Category: Uncategorized

Deep Dive – Round 25

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

Round 25 (Seizure)

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

Deep Dive – Round 24

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)

Deep Dive – Round 23

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

Round 23 (High Blood Pressure)

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)

Deep Dive – Round 22

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)

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)

Deep Dive – Round 21

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)

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

Deep Dive – Round 20

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.

Deep Dive – Round 18

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

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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