Author: Mike Estephan (Page 1 of 4)

Deep Dive MW R21

Orbital Compartment Syndrome – needs to be diagnosed CLINICALLY

On exam, LOOK for: Proptosis, Ophthalmoplegia, Afferent Pupillary Defect, Vision Loss

On exam, FEEL for: Rock hard globe, tense eyelids, resistance to retropulsion

IOP > 40 means immediate canthotomy is indicated!

Don’t perform if open globe is present

Lateral Canthotomy Procedure: Anesthetize, Devascularize, Canthotomy, Cantholysis (inferior crus first)

Paperclip Eyelid Retractors

Deep Dive MW R20

Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.  

The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags. 

Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’s paralysis.  

Management/treatment thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (<185/110 if treating, <220/120 if no treatment). 

Remember that time is brain, so move fast! 

AAEM tPA Infographic

AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

Deep Dive MW R19

  • 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

Deep Dive MW R18

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

Deep Dive MW R17

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

Deep Dive MW R15

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

Deep Dive MW R11

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

Deep Dive MW R10

  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.

Deep Dive MW R9

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 

Deep Dive MW R8

  • Two Types of Priapism
    • Low Flow “Ischemic” (Most Common >95% of Cases)
      • Urologic Emergency
        • Results in Erectile Dysfunction
      • Painful
      • Common Etiologies
        • Idiopathic
        • Erectile Dysfunction Drugs (ex. sildenafil)
        • Sickle Cell Disease
        • Trazodone (“TrazoBONE”)
        • Cocaine/Meth
    • High Flow
      • Caused by Trauma and AV Fistulas
  • Management
    • Analgesia
      • Dorsal Penile Nerve Block
    • Aspiration
      • Can intermittently irrigate with normal saline to dilute the clot
    • Injection
      • Phenylepherine
        • Recommend cardiac monitor

Deep Dive MW R7

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

Round 7 (MW) – Vomiting Blood

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

Deep Dive MW R6

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

Round 6 (MW) – Weakness

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

Round 5 (MW) – Leg Pain

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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