Author: Mike Estephan (Page 1 of 4)

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• Common during the first year of life as well as during puberty
• Presents with nausea/vomiting, abdominal pain, and/or testicular pain
• ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)
• Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex
• Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound
• Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US
• Attempt manual detorsion if there will be a significant delay to surgery

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Phase One: CNS

• Ataxia, Slurred Speech, Confusion, N/V, Seizures

Phase Two: Cardiopulmonary

• CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS

Phase Three: Renal

• Flank pain, Hematuria, Oliguria, Renal Failure

Diagnosis:

• HIGH INDEX OF SUSPICION
• Ethylene Glycol Serum Level
• Elevated Osmolar Gap
• Serial Anion Gap Measurements

Treatment:

• Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid
• Hemodialysis
• Consider Bicarb drip, pyridoxine, and thiamine

Further Reading:

EMCrit Toxic Alcohols

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Hypertensive Emergencies of Pregnancy

PreEclampsia, Eclampsia, HELLP syndrome

Diagnosis: BP >140/90 plus end organ dysfunction

• Acute Kidney Injury
• Proteinuria
• Thrombocytopenia
• Transaminitis
• Hemolysis
• Pulmonary Edema
• Cerebral Edema / Hemorrhage
• Headache refractory to tylenol
• Visual Changes
• RUQ Pain not attributable to another diagnosis

Treatment

• Loading Dose: IV Magnesium 4-6g over 20-30 min OR 5g IM in each buttock
• Maintenance Dose: 1g/hr IV
• Antihypertensives (goal 20% reduction): Labetalol, Nicardipine, Hydralazine
• Delivery of fetus and placenta

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Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion

• Hypovolemic Shock
  • Hemorrhage
  • Volume Loss (vomiting/diarrhea, dehydration)
• Cardiogenic Shock
  • ACS, Myocarditis, CHF, Valve failure, Endocarditis, etc
• Obstructive Shock
  • Massive PE, Tension Pneumothorax, Cardiac Tamponade
• Distributive Shock
  • SIRS (Septic Shock, Pancreatitis, Severe Burns)
  • Anaphylactic Shock
  • Neurogenic Shock
  • Adrenal Crisis

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The 6 STEMI Equivalents:

1. Posterior MI
   • ST Depression V2/V3 (or STE in V7-V9)
2. Right Ventricular MI
   • STE V1 associated with inferior MI ; or STE V4R-V6R
3. Wellens Syndrome
   • Type A: Biphasic T-waves V2/3
   • Type B: Deep Symmetric T-wave Inversion V2/V3
4. De Winter’s T Wave
   • ST Depression with a large, symmetric, upright T wave
5. STE avR with diffuse ST-Depression
   • Usually a strain pattern due to underlying pathology, in correct clinical context can represent a left main or proximal LAD coronary occlusion
6. Modified Sgarbossa Criteria in LBBB
   • Concordant STE in any lead
   • Concordant ST Depression in V1-V3
   • Excessive Discordance (ST/S ratio >0.25)

Other atypical ischemic EKG findings:

1. Isolated TWI in avL – early sign of inferior MI
2. Hyperacute TWave
3. NTTV1 (New Tall T-wave in V1)

Further Reading (see photos in the article):

ECG Diagnosis of Life-Threatening STEMI Equivalent’s: Journal of the American College of Cardiology

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1. The MILDLY agitated patient : verbal de-escalation or PO benzo/antipsychotic
2. The MODERATELY agitated patient : IM benzo/antipsychotic
3. The SEVERELY agitated patient : IM Ketamine 5mg/kg

Consider removing the terminology “Agitated Delirium” from your vocabulary, as there is significant racial bias behind this term.

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Indications for LP: CNS infection, SAH, Guillian Barree, IIH

Contraindications for LP: Space occupying lesion with mass effect ; severe thrombocytopenia and coagulopathy; cellulitis over LP site or concern for epidural abscess ; traumatic injury to spine

Complications for LP: Post LP Headache, spinal hematoma, brainstem herniation

Technique for LP: Positioning is everything.  Use US if necessary.  Check for CSF early and often.  

When to CT before LP?: AMS; focal neuro deficit; new onset seizures, known CNS lesions; immunosuppression; papilledema 

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Obtain IV Access – get two large bore IVs (18g or larger)

Resuscitate – un-crossmatched blood at first, don’t forget type and screen!

Medicate – Give Pantoprazole always, Octreotide and Ceftriaxone if hx liver disease, reverse anticoagulation if indicated

Imaging – Upright CXR to assess for perforation, CTA if concerned for lower GIB

Consult – GI if unstable / if variceal bleeding

Disposition – based on amount of bleeding and hemodynamic stability

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You are working at Clerkship General when the charge nurse grabs you – “hey we got a real sick one, a 57yo Male who I just put in the resuscitation bay, he is vomiting blood”.

Initial Vitals:
BP: 77/34

HR: 135

RR: 24

O2%: 95%

Temp: 98.8F

Critical Actions:

1. Place two large bore IVs
2. Transfuse emergency uncross matched blood
3. Administer IV Pantoprazole
4. Administer IV Ceftriaxone and IV Octreotide
5. Consult GI

Further Reading: EMDocs – GI Bleed

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Aortic Dissection – when there is a tear in the intima layer of the aorta and the blood dissects the intima away from the media creating a false lumen in the aorta

1. Historical Features
   • Be VERY suspicious with ABRUPT onset of chest/back pain that reaches MAXIMAL SEVERITY immediately after onset of pain.
   • Chest pain or Back pain with a neurologic deficit
   • Pain “above and below the diaphragm”
2. Diagnosis
   • CT Angiography of chest abdomen and pelvis is gold standard
   • Can see widened mediastinum on CXR or dissection flap on POCUS
3. Treatment
   • Pain control first
   • Heart rate control second (goal <60bpm, use esmolol)
   • Blood pressure control third (goal 100-120SBP, use nicardipine/clevidipine)
   • CT Surgery consult (should go directly to OR with a Type A dissection)
   • Arterial Line placement

Further Reading:

Core EM – Aortic Dissection

LITFL – Aortic Dissection

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You are working at Clerkship General when the base command phone rings –

“Hey doc just wanted to give you a heads up on this stroke alert we’re bringing you – we have a 70yo M with sudden onset left arm numbness and weakness, last known well 2 hours ago, we’ll be there in about 5 minutes”

Initial Vital Signs:

HR 120

BP 180/90

RR 22

O2 97%

Temp 97.7F

Critical Actions:

1. Check a blood glucose

2. Diagnose Aortic Dissection

3. Give Esmolol first, titrate to HR<60

4. Give Nicardipine/Clevidipine second, titrate for SBP 100-120

5.   Consult cardiothoracic surgery for type A dissection

Further Reading:

EMCrit – Aortic Dissection

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Not your typical wellness episode – by Zack

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You are working at Clerkship General Hospital when EMS calls in a female with opioid overdose, but she won’t stop complaining of leg pain…

Initial Vitals:

Temp: 98

BP: 120/80

HR: 89

RR: 20

O2 Sat: 100%

Critical Actions:

• Treat patient’s pain without NSAIDs (history of solitary kidney)
• Assess patient’s leg pain beyond the point of just fracture vs. no fracture
• Recognize the signs and symptoms of compartment syndrome
• Get orthopedic surgery to bedside emergently for fasciotomy
• Recognize and treat rhabdomyolysis

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Diabetic Ketoacidosis – hyperglycemia, ketosis, and anion gap metabolic acidosis

• Don’t forget about euglycemic DKA (especially in setting of SGLT2 inhibitor) or mimics such as alcoholic ketoacidosis

1. Treatment of the ketoacidosis
   • Insulin (usually a drip or bolus + drip) – only once K>3.5
   • Volume Resuscitation (NS initially, change to LR)
   • Bicarb drip (poor evidence, only as last resort for critical patients)
2. Treatment of electrolyte abnormalities
   • Correct sodium for hyperglycemia
   • Replete potassium if K<5.0, PO and IV simultaneously
     • consider central line if patient hypokalemic and in extremis/critical DKA
3. Management of respiratory status
   • Avoid intubation at all costs unless altered or impending respiratory failure
     • APNEA KILLS
     • Mechanical ventilation limits your minute ventilation, leading to worsening acidosis. Breath stacking occurs if you set the RR too high.
   • Support work of breathing with NIPPV (high IPAP, low EPAP)
   • If intubation necessary, consider awake intubation or consider using bicarb pushes if performing RSI

Further Reading:

EMCRIT – DKA

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You are working a shift at Clerkship General when the charge nurse comes and grabs you to see a 24yo male who appears to be in respiratory distress.

Critical Actions:

1. Diagnose DKA
2. Replete potassium
3. Start insulin AFTER potassium repletion
4. EITHER place central line for faster K repletion OR initiate bipap to allow time for potassium repletion via existing peripheral line
5. Admit to ICU

Further Reading:

EMCrit – DKA

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Before interview day, do your research on programs and interviews and reflect on the way in which you want to portray yourself.

On interview day, have a cheat sheet with notes about your conversations, questions, and pro-cons. Remember to stay calm, take a pause if you need to, and above all be authentic to who you are.

After interview day, be sure to capture you gut impression and write down any follow-up questions or concerns remaining.

Here are some resources to use for interview day:

EMRA Residency Interview Guide

AliEM – Dos and Don’ts of residency interviewing

EMRA – Common Interview Questions

EMRA – Making the most out of interview day

ALiEM – EM Match Advice Podcast Episode

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show notes coming soon

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Show comments to be posted shortly

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1. Understand the timeline – research programs to find out when they extend invites and when they host interviews
2. Prepare for invitations – set up email and text notifications, get a calendar
3. Accept invitations – respond promptly and keep your calendar updated
4. Optimize invitations – any interview date you get is a good one, but planning ahead can help you optimize timing
5. Too many or too little interviews – drop early, keep tabs with whether programs have extended invites and stay in close contact with your advisors