Category: Uncategorized (Page 3 of 3)

Neonatal Resuscitation (Deep Dive R22)

June 15, 2021 /

Podcast: Play in new window | Download

Neonatal Resuscitation

*THIS IS A BASIC FRAMEWORK AND IS NOT COMPREHENSIVE*

  1. EVALUATE
    • Is the newborn crying/breathing spontaneously? Does the newborn have good tone? Is the newborn a term infant?
      • If YES, hand baby to mom for direct skin-to-skin.
      • If NO, proceed to step 2.
  2. INTERVENE
    • STIMULATE – dry vigorously
    • WARM – place cap on head, place in warmer
    • OPEN AIRWAY – sniffing position, oral/nasal airway, suction if necessary
  3. ASSESS HR (manually)
    • If HR>100, continue above interventions and move to PPV if not improving/if pulse ox low
    • If HR 60-100, attach to telemetry and pulse oximetry and begin PPV with room air at a rate of 60.
    • If HR<60, this is a CODE situation. Chest compressions and ventilations in a 3:1 ratio (“one and two and three and breath”), use PPV with 100% FiO2. Obtain access via UC or IO line, and intubate. Use epinephrine / fluid bolus if no improvement in 60 seconds. Check glucose, supplement with dextrose if necessary.

PEARL: At one minute of life, we expect an SpO2 of 60%.  Every minute afterwards, we expect the SpO2 to increase by 5%, so by 5 minutes of life it should be around 80%.  

Neonatal Resuscitation – Emergency Medicine Cases

Round 22 (Cardiac Arrest)

June 1, 2021 /

Podcast: Play in new window | Download

CAUTION: THESE NOTES CONTAIN SPOILERS!!!

Case Introduction

You are working a shift at EM Clerkship General when the triage nurse runs and grabs both you and your attending for a patient in triage who has active CPR in progress.

Initial Vitals

  • Temp 98.0F
  • HR 0
  • RR 0
  • BP unmeasurable
  • O2 70%

Critical Actions

  • Identify pregnancy by exam, POCUS, or history
  • Place patient in left lateral decubitus
  • Perform resuscitative hysterotomy
  • Resuscitate the neonate

Further Reading

Neonatal Resuscitation (EMCases)

Resuscitative Hysterotomy (EMCases)

Torsades de Pointes (Deep Dive R21)

May 15, 2021 /

Podcast: Play in new window | Download

Torsades de Pointes (TdP)

A type of polymorphic ventricular tachycardia that is inherently unstable and often quickly degrades into ventricular fibrillation. It usually occurs in the setting of a prolonged QT interval, which can either be genetic or acquired.

Treatment

  1. Defibrillation – per ACLS, ventricular tachycardia with a pulse should receive synchronized cardioversion. But in real life, the defibrillator often isn’t able to “sync” with TdP, forcing you to perform unsynchronized cardioversion (aka defibrillation).
  2. IV Magnesium – treats and prevents TdP, even when magnesium levels are normal
  3. Overdrive Pacing – by preventing bradycardia, we help prevent TdP (bradycardia prolongs the QT interval).
    • Electrical Overdrive Pacing – transcutaneous or transvenous pacemaker
    • Chemical Overdrive Pacing – beta agonist therapy (isoproterenol)
  4. Lidocaine – anti-arrhythmic therapy that does not prolong QTc.
  5. Fix underlying cause – congenital long QT syndrome, hypokalemia, hypocalcemia, medication induced (psych meds, anti-emetics, methadone, fluoroquinolones, many more)

Defibrillation and IV Magnesium are used for patients who are ACTIVELY in TdP. Once you shock/mag them into a stable rhythm, you can use Overdrive Pacing / Lidocaine / Treat Underlying Cause to PREVENT them from going back into TdP.

Round 21 (Drowning)

May 1, 2021 /

Podcast: Play in new window | Download

CAUTION: THESE NOTES CONTAIN SPOILERS!!!

Case Introduction

You are working a shift at EM Clerkship General when EMS calls you on the radio… “Hey doc we’re bringing a young female who drowned in a pool ETA 1 minute”.

Initial Vitals

  • Temp 95.0F
  • HR 55
  • RR 5-6
  • BP 110/82
  • O2 90%

Critical Actions

  • Evaluate for traumatic injury (and/or place C-Collar)
  • Intubate the patient
  • Identify Long QT Syndrome on ECG
  • Treat Pulseless Polymorphic VTach with defibrillation and IV magnesium
  • Treat Polymorphic VTach (pulse present) with overdrive pacing (transcutaneous pacing or isoproterenol)

Further Reading

Torsades de Pointes – EMCrit

Kawasaki Disease (Deep Dive R20)

April 15, 2021 /

Podcast: Play in new window | Download

Kawasaki Disease

A small vessel vasculitis that affects children, usually <5 years old.

Symptoms – remember the CRASH AND BURN mnemonic!

Conjunctivitis

Rash – nonspecific morbilliform or maculopapular rash, usually on torso

Adenopathy – usually unilateral cervical lymphadenopathy

Strawberry Tongue – erythema, swelling, or cracking of lips/mucous membranes

Hands – swelling, erythema, or desquamation of the hands/feet

BURN – 5 days of fever

Diagnosis:

  • COMPLETE KAWASAKI – 5 days of fever and 4/5 of the CRASH symptoms
  • INCOMPLETE KAWASAKI – 5 days of fever and 2-3/5 of the CRASH symptoms, in the setting of elevated inflammatory markers (WBC, ESR, CRP)

Treatment: IVIG and High Dose Aspirin

Multisystem Inflammatory Syndrome in Children (MIS-C)

A new disease entity seen in children defined by widespread systemic inflammation affecting multiple organ systems that presents weeks after infection by COVID-19.

Symptoms:

  • Persistent Fever
  • Skin involvement – nonspecific rash, conjunctivitis, changes to mucous membranes
  • GI involvement – nonspecific abdominal pain, nausea, vomiting, diarrhea
  • Renal involvement – acute kidney injury with elevated creatinine
  • Cardiac involvement – elevated troponin/pro-BNP, reduced EF, cardiogenic shock
  • Neuro involvement – altered mental status

Diagnosis and Treatment: Varies by hospital, but usually involves the presence of clinical symptoms along with a positive covid IgM/IgG, elevated inflammatory markers (WBC, ESR, CRP, Ferritin, DDimer), multisystem involvement (elevated troponin/proBNP, elevated creatinine, elevated LFTs, etc). These children need a stat ECHOcardiogram to rule out significant cardiac dysfunction.

Identification of Sepsis (Deep Dive R18)

February 15, 2021 /

Podcast: Play in new window | Download

Four definitions you must know:

  1. SIRS – Must have at least 2 of 4 SIRS criteria (listed below):
    • Fever (>38C) or Hypothermia (<36C)
    • WBC >12k or <4k ; OR Bandemia >10%
    • Tachycardia > 90
    • Tachypnea > 20
  2. SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc)
  3. SEVERE SEPSIS – Must have Sepsis + ONE of the following criteria indicative of end organ dysfunction:
    • Hypotension (MAP<65 or SBP<90)
    • Creatinine > 2.0 (with normal baseline renal function)
    • Lactate > 2.0
    • Platelets < 100k
    • INR > 1.5
    • Bilirubin > 2
  4. SEPTIC SHOCK – Must have severe sepsis PLUS one of the following
    • Hypotension DESPITE adequate fluid resuscitation (usually 30cc/kg bolus)
    • Lactate > 4.0 DESPITE adequate fluid resuscitation (usually 30cc/kg bolus)

GENERAL GUIDELINES (exact management depends on clinical scenario):

  • If patient meets SIRS criteria you work the patient up for sepsis / severe sepsis:
    • Lactate, Blood Cultures, Urinalysis/Culture, Chest XRay
    • CBC, BMP, Coags, LFTs
  • If patient meets SEPSIS criteria, you add in broad spectrum antibiotics +/- intravenous fluids
  • If patient meets SEVERE SEPSIS criteria, you give a 30cc/kg fluid bolus,
  • If patient meets SEPTIC SHOCK criteria and is HYPOTENSIVE, you start vasopressors (norepinephrine usually)

MDCalc – Sepsis

Sepsis-2 and Sepsis-3 Guidelines Summarized

Introduction

March 20, 2016 /

Podcast: Play in new window | Download

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)
Newer posts »

Links

Terms and Conditions

Privacy Policy

Contact Us

© 2024 EM Clerkship, LLC

Theme by Anders Noren — Up ↑