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You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache. Initial Vitals: HR: 56 BP: 172/93 Temp: 98.8F RR: 18 O2: 97% Critical Actions:

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Diagnosing PE: Step 1: Consciously consider the diagnosis Step 2: Risk Stratify into low, intermediate, and high risk Step 3: Choose appropriate testing based on pre-test probability Classification of PE Treatment of PE

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You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.” Initial Vitals: HR: 122 BP: 75/40 Temp: 100.1 RR: 24 O2: […]

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

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You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision” Initial Vitals: HR: 65 BP: 88/50 Temp: 97.0F RR: 20 O2: 96% Room Air Critical Actions:

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* Differential

* Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter

* Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors

* Work-up

* XRay

* Labs to evaluate for septic arthritis – CBC BMP ESR CRP

* Kocher Criteria

* Non-weight bearing

* Fever >38.5C

* ESR >40

* WBC >12

* Kocher Criteria Statistics

* 0 points: 0.2% (or 2% in prospective studies)

* 1 point: 3% (or 9% in prospective studies)

* 2 points: 40%

* 3 points:93%

* 4 points: 99%

* Septic Arthritis DX

* >50,000 WBC

* Age 0-3mo : group B strep

* Age 3mo – 12 years: Staph Aureus

* Age 12-18 years: Gonorrhea

* Sickle Cell Disease: Salmonella

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You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury. Initial Vitals: HR: 112 BP: 97/67 Temp: 99.2F RR: 20 O2: 97% Room Air Critical Actions:

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* Focused Physical Exam

* Tachypnea and Hypoxemia

* Able to speak in complete sentences

* Accessory muscle use/retractions

* Moving air or quiet on auscultation

* Basic Treatment Algorithm

* Albuterol Inhaler

* Albuterol/Ipratropium Nebulized (Duoneb)

* Steroids

* IV Magnesium

* Non Invasive Ventilation (CPAP or BiPAP)

* Decreases Work of Breathing

* Epinepherine

* Less Common Treatments

* Benzodiazepines

* Ketamine

* Heliox

* Intubation (Last resort)

* Use a large ETT (8.0)

* Increase the Expiratory Time

* “Permissive Hypercapnea”

* Appropriate ventilator management of asthma frequently results in mild hypercapnia and respiratory acidosis. IT’S OK

* Air Trapping

* Results in decreased preload, obstructive shock and pneumothorax

* Suspect with high airway pressures and when waveform doesn’t return to zero (see media)

* Treat by briefly unhooking ventilator and gently pressing on the patient’s chest to get out the trapped air

* Ventilator Settings

* Decrease the respiratory rate (ex 10)

* Increase the tidal volume (although some hypercapnia is permitted)

* Increase I:E ratio (1:4 or greater)

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You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes” Initial Vitals: HR: 123 BP: 142/78 Temp: Unknown RR: 36 O2: 97% (NonRebreather) Critical Actions:

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Introduction Clinical Presentation Treatment