Category: Uncategorized (Page 1 of 3)

Round 12 (MW) Respiratory Distress

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General. We are bringing you an unresponsive 6-year-old female found foaming at the mouth by her babysitter. ETA 2 minutes.”

Initial Vitals:

BP: 125/80

HR: 62

RR: 34

O2: 81% (Non Rebreather)

Critical Actions:

  1. Grab the Broslow!
  2. Fingerstick Glucose
  3. Choose Endotracheal Tube Size
  4. Administer Atropine until bronchial secretions stop
  5. Pralidoxime

The Ischemic EKG (Deep Dive R11 MW)

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

Agitation (Deep Dive R10 MW)

  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.

Lumbar Punctures (Deep Dive R9 MW)

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 

Upper GI Bleed (Deep Dive R7 MW)

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

Aortic Dissection (Deep Dive R6 MW)

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

DKA (Deep Dive R4 MW)

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
      • 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:


Round 4 (MW) – Shortness of Breath

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

Interviews Part 2 – Acing your interview

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

Interviews Part 1 – Crafting your schedule

  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

Ectopic Pregnancy (Deep Dive R2 MW)

Summary of Key Points

1. You should consider ectopic pregnancy in every patient who is capable of bearing children

2. If a patient of child bearing age presents with severe abdominal pain or vaginal bleeding and is either hemodynamically unstable or very ill appearing, this is a ruptured  ectopic pregnancy until proven otherwise and I would recommend performing a bedside FAST exam immediately.

3. Remember that the discriminatory zone for TVUS is approximately 1500.  

4. Don’t forget your three ACEP clinical policies on this topic: just to remind you, 

4a.  It is a level B ACEP clinical policy to obtain a TVUS in every stable pregnant patient presenting with abdominal pain or vaginal bleeding, regardless of serum b-HCG level

4b.  There is also a level B ACEP clinical policy stating that in patients with an indeterminate TVUS, you cannot use serum bHCG value to rule out ectopic pregnancy.

4c. It is a level C ACEP clinical policy to obtain specialty consultation or arrange close outpatient followup in all patients with an indeterminate TVUS result.

5. Although this isn’t an ACEP recommendation, ACOG recommends rhogam for all Rh negative women diagnosed with an ectopic pregnancy

6. Don’t forget to consider heterotopic pregnancy, especially if IVF was used to help conceive. 

Further Reading:

ACEP Clinical Policy – Early Pregnancy

Round 2 (MW) – Abdominal Pain

You are working at Clerkship General when the next chart gets handed to you – a 31 year old female presenting with abdominal pain.

Initial Vitals:

BP: 109/65

HR: 96

RR: 21

O2: 99%

Temp: 99.1F

Critical Actions:

  1. Obtain pregnancy test
  2. Confirm IUP
  3. Administer Rhogam
  4. Treat UTI
  5. Counsel the patient and discharge them

Further Reading:

CoreEM – Utility of Anti-D Immunoglobulin(Rho Gam) During First Trimester Pregnancy

EMDocs – Bleeding in Early Pregnancy

Selecting Programs

Things to consider when selecting residency programs to apply to:

 1.  What type of program (County, Community, Academic)
 2.  What length of program (3 year vs. 4 year)
 3.  Location
 4.  Culture and Lifestyle
 5.  Niches in EM

Further Resources:

EMRA Residency Map
Doximity Navigator
SAEM Residency Fair
EMRA Residency Fair


3 Steps to assessing your competitiveness for matching in an EM residency:

 1.  Get a good advisor.
 2.  Look at the data.
 3.  Maximize your potential.

Further Reading:

EMRA – Apply smarter not harder
EMRA Hangouts
EMRA Student-Resident Mentorship Program
NRMP Charting the Outcomes
NRMP Residency Data
ALiEM – Match Advice

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