Category: Uncategorized (Page 2 of 3)

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You are working at Clerkship General when you are called to the resuscitation bay for a 55yo M presenting in respiratory distress.

Initial Vitals

• Temp 99.9
• HR 110
• RR 22
• BP 122/82
• O2 82% on BiPAP 10/5 100%FiO2

Critical Actions

• Correctly interpret CXR #1 (multifocal PNA)
• Correctly interpret CXR #2 (bilateral PNTX)
• Treat with Oseltamivir
• Troubleshoot vent alarm#1 (increase sedation)
• Troubleshoot vent alarm#2 (place bilateral chest tubes)
  

Further Reading:

Acute Exacerbation of COPD – EMCrit

COPD – EM@3AM

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Cardiac Glycoside containing plants : Foxglove, Lilly of the Valley, Oleander, Squill

• Contain cardiac glycosides, which act as a negative chronotrope as well as a positive inotrope.
• Patients present with nausea, vomiting, visual changes, bradycardia/arrhythmia, and may develop hyperkalemia – a poor prognostic factor
• Treatment is Digibind/DigiFAB – look out for the side effects of hypokalemia as well as anaphylaxis.

Anticholinergic Alkaloid containing plants: Jimson Weed, Angels Trumpet, Deadly Nightshade

• Contain alkaloids that act as anticholinergics ; often used recreationally
• Patients present with delirium/hallucinations, pupillary dilation, anhydrosis, hyperthermia, skin flushing, urinary retention
• Treatment is support care, with physostigmine for severe cases – remember to go low and slow!

Toxic Mushrooms

• Important to distinguish between acute onset symptoms (<6hours) or delayed onset (6-24 hours)
• Inocybe : acute onset ; cholinergic crisis; treat with atropine
• Amanita Muscarina: acute onset; CNS toxicity – delrium, myoclonus, seizures ; supportive care and benzos as needed
• Amanita Phalloides: delayed onset ; treat with NAC and maybe Silibinin
  • Phase 1: 6-24 hrs after ingestion, nausea vomiting diarrhea
  • Phase 2: transient recovery, 24-60 hours after ingestion
  • Phase 3: Hepatic / multisystem organ failure
• Gyromitra: delayed onset; causes acute B6 deficiency leading to refractory seizures, treat with pyridoxine (vitamin B6) as well as usual seizure care.

Further Reading:

Stone Heart Syndrome – LITFL

Gyromitra – Indiana Poison Center

Anticholinergic Intoxication – EMCrit

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You are working at Clerkship General when you see your next patient : a 3 year old male accompanied by his father with chief complaint of vomiting. 

Initial Vitals

• Temp 98.6
• HR 50
• RR 20
• BP 95/55
• O2 100%

Critical Actions

• Identify the history of ingestion
• Check a blood glucose
• Call Poison Control
• Treat with DigiBind
• Treat subsequent anaphylaxis
  

Further Reading:

EMCrit – Digoxin Toxicity

The Tox and the Hound – Digoxin: to bind or not to bind

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• Opioid overdose is the number one leading cause of death in adults under the age of 50.
• Many ED Physicians fail to recognize that offering MAT (medication assisted therapy) to victims of opiate overdose is one of the most effective interventions we can offer in medicine.
• 1 in 2 using high-dose buprenorphine (≥ 16 mg) had retention in treatment – meaning NNT of 2!

Further Reading:

TheNNT – Opioid Use Disorder

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Critical Actions:

• Administer Naloxone
• Minimize Unnecessary Testing
• Discuss options for Rehab
• Offer opioid replacement therapy
• Provide Social Support

Further Reading:

Buprenorphine – EMDocs

Naloxone – EMDocs

Initiating Opioid Treatment in the ED – ACEP

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AFib with Rapid Ventricular Rate (RVR) – Rate >110

Primary AFib – Patients symptoms or their hemodynamic instability is due to the AFib itself. Treatment is by rate or rhythm control.

Secondary AFib – Patients AFib rate or their hemodynamic instability is due to an underlying secondary process (eg thyrotoxicosis, PE, sepsis, drugs, etc). Treatment is by treating the underlying process.

Unstable Primary AFib – The presence of hypotension, altered mental status, or pulmonary edema. Treatment is immediate cardioversion, second line agents include digoxin or amiodarone.

Stable Primary AFib (<48 hours duration ) – Treatment is by cardioversion in the ED

Stable Primary AFib ( >48hours or unknown duration) – Treatment is by rate control by CCB (diltiazem or verapimil), or by BB (metoprolol or esmolol)

Anticoagulation – Calculate CHADS2VASC and HASBLED score. Weigh risk of stroke versus risk of major bleeding prior to starting anticoagulation

Further Reading:

Atrial Fibrillation (EMCrit)

Atrial Fibrillation (ACEP Guidelines)

CHADS2VASC Score (MD Calc)

HASBLED Score (MD Calc)

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You are working a shift at Clerkship General Hospital when you go see your next patient, a 70 year old male presenting with chest pain.

Initial Vitals

• Temp 98.7
• HR 140
• RR 20
• BP 125/85
• O2 99%

Critical Actions

• Obtain EKG
• Treat AFib RVR via rate control (and not cardioversion)
• Diagnose Acute Arterial Occlusion
• Treat with Heparin
• Consult Vascular Surgery for further management (possible thrombectomy, bypass, etc)
  

Further Reading:

EMDocs – Acute Limb Ischemia

EMDocs – Systematic Approach to the Peripheral Vascular Exam

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tPA usage is controversial. Listen to find out why. Read more to form your own opinions.

Episode Sources:

After Re-Analysis, No Trials Show Efficacy of tPA in Acute Ischemic Stroke

Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department

Why we can’t trust clinical guidelines – BMJ

Alteplase for Stroke: Money and Optimistic Claims Buttress the “Brain Attack” Campaign

Tissue Plasminogen Activator (tPA) for Acute Ischemic Stroke: Net benefits and harms unclear due to uncertainty in data – the NNT

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Initial Assessment:

• Obtain Vitals and blood glucose level
• Time of onset (important for tPA/TNK vs thrombectomy)
• Neurologic and Cardiac Examination / NIHSS
  • do not delay head CT to complete NIHSS, can always finish after CT
• Assess contraindications for tPA

Workup:

• Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck
• CXR and UA (infections can cause recrudescence of prior cva)
• ECG looking specifically for AFib
• Stat Imaging: CT Head noncontrast, followed by CTA Head/Neck and/or CT Perfusion

Treatment:

• tPA / TNK if significant neurologic deficits are present and no contraindications exist
• Thrombectomy if large vessel occlusion present without contraindications
• Admission to stroke unit to…
  • Workup the etiology of stroke (usually carotid US, Echo /w bubble study, telemetry monitoring),
  • Optimize treatment of risk factors such has HLD, HTN, AFib, etc
  • Obtain early PT/OT/Rehab

Post-tPA Complications: Angioedema (2-5%) and Hemorrhage (2-7%)

• Have a high index of suspicion for hemorrhage – monitor for headaches, change in mental status, signs of ICP, etc
• Stop tPA immediately
• If concerned for hemorrhage, elevate head of bed and obtain STAT CT Head
• For hemorrhage, consider TXA, Platelets, Cryoprecipitate (as recommended by the AHA, however evidence is extremely poor) and consult Neurosurgery
• For Angioedema, monitor airway closely, intubate if necessary, and consider medical treatment (FFP, Antihistamines, Steroids, Epinephrine, TXA – all of which have poor evidence for benefit)

Further Reading:

MD Calc- tPA Contraindications

EMDocs – Post tPA Complications

EMRA – Post tPA Hemorrhage

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ATLS – Advanced Traumatic Life Support

Primary Survey

• Airway
• Breathing
• Circulation
• Disability
• Exposure

Secondary Survey

• Head to Toe Examination
  • Look for injury patterns and important injuries, such as
    • Battle Sign (post auricular ecchymosis)
    • Raccoon Eyes (infraorbital ecchymosis)
    • Hemotympanum
    • Nasal Septal Hematoma
    • Urethral Injuries
    • Circumferential Burns
• Obtain a basic medical history
• Obtain XRs, FAST exam, CT scans

Tertiary Survey

• Repeat the examination portion of the secondary survey to ensure no minor injuries were missed

Further Reading:

Unbound Medicine – ATLS Outline

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You are working a shift at ABEM General when you receive a call from EMS over the radio for a patient involved in a house fire.

Initial Vitals

• Temp 99.0
• HR 150
• RR 40
• BP 90/50
• O2 95%

Critical Actions

• Administer 8L IVF in first 8 hours
• Administer supplemental oxygen for CO poisoning
• Administer TDAP
• Give hydroxycobalamine for cyanide toxicity
• Obtain head CT to diagnose SDH
  

Further Reading:

Cyanide Poisoning (LITFL)

Carbon Monoxide Poisoning (EMCrit)

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• 50% of cases of Pelvic Inflammatory Disease (PID) is caused by common STIs (Gonorrhea, Chlamydia ) but up to 50% is caused by native vaginal flora/other organisms
• No SINGLE historic, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID
• Women with PID may be asymptomatic!!
• Presumptive treatment of PID should be initiated for sexually active women if they are experiencing pelvic/lower abdominal pain and if…
  • No alternative explanation can be found to explain patient’s pain, OR
  • ANY one of the three following findings are discovered on pelvic examination: cervical motion tenderness, adnexal tenderness, uterine tenderness
• All antibiotics used to treat PID should also be effective against Gonorrhea and Chlamydia because negative endocervical screening for these organisms do not rule out upper genital tract infection
• Many antibiotic treatment combinations exist: Ceftriaxone, Doxycycline, and Metronidazole is a common regimen

Further Reading: CDC STI Treatment Guidelines

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You are working a shift at ABEM General when three patients check in simultaneously at the start of your shift at 6AM.

Initial Vitals#1 (Ms. Taylor, 65F with Back Pain)

• Temp 98.8
• HR 120
• RR 22
• BP 210/110
• O2 97%

Critical Actions#1 (Ms. Taylor, 65F withBack Pain)

• Obtain Medication/Social Hx (Ciprofloxacin use, Cocaine use)
• Diagnose Aortic Dissection (Type B)
• Treat HR Appropriately (Esmolol drip)
• Treat BP Appropriately (Cardene drip)
• Treat Pain
  

Initial Vitals#2 (Ms. Thomas, 50F with Dysuria)

• Temp 101.0F
• HR 120
• RR 22
• BP 106/65
• O2 98%

Critical Actions #2 (Ms. Thomas, 50F with Dysuria)

• Obtain pregnancy test
• Perform chaperoned pelvic exam
• Diagnose PID /w Fitz Hugh Curtis & Treat /w abx
• Treat pain
• Council patient appropriately on +STD (treatment of partner, no intercourse until treated)

Initial Vitals#3 (Ms. Wells, 40F with Knee Pain)

• Temp 99.9F
• HR 90
• RR 18
• BP 120/80
• O2 98%

Critical Actions#3 (Ms. Wells, 40F with Knee Pain)

• Obtain appropriate workup (ESR, CRP, XRay, Cultures)
• Treat pain
• Perform Arthrocentesis
• Gonococcal Arthritis
• Treat with appropriate Antibiotics

Further Reading

Aortic Dissection – CoreEM

Pelvic Inflammatory Disease – EMDocs

Septic Arthritis – EMDocs

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Cardiac Tamponade

Cardiac Tamponade – A physiological state caused by a pericardial effusion in which the pressure in the pericardial sac is higher than the pressure inside the right sided chambers of the heart, leading to impaired filling, decreased cardiac output, and hemodynamic collapse.

Pericardial Effusions – Can be caused by infections, rheumatologic diseases, malignancy, uremia, hypothyroidism, trauma, aortic dissections, etc

Diagnosis on Exams:

• Becks Triad – Hypotension, JVD, Muffled Heart Sounds
• Pulsus Paradoxus – SBP drops >10mmhg during inspiration
• Electrical Alternans on ECG

Diagnosis in Real Life:

• Mix of clinical and cardiac ultrasound
• Clinically patients usually complain of dyspnea, sometimes chest pain. They can have ALL, SOME, or NONE of the features of Beck’s Triad!
• On ultrasound, RIGHT VENTRICULAR COLLAPSE DURING DIASTOLE is most specific for tamponade.
• On ultrasound, a PLETHORIC IVC is most sensitive for tamponade (but is totally non-specific as we see this with many other conditions including CHF, PE, PNTX, etc)

Treatment:

• Initial fluid bolus (stop if they worsen clinically)
• Vasopressors if needed to bridge unstable patient to definitive treatment
• Definitive treatment is pericardiocentesis.

Further Reading:

NEJM – Diagnosis of Cardiac Tamponade and how to perform pericardiocentesis

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Case Introduction

You are working a shift at your local free-standing emergency room when a family of three checks in to be seen (a father and his two sons).

Initial Vitals#1 (Chris, 18mo with stridor)

• Temp 100.4F
• HR 120
• RR 40
• O2 93%

Critical Actions#1 (Chris, 18mo with stridor)

• Check pulse oximetry (hidden)
• Administer PO Steroids
• Administer Racemic Epinephrine
• Reassess patient after therapy
• Discharge patient
  

Initial Vitals#2 (Ronnie, 3yo with vomiting)

• Temp 98.0F
• HR 140
• RR 38
• O2 98%

Critical Actions #2 (Ronnie, 3yo with vomiting)

• Identify Iron overdose
• Obtain abdominal XR
• Obtain Iron level
• Administer IVF bolus
• Administer deferoxamine

Initial Vitals#3 (Carson, 55yo with shock)

• Temp 98.0F
• HR 130
• RR 28
• BP 82/68
• O2 92%

Critical Actions#3 (Carson, 55yo with shock)

• Obtain ECG
• Identify pericardial tamponade
• Administer IVF Bolus (tamponade is preload dependent)
• Perform pericardiocentesis
• Consult CT Surgery/CVICU

Further Reading

Life in the Fast Lane – Iron Toxicity

EMDocs – Croup

EMDocs – Pericardial Tamponade

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Hyponatremia in the ED

Four questions to ask yourself:

1. Is the patient symptomatic from their hyponatremia (confusion, nausea/vomiting, ams, seizures, etc)?
   • If not, outpatient followup (unless super low)
2. Is the patient having severe neurologic symptoms from their hyponatremia? (seizures, AMS)
   • If yes, treat with hypertonic saline (3%)
3. Is the patient going to be admitted from their hyponatremia?
   • If yes, obtain serum osmolarity to rule out pseudohyponatremia
4. Is the patient dehydrated/hypovolemic?
   • If yes, treat with NS bolus
   • If euvolemic/hypervolemic, treat with fluid restriction

Further Reading:

EMCrit – Hyponatremia

EMDocs – Critical Hyponatremia

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CAUTION: THESE NOTES CONTAIN SPOILERS!!

Case Introduction

You are working a shift at EM Clerkship General when you are called to the waiting room by the charge nurse for a seizing patient.

Initial Vitals

• Temp 99.0F
• HR 97
• RR 16
• BP 120/80
• O2 90%

Critical Actions

• Perform airway maneuvers to clear obstruction
• Administer IV Benzodiazepines
• Administer Hypertonic Saline
• Diagnose Anterior Shoulder Dislocation
• Perform & Describe Shoulder Reduction Procedure

Further Reading

EMDOCs – Anterior Shoulder

ALiEM – Park Method for Anterior Shoulder Dislocation

EMCrit – Hyponatremia

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Acetaminophen Overdose & Toxicology Pearls

• History: Figure out how much was taken, what time the ingestion occurred, and if any other toxins were ingested
• Physical Exam: Perform a regular physical exam, and in addition, perform the toxicologic physical exam!
  • Check pupil size
  • Assess neuromuscular status for rigidity/clonus
  • Perform the “toxicologist handshake”
  • Listen to bowel sounds
• Workup:
  • Accucheck
  • ECG
  • CBC, CMP, VBG
  • Acetaminophen Level (now and at four hours); Salicylate Level
  • UDS
  • Consider specific drug levels (eg digoxin, lithium, valproic acid, etc) ; consider ammonia level for valproic acid OD
• Management:
  • ABCs first
  • Consider decontamination (remove clothes, hose down with water if chemical exposure, consider activated charcoal or gastric lavage for early ingestions)
  • Consult poison control/toxicology
  • Consult psychiatry if it was an attempt at self harm
  • Administer NAC if considered to be a “toxic ingestion of acetaminophen”
• Definition of an “Acetaminophen Toxic Ingestion”
  • Single ingestion of acetaminophen greater than 150mg/kg
  • Data point on Rumack-Matthew Nomogram that is above the treatment line
  • If UNKNOWN amount / UNKNOWN timing of ingestion, treat if LFTs are elevated or if serum acetaminophen level is above normal limits
• Rule of 150
  • Toxic Ingestion is considered to be a single ingestion greater than 150mg/kg
  • Toxic Ingestion is considered to be if the acetaminophen level at the four hour mark is >150ug/mL (this would be above the treatment line on the Rumack-Matthew Nomogrom)
  • Dose of NAC is 150mg/kg IV

Further Reading:

Rumack-Matthew Nomogram (MDCalc)

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Asymptomatic Hypertension

• Make SURE the patient isn’t having symptoms of end organ dysfunction, which could make this hypertensive emergency (confusion, severe headache, blurry vision, weakness, chest pain, shortness of breath, seizures during pregnancy, etc).
• ACEP clinical policy states, that in the patient with true asymptomatic hypertension who presents to the emergency department, no routine testing or treatments are indicated.
• You risk causing HARM to your patients by treating these asymptomatic patients. For example, if you push IV hydralazine for asymptomatic hypertension in a patient who chronically lives at a BP of 230/120 and their blood pressure drops precipitously, you may cause a stroke/watershed infarcts.
• ACEP clinical policy also states that in a patient who has poor access to followup (eg homeless), you may consider routine testing or initiation of long term anti-hypertensive treatment.

Further Reading:

ACEP Clinical Policy – Asymptomatic Hypertension

EM Docs – Hypertensive Emergency

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CAUTION: THESE NOTES CONTAIN SPOILERS!!

Case Introduction

You are working a shift at EM Clerkship General when you are handed the next chart, a 60 year old male presenting with high blood pressure.

Initial Vitals

• Temp 98.0F
• HR 90
• RR 18
• BP 220/120
• O2 98%

Critical Actions

• Perform thorough neurological exam (and find papilledema)
• Diagnose Hypertensive Emergency
• Start anti-hypertensive drip (usually Nicardipene)
• Recheck patient’s blood pressure after intervention
• Admit to ICU

Further Reading

Hypertensive Emergency (EMCrit)