basic Approach to Facial Injury

Step 1: Airway
- Indications for intubation after trauma
  - Burns to the airway
  - Rapidly expanding hematoma
  - GCS <8
Step 2: CT Maxillofacial Without Contrast
Step 3: Supportive Care
- Stop bleeding
  - Apply pressure
  - Control epistaxis
    - Caution advised with packing if patient has basilar skull fracture
- Ice
- Analgesics
Step 4: Antibiotics
- Common indications
  - Fractures of a sinus
  - Open fractures
Step 5: Consider Consulting the Appropriate Specialist
- Eye trauma -> Ophthalmology
- ENT trauma -> ENT
- Oral/Dental trauma -> Oral/maxillofacial surgery or dentistry

Six Key Facial Injuries

Frontal bone
- Fractures of the INTERNAL frontal sinus wall = BAD
Eyes and orbits
- “Blowout” fractures with entrapment of the extra-occular muscles = BAD
Nose
- Septal hematoma = BAD
Zygoma (Cheekbone)
- Zygomaticomaxillary complex fracture (aka Tripod fracture) = BAD
Maxilla (Upper jaw)
- Le Fort fractures = BAD
Mandible (Lower jaw)
- Open fractures (intraoral laceration) = BAD

Additional Reading

Trauma Basics (EM Clerkship)
CORE EM: Facial Fractures (emDOCs)

Head Trauma

September 11, 2016 / Zack

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CT scan without contrast is your test of choice.

Step 1: Consider Your Differential Diagnoses

Five high-yield head trauma diagnoses
- Skull fracture
  - External skull fracture
  - Basilar skull fracture
- Epidural hematoma
- Subdural hematoma
- Traumatic subarachnoid hemorrhage (SAH)
- Concussion

Step 2: Important Add-ons When Taking History

Specific mechanism of injury
Loss of consciousness
Blood thinners/antiplatelet agents

Step 3: Important Add-ons To Your Physical Exam

GCS Score (MDCalc)
Pupils
Basilar Skull Findings
- Raccoon eyes
- Battle sign
- CSF rhinorrhea
- Hemotympanum

Step 4: Calculate Canadian Head CT Rule

Only apply to patients with…
- Loss of consciousness
- Amnesia to event
- Witnessed disorientation
Exclude patients with
- Blood thinners
- Seizure(s)
- Age <16
High risk criteria
- GCS <15 2 hours post injury
- Suspected open/depressed skull fracture
- Signs of basilar skull fracture
- 2 or more episodes of vomiting
- Age >65
“Moderate” risk criteria
- Retrograde amnesia >30 minutes
- Dangerous mechanism
  - Fall >3 ft
  - Motor vs pedestrian
  - Ejected from MVA

Additional Reading

Canadian CT Head Injury/Trauma Rule (MDCalc)
Evaluation and Management of Concussion in Sports (AAN)

Abdominal Pain Basics

August 28, 2016 / Zack

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Elderly people die from abdominal pain

Step 1: Risk Stratify

Certain patient groups have VERY high mortality when having abdominal pain
- Geriatrics
- Immunocompromised
- Diabetics

Step 2: Consider Genitourinary Causes

Be especially cautious with lower abdominal/flank pain
- Mention that you performed or considered performing GU exam during presentation!
Common GU causes of abdominal pain
- Testicular/ovarian torsion
- Prostatitis/pelvic inflammatory disease
- Ectopic pregnancy

Step 3: High-Yield Tests to Consider

CBC and Electrolytes
EKG and Troponin
Liver Panel and Lipase
Urinalysis and Urine pregnancy

Step 4: Order Appropriate Imaging

CT scan is most useful test with abdominal pain in adults
- Need to give IV contrast if concerned for vascular pathology
- Usually performs just as well as ultrasound (even in cases where ultrasound is the classic, initial test)
3 “exceptions” to the CT first rule
- If concerned for biliary pathology
  - RUQ ultrasound
- If concerned for genitourinary pathology
  - Testicular/Pelvic ultrasound
  - Renal ultrasound (kidney stone)
- If concerned for Abdominal Aortic Aneurysm
  - Bedside Aorta ultrasound

Step 5: Disposition

Classic teaching is that patients discharged with undifferentiated abdominal pain need follow up in 12-24 hours
It’s ok to have them come back to the ED if necessary

Additional Reading

Abdominal Pain History (EM Clerkship)
Abdominal Pain Exam, Plan, and Disposition (EM Clerkship)

Stroke

August 21, 2016 / Zack

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Get your attending!

Step 1: Obtain Last Known Well

Stroke treatments including tPA and thrombectomy both require last known well
- <3-4.5 hours for tPA
- <24 hours mechanical thrombectomy

Step 2: Finger Stick Blood Glucose

Hypoglycemia is classic mimic of CVA
Results can be obtained immediately

Step 3: STAT Head CT Without Contrast

Poor sensitivity for ischemic stroke
- Primary use is identification of hemorrhagic stroke
- Required prior to administration of tPA!

Step 4: Perform NIHSS

Use calculator (MDCalc)

Step 5: Give tPA (If No Contraindications)

Follow department protocol and contraindications
- Frequently being updated

Additional Reading

tPA Basics (EM Clerkship)
2013 AHA Stroke Guidelines (AHA)
NIH Stroke Scale/Score (MDCalc)

Shortness of Breath

August 14, 2016 / Zack

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You need an organized, anatomical approach.

Step 1: Consider Differential Diagnosis

Upper airway
- Angioedema
- Foreign body
- Abscess
Lower airway
- COPD
- Asthma
Alveoli
- Pneumonia
- Pulmonary edema
Blood
- Anemia
- Acidosis
  - DKA
  - Sepsis (lactic acid)
  - Toxins (salicylic acid)
Blood vessels
- Pulmonary embolism
- Aortic dissection
Heart
- Myocardial infarction
- Acute heart failure
- Cardiac tamponade

Step 2: Examine Anatomically

Upper airway
- Stridor
- Voice changes
Lower airway
- Wheezing
Alveoli
- Crackles
Blood
- Pallor
Heart
- Dysrhythmia
- Jugular vein distension (JVD)
- Edema

Step 3: Testing Plan

Common tests
- Chest x-ray
- EKG
- CBC
- Electrolytes
Less common tests
- Blood gas
- Troponin
- BNP
- D-Dimer

Step 4: Calculate Wells Score and PERC

Wells Score (MDCalc)
PERC Rule (MDCalc)

Additional Reading

Pulmonary Embolism (EM Clerkship)
Shortness of Breath (SAEM)

Syncope

August 7, 2016 / Zack

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6 EKG Findings. 6 Risk Factors. 6 Mimics.

Step 1: Get an EKG

This is the only “required” test for a patient with syncope
Other common tests
- CBC
  - Evaluate for anemia
- hCG
  - If patient might be pregnant

Step 2: Look For 6 High Risk EKG Patterns

Mnemonic: QT-BRIDE
- QT prolongation
  - Especially QTc >500
- Brugada pattern
- Right heart strain
  - Tachycardia
  - S1Q3T3
  - Inverted T waves precordial leads
- Ischemic changes
  - ST segment elevation/depression
  - T wave inversion
- Delta waves
  - Seen in Wolf-Parkinson White (WPW)
- Epsilon waves
  - Seen in arrhythmogenic right ventricular dysplasia (ARVD)

Step 3: Ask the 6 High Risk Historical Questions

Mnemonic: CHESS +1
- Cardiac history
  - CHF
  - Structural heart disease
- Hematocrit <30%
- “Elderly”
- Shortness of Breath
- Systolic BP <90
- (+1) Family history of sudden cardiac death

Step 4: Consider 6 Deadly Syncope Mimics

15% of the following diseases reportedly present as “syncope”
- AKA “Rule of 15s”
Subarachnoid hemorrhage
Myocardial infarction
Pulmonary embolism
Aortic dissection
Abdominal aortic aneurysm
Perforated GI
- Ulcers
- Ectopics

Additional Reading

QT Intervals (LITFL)
Brugada Syndrome (LITFL)
Right Heart Strain (LITFL)
Delta Wave (LITFL)
Epsilon Wave (LITFL)

Common Pain Medications

July 24, 2016 / Zack

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Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone.

Oral Acetaminophen (Tylenol)

Give every 4-6 hours
Regular strength – 325mg
Extra strength – 500mg
Maximum Daily Dose – 3000mg

Oral Ibuprofen (Advil)

NSAID
Give every 4-6 hours
Regular strength – 200mg
Therapeutic Ceiling – 400mg

Oral Hydrocodone-Acetaminophen (Vicodin, Norco)

Give ever 4-6 hours
Common doses – 5-325mg, 7.5-325mg, and 10-325mg

IV/IM Ketorolac (Toradol)

NSAID
Common dosing – 15-30mg
Therapeutic ceiling – 10mg

IV/IM morphine

Classic dose (0.1mg/kg)
- This would be 7-10mg in adults!
More COMMON dosing is 4mg
- Repeat as needed

IV/IM Hydromorphone (Dilaudid)

COMMON dosing – 0.5-1mg
This drug is notorious for bringing you to peer-review/MM conference
- Be careful!

Contraindications to NSAIDS

Pregnant patients
Elderly patients
Renal disease patients
Cardiac patients
GI/ulcer patients

Side Effects of Opiates

Sedation
- No driving
- Do not mix with alcohol
- Do not mix with other sedatives
Constipation
Opiate dependency/addiction

Additional Reading

Pain Management In the Emergency Department: A Review (PubMed)
Myths in EM: The Anti-Inflammatory Properties of NSAIDS (ACEP Now)

Author: Zack (Page 8 of 9)

Procedural Sedation

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Back Pain

Dental Pain

Minor complaint. Huge SLOE points!

Vertigo

Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo?

Hyperkalemia

Hyperkalemia = EKG… EKG changes = Calcium…

How to Interpret a Chest X-Ray

A-B-C-D-E-F-G

Trauma in Pregnancy

Mom is Scared. You are Scared. Don’t Be Scared.

Genitourinary Trauma

Four important injuries. Four different imaging studies to obtain.

Abdominal Trauma

Cardiac Trauma

Cardiac tamponade. Aortic Dissection. Blunt cardiac injury.

Thoracic Trauma

Neck Trauma

The hardest question… Should you get a CTA?

C-Spine Trauma

Facial Trauma

There are 6 major areas/injuries to the face.

Head Trauma

CT scan without contrast is your test of choice.

Abdominal Pain Basics

Elderly people die from abdominal pain

Stroke

Get your attending!

Shortness of Breath

You need an organized, anatomical approach.

Syncope

6 EKG Findings. 6 Risk Factors. 6 Mimics.

Common Pain Medications

Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone.

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