Author: Zack (Page 9 of 9)

STEMI

July 17, 2016 /

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You have 90 minutes to restore blood flow.

Step 1: Obtain EKG and Call STEMI Alert

  • This activates ED resources as well as cath lab, interventional cardiology, etc

Step 2: Stop the Platelets

  • Dual anti-platelet therapy
    • Aspirin 325mg chewed (or PR)
    • Plavix 600mg (not usually given in ED)
      • Complicates management if patient needs CABG

Step 3: Stop the Coagulation Cascade

  • Heparin 60 units/kg (MAX 4000 units)

Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now

  • If you DON’T have cath lab
    • Option 1: 30 minutes to give thrombolytics
    • Option 2: 120 minutes to get them to a different hospital with cath lab

Sgarbossa Criteria

  • Left bundle branch block (LBBB)
  • PLUS
  • Concordant ST elevation (>1mm) in leads with positive QRS
  • OR
  • Concordant ST depression (>1mm) in leads with negative QRS
    • Typically V1-V3
  • OR
  • Severely discordant ST elevation (>5mm) in leads with negative QRS

“MONA”

  • Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain
  • Oxygen has been shown to worsen outcomes if given indiscriminately
    • Not ideal to be giving supplemental O2 when SaO2 is 100%
  • Nitroglycerine
    • Nitroglycerine 0.4 mg SL q5min
    • OR
    • Nitroglycerin 10mcg/min drip (will need to be titrated UP)
      • For comparison…
        • 0.4 mg SL nitroglycerine releases approximately 80mcg/min
    • Contraindications
      • Inferior/Right heart infarction
        • Patients usually preload dependent
        • Nitro drops preload
      • Sildenafil (Viagra)
        • Can cause sudden/severe drop in blood pressure
      • Hypotension

Additional Reading

Altered Mental Status

July 10, 2016 /

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Mnemonic: AEIOU-TIPS

Step 1: Evaluate the Airway

  • General principles
    • “If they can’t speak, they can’t control their airway”
    • “If GCS is <8, intubate”
  • In the real world, it’s a clinical judgement call
    • Postictal patients?
    • Intoxicated patients?

Step 2: Point of Care Labs

  • Finger stick blood glucose
  • EKG
    • Dysrhythmia?
    • Ischemia?
    • Abnormal intervals?
  • Pregnancy test

Step 3: Consider Naloxone

  • Classic dose – 0.4 to 2mg IV/IM
    • Many start with lower doses to lower chance of severe withdrawal
  • Can also be given intranasal (2-4mg)

Step 4: Consider Differential Diagnosis

  • Mnemonic: AEIOU-TIPS
    • *Note: You don’t need to order all of these tests on every patient with altered mental status!!!
  • Alcohol
    • Blood alcohol level
    • Thiamine
  • Endocrine/Electrolytes
    • Includes
      • Hypoglycemia
      • Hepatic encephalopathy
      • Myxedema coma
      • Hyponatremia
    • Obtain
      • Electrolyte panel
      • Hepatic panel
      • TSH
      • Ammonia
  • Ischemia (Cardiac)
    • EKG
    • Troponin
  • Opiates
  • Uremia
  • Trauma
    • CT head without contrast
    • CT cervical spine without contrast
  • Infection
    • Urinalysis
    • Chest x-ray
    • Lumbar puncture
    • CBC
    • Lactic acid
    • Blood cultures
  • Poisoning
  • Stroke
    • CT head without contrast
    • Neuro exam for focal deficits

Additional Reading

The “Big 5” Toxidromes

July 3, 2016 /

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Poison Control Hotline: 1-800-222-1222

Step 1: Evaluate the Airway

  • General principles
    • “If they can’t speak, they can’t control their airway”
    • “If GCS is <8, intubate”
  • In the real world, it’s a clinical judgement call

Step 2: Toxicology History

  • What did they take?
  • How much did they take?
  • Why did they take it?
  • When did they take it?

Step 3: Toxicology Exam

  • Vital signs
  • Pupils
  • Skin

Step 4: Medication List

  • Make note of all bottles with patient
  • Make EXTRA note if any pills seem to be missing
  • Bonus points if you bring your attending a med list

Step 5: Common Toxicology Tests

  • Assessing for damage
    • Electrolytes
    • Liver function test
    • EKG
    • Pregnancy
  • Assessing for co-ingestion
    • Serum acetaminophen
    • Serum salicylate
    • Serum alcohol
    • Urine drug screen

The “Big 5” Toxidromes

  • Anticholinergic
    • Increased vitals
    • Big pupils
    • Dry skin
    • Treatment – Physostigmine (rarely given)
  • Cholinergic
    • Decreased vitals
    • Small pupils
    • Moist skin
    • Treatment – Atropine
  • Opioid
    • Decreased vitals
    • Small pupils
    • Dry skin
    • Treatment – Naloxone
  • Sedative/Hypnotic
    • Decreased vitals
    • Normal pupils
    • Dry skin
    • Treatment – Flumazenil (rarely given)
  • Sympathomimetics
    • Increased vitals
    • Big pupils
    • Moist skin
    • Treatment – Benzodiazepines

Additional Reading

Brief Resolved Unexplained Events (BRUE)

June 19, 2016 /

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3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE.

Step 1: Is This a BRUE?

  • Brief
    • <60 seconds
  • Resolved
    • Exam and vitals back to baseline in the ED
  • Unexplained
    • No symptoms other than event itself
  • Event
    • Concerning change in any of the following…
      • Tone
      • Color
      • Breathing
      • Mental status

Step 2: Is This Low Risk BRUE?

  • Five low risk criteria
    • Age >2 months
    • Born at >32 weeks gestational age
    • First and only episode
    • No CPR by medical providers
    • No “Red Flags”

Step 3: Do They Have Red Flags?

  • For abuse
    • History of SIDS/BRUE in sibling
    • Mental illness at home
    • Drug use at home
  • For dysrhythmia
    • Family history of sudden unexplained death
  • For infection
    • Fevers
    • Unimmunized
    • Sick contacts
    • Rash

Step 4: Examine for Non-Accidental Trauma

  • Bulging fontanelle
  • Petechia
  • Torn frenulum
  • Blood

Step 5: Place Patient Into One of Three Categories

  • NOT a BRUE
    • Treat as you normally would
  • HIGH risk BRUE
    • Admit
  • LOW risk BRUE
    • Discharge without testing
    • May consider EKG and pertussis

Additional Reading

  • Brief Resolved Unexplained Events (AAP)

ATLS

June 6, 2016 /

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Airway/C-spine. Breathing. Circulation. Disability. Exposure. Secondary Survey.

Airway and C-Spine

  • General airway principles
    • “If they can’t speak, they can’t control their airway”
    • “If GCS is <8, intubate”
      • In the real world, it’s a clinical judgement call
  • General c-spine principles
    • Clear c-spine with NEXUS/Canadian rules
    • Otherwise stabilize spine and place in cervical collar

Breathing

  • If patient has tachypnea, hypoxemia, or respiratory distress
    • Give O2
    • Examine for tension pneumothorax
      • Deviated trachea
      • Asymmetric breath sounds
        • If concerned perform needle decompression
        • THEN
        • Tube thoracostomy

Circulation

  • If patient has tachycardia, hypotension, or obvious blood loss
  • Stop the bleed
  • Emergent transfusion
  • Consider early OR if unstable
    • In the real world, CT is frequently obtained pre-op regardless of stability

Disability

  • Pupils
  • GCS
  • If concerned for head injury
    • Obtain CT head without contrast

Exposure

  • Fully undress the patient
  • Warm blankets

Secondary Survey

  • Visualize everything
  • Palpate everything
  • Bedside chest/pelvic x-ray and FAST scan

Common Labs

  • Type and screen
  • CBC
  • Electrolytes
  • Urinalysis
  • EKG
  • Blood alcohol level
  • Lactic acid (if concerned for shock)

Common Imaging

  • CT head without contrast
  • CT maxillofacial without contrast
  • CT cervical spine without contrast
  • CTA neck
  • CT abdomen/pelvis WITH contrast
  • Retrograde urethrogram
  • Additional x-rays

Common Treatments

  • Blood products
  • Tetanus immunization
  • Analgesics

Additional Reading

Priapism

May 30, 2016 /

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The nerve, artery, and vein are at 12 o’clock. The urethra is at 6 o’clock.

Two Types of Priapism

  • High flow (non-ischemic)
    • Common causes
      • Trauma
      • AV malformations
      • Tumors
    • Priapism from too much blood coming IN
    • Not painful
    • Consult urology
  • Low flow (ischemic)
    • Common causes
      • Sickle cell disease
      • Drug side-effects
    • Priapism from blood being unable to flow OUT
    • Patient requires emergent detumescence
      • 50% chance of erectile dysfunction

Step 1: Prepare (4c approach)

  • Collect
    • 19G needle
    • 21G needle
    • Variety of syringes
    • Gauze
    • Sterile drape
    • Betadine
    • Normal saline
  • Consent
    • 50% chance of erectile dysfunction even with successful procedure
  • Clean
    • Set up supplies and sterile field
  • Control pain

Step 2: Drain

  • Nerve/Artery/Vein on top (12 o’clock)
  • Urethra on bottom (6 o’clock)
  • Insert 19G needle at either 3 or 9 o’clock and aspirate
    • UPDATE: Recommended insertion at either 2 or 10 o’clock
  • 30% chance of detumescence at this step alone

Step 3: Send Venous Blood Gas

  • Confirms high-flow (non-ischemic) from low-flow (ischemic) priapism

Step 4: Irrigate

  • Inject normal saline through the needle and then aspirate

Step 5: Phenylepherine

  • Dilute 1ml (10 mg/ml) in 9 ml NS (results in 1mg/ml solution)
    • Inject 0.25 ml of 1 mg/ml solution and repeat q10 minutes
    • Alpha agonist effect constricts smooth muscle and facilitates venous outflow

Additional Reading

Preeclampsia

May 23, 2016 /

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Never ignore a pregnant woman’s blood pressure.

Introduction

  • Pre-Eclampsia
    • Pathophysiology unknown
    • Pregnancy induced multi-organ dysfunction
    • Definition
      • Pregnancy
        • PLUS
      • BP 135/85
        • PLUS
      • Proteinuria
  • Eclampsia
    • Preeclampsia
    • PLUS
    • Seizures
  • HELLP Syndrome
    • Preeclampsia
    • PLUS
    • Hemolysis
    • PLUS
    • Elevated liver enzymes
    • PLUS
    • Low platelets

Step 1: Evaluate For Four Big Symptoms

  • Swelling/edema
  • Headache
  • Visual changes
  • Abdominal pain

Step 2: Testing

  • Urinalysis
    • Proteinuria
  • CBC
    • Hemolysis
    • Thrombocytopenia
  • Electrolytes
  • Liver function tests

Step 3: Start Magnesium

  • Hypomagnesemia = Hyporeflexia

Step 4: Control the Blood Pressure

  • Hydralazine
  • Labetalol

Step 5: Admit

  • OB emergency
  • All patients need fetal monitoring

Additional Reading

Headache

May 16, 2016 /

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With this complaint, it’s ALL about doing a good history and exam.

Step 1: Write Out Your Differential Diagnosis

  • The KING
    • Subarachnoid hemorrhage
  • The QUEEN
    • Meningitis
  • 3 Killers in the BRAIN
    • Stroke
    • Hematomas
    • Elevated ICP/Tumors
  • 3 Killers in the VESSELS
    • Arterial dissection
    • Brain DVT (Dural Venous Sinus Thrombosis)
    • Giant cell/temporal arteritis
  • 3 MISCELLANEOUS killers
    • Preeclampsia
    • Carbon monoxide toxicity
    • Glaucoma

Step 2: How Does This Compare to Previous Headaches?

  • Finding the answer to this question is not always easy!

Step 3: Do a FULL Neuro Exam

  • Mental status
  • Neck stiffness
  • Extra-ocular movements
  • Visual fields
  • Cranial nerves
  • Speech
  • Motor
  • Sensation
  • Finger to Nose
  • Gait

Step 4: Order Tests As Necessary

  • CT head without contrast
  • MRI brain
  • Lumbar puncture
  • ESR
  • Carbon monoxide level

Step 5: Give “Headache Cocktail”

  • Mix and match based on personal and patient preferences
    • IV Dopamine antagonist
    • IV Antihistamine
    • IV Steroid
    • IV NSAIDS
    • IV Fluids
    • Tylenol
  • Triptans and opiates rarely indicated

Additional Reading

Pediatric GI Complaints

May 2, 2016 /

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Don’t forget to do a thorough GU exam!

Step 1: Write Out Your Differential Diagnosis

  • Remember 2-4-2-4
  • (2) In the upper abdomen
    • Pyloric stenosis
    • Pneumonia
  • (4) In the lower abdomen
    • Hirschsprung’s disease
    • Intussusception
    • Appendicitis
    • Hernia
  • (2) Genitourinary
    • UTI
    • Testicular/Ovarian torsion
  • (4) Generalized
    • Volvulus
    • Necrotizing enterocolitis
    • Henoch Schonlein Purpura
    • Diabetic ketoacidosis

Step 2: Do Pediatric History and Exam

  • Pediatric assessment triangle
    • Appearance
    • Breathing
    • Color
  • Birth history
    • Gestational age
    • Complications
  • Eating/drinking/peeing/pooping
  • Immunizations
  • Physical exam
    • Don’t forget GU exam!

Step 3: Five Important Tests

  • Finger stick blood glucose
  • Urinalysis
  • Chest x-ray
  • Abdominal x-ray
  • Abdominal ultrasound

Step 4: Common Treatments

  • Fever/Pain
    • Acetaminophen
  • Vomiting
    • Zofran
  • Diarrhea
    • NOTHING
  • Dehydration
    • Pedialyte

Additional Reading

Circulation

April 25, 2016 /

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Tank. Clogged Pipes. Broken Pipes. Pump.

Introduction

  • “Tank”
    • Hypovolemic shock
    • Hemorrhagic shock
  • “Clogged Pipes”
    • Cardiac tamponade
    • Tension pneumothorax
    • Pulmonary embolism
  • “Broken Pipes”
    • Septic Shock
    • Neurogenic Shock
    • Anaphylactic Shock
  • “Pump”
    • Cardiogenic Shock

Step 1: Fill the Tank

  • Establish an IV
    • IO line alternative in emergent situations

Step 2: Consider Clogs

  • Cardiac tamponade
    • Diagnosis: Ultrasound
    • Treatment: Pericardiocentesis
  • Tension pneumothorax
    • Diagnosis: Clinical/Xray/Ultrasound
    • Treatment: Needle decompression and tube thoracostomy
  • Pulmonary embolism
    • Diagnosis: Clinical/CTA
    • Treatment: Thrombolytics

Step 3: Squeeze the Pipes

  • Administer vasopressors
    • Most common: Norepinephrine
    • Alternatives: Epinephrine, Phenylepherine

Step 4: Analyze the Pump

  • Get an EKG
    • Ischemia = Aspirin/Heparin/Cath lab
    • Dysrhythmia = Electricity

Additional Reading

Breathing

April 18, 2016 /

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Hypoxemia fixed by only TWO things: FiO2 and PEEP

Step 1: Add FiO2

  • If the patient is breathing…
    • Nasal cannula
    • Non-rebreather mask
  • If the patient is NOT breathing…
    • Bag-valve mask

Step 2: Add PEEP

  • *Cannot be completed in 60 seconds, but equipment can be requested
  • If patient is breathing…
    • BiPAP
  • If the patient is NOT breathing…
    • Intubation

Additional Reading

Airway

April 10, 2016 /

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“Airway” does not necessarily mean “Intubation”

Introduction

  • In emergency medicine we are taught “A-B-Cs”
    • These are actions that can be accomplished in first 60 seconds of patient encounter
      • Intubation takes several minutes to accomplish
      • Intubating a crashing patient might even KILL them!
    • Resuscitate THEN intubate

Step 1: Suction

  • Immediately suction if patient is…
    • Altered and vomiting
    • Gurgling

Step 2: Move the Tongue

  • Bedside maneuvers
    • Head tilt
    • Chin lift
    • Jaw thrust
  • Adjunct equipment
    • Oropharyngeal airway
    • Nasopharyngeal airway

Additional Reading

Epistaxis

April 3, 2016 /

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Don’t forget to wear protective gear. Gown up!

Initial Encounter

  • History
    • Anticoagulants
    • Easy bleeding/bruising
    • Lightheadedness
  • Exam
    • Pallor
    • Tachycardia/Hypotension

Step 1: Put on Personal Protective Equipment

  • Gown
  • Gloves
  • Mask
  • Eye Protection

Step 2: Clear Nose and Visualize Bleeding

  • Have patient blow out/remove any clot and look for source of bleed
  • Kiesselbachs plexus
    • “Anterior” epistaxis
  • Sphenopalatine artery
    • “Posterior” epistaxis
      • Most severe/dangerous form

Step 3: Spray In Oxymetazoline (Afrin)

  • Hold pressure for 15 minutes after initial application

Step 4: Cauterize With Silver Nitrate

  • Avoid bilateral cauterizations
    • Can cause septal perforation
  • Anesthetize as necessary
    • 4% lidocaine on gauze and leave in nose for 10 minutes prior to cauterization

Step 5: Pack the Nose

  • Multiple commercial products available for this
  • The utility of antibiotic prophylaxis at this step is unclear
  • Patient goes home with packing in place

Additional Reading

Chest Pain

March 27, 2016 /

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There are six cardiopulmonary causes of chest pain that you need to know.

The SIX Causes

  • Cardiac
    • Acute coronary syndrome (ACS)
    • Pericarditis with tamponade
  • Pulmonary
    • Pneumonia
    • Pneumothorax
  • Vascular
    • Pulmonary embolism
    • Aortic dissection

Step 1: Core Measures

  • Aspirin
  • EKG

Step 2: Look for the “King” (Acute Coronary Syndrome)

  • Four high yield symptoms
    • Radiation to the RIGHT shoulder
    • Vomiting
    • Worsens with exertion
    • Diaphoresis

Step 3: Look for the “Queen” (Pulmonary Embolism)

  • Wells score
  • PERC rule

Step 4: Print a Previous Cath Report

  • Major bonus points with attending!
  • Other useful information
    • Previous echocardiograms
    • Previous stress tests
    • Previous CTAs for PE

Step 5: Basic Testing Plan

  • If concerned for cardiac causes
    • Troponin
  • If concerned for pulmonary causes
    • Chest x-ray
  • If concerned for vascular causes
    • CTA of the chest

Additional Reading

Patient Presentations

March 27, 2016 /

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Patient presentations are the single most important skill to develop for your Emergency Medicine rotation.

General Principles

  • Stay focused, thorough, and organized
  • Write out the basic 8-step presentation for reference

The 8-Step Patient Presentation

  1. Summary statement
    • Demographics
    • Risk factors/Past medical history
    • Chief complaint
  2. History
    • OPQRST
    • Try to give at least 4 descriptors
      • This is for billing reasons
  3. Pertinent positives/negatives
    • Give approximately 5 most pertinent symptoms
  4. Vitals
  5. Physical exam
    • Give approximately 3 MOST pertinent findings
  6. Differential diagnosis
    • Briefly argue for/against
    • Include both most likely and most dangerous
  7. Testing plan
  8. Treatment plan
    • This is the most commonly forgotten step of presentation

Additional Reading

  • Abdominal Pain Presentation – History (EM Clerkship)
  • Abdominal Pain Presentation – Exam, Plan, and Disposition (EM Clerkship)
  • Patient Presentations in Emergency Medicine (EMRA)

Introduction

March 20, 2016 /

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To Do Well On WRITTEN Exam

  • Study the “Core 4” body systems
    • Neurology
      • Headache
      • Strokes
      • Meningitis
    • Cardiology
      • Chest pain
      • ACS
      • EKG interpretation
    • Pulmonary
      • Shortness of breath
      • PE
    • GI
      • Abdominal pain
      • Nausea/vomiting
      • Appendicitis

To Do Well In the DEPARTMENT

  • Study the “other stuff”
    • Epistaxis
    • Foley catheter issues
    • Rectal bleeding
    • Laceration repair
    • Rashes
    • Geriatric falls
    • Suicidal ideation
    • The list goes on and on…

Additional Reading

  • Emergency Medicine Advanced Clinical Subject Exam Content Breakdown (NBME Website)
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