EM Clerkship

It’s time to stop thinking in quadrants…

I→ Episode Summary

Good luck!!!

Good luck!!!

When we get labs, we are usually getting a CBC as part of our testing. This week we will discuss what to do when the patient has a thrombocytopenia that you weren’t expecting.

Clinical Presentation * Incidental finding on routing CBC* Petechiae/purpura* Mucosal bleeding* Epistaxis* Gingival bleeding* Hematuria* Vaginal bleeding 5 Major Causes of Thrombocytopenia * Thrombotic Thrombocytopenic Purpura (TTP)* Clinical presentation (pentad)* Thrombocytopenia* Fever* Microangiopathic hemolytic anemia* “schistocytes”* Neurologic abnormalities* Renal dysfunction* Physiology* Low ADAMTS13 results in impaired vWF breakdown* Widespread “platelet plugs”* Treatment* Plasma exchange* Hemolytic Uremic Syndrome (HUS)* Clinical presentation* Pediatric patient with bloody diarrhea* Renal dysfunction* Thrombocytopenia* Treatment* Supportive care* Heparin Induced Thrombocytopenia (HIT)* Clinical presentation* Recent heparin administration* Acute thrombocytopenia (<150) or 50% decrease in platelets* Treatment* Stop heparin and choose different anticoagulant* Disseminated Intravascular Coagulation (DIC)* Clinical presentation* Patient septic, severe trauma, or otherwise critically ill/injured* Multiple abnormal labs* Increased PT/PTT* Increased D-dimer* Increased fibrinogen degradation products* Treat underlying trigger* Immune/Idiopathic Thrombocytopenic Purpura (ITP)* Common condition* Relatively benign* Treatment* Steroids* Occasionally platelet transfusion* Other causes* HIV* Hepatitis* Heavy alcohol use Additional Reading * Thrombocytopenia: An ED Approach (emDOCs)

Nausea and vomiting has a HUGE differential diagnosis but usually ends up being simple gastritis in the end. This week we will discuss a basic approach, treatment protocol, as well as to help out your attending.

The hardest part about this chief complaint is expanding your differential beyond gastritis!!! Step 1: Expand Your Differential Diagnosis * Early appendicitis* Bowel obstructions* Myocardial infarction* Elevated ICP* Diabetic Ketoacidosis Step 2: Give a Testing Plan * High yield tests to consider* EKG – older adults* Pregnancy test – women of child bearing age* Electrolytes – most patients* Other tests to consider* CBC* LFTs/Lipase* Urinalysis Step 3: Give a Treatment Plan * IV fluids (1L normal saline)* Antiemetics* Ondansetron (Zofran)* Promethazine (Phenergan)* Prochlorperazine (Compazine) Step 4: PO Challenge * Prior to discharge patient needs to keep fluids down* Bonus points if you update your attending on this Step 5: Repeat Abdominal Exam * Perform this prior to discharging patient Additional Reading * Antiemetic Pearls (EM Cases)

We commonly see patients with advanced liver disease in the Emergency Department and we screen all of them for 5 common complications every time.

Organ Failure Complications * Hepatorenal syndrome (renal failure)* Decreased urine output* Labs show elevated creatinine* Admit to hospital (high mortality)* Hepatic encephalopathy (brain failure)* Introduction* Liver clears ammonia from body* In advanced liver failure, ammonia increases* Symptoms* Altered mental status/confusion* Asterixis* Treatment* Lactulose* Binds ammonia and is excreted* Rifaximin* Eliminates bacteria responsible for producing ammonia Portal Hypertension Complications * Gastric/esophageal varices* Symptoms* Altered mental status* Hepatic encephalopathy triggered by reabsorbed GI blood* Melena* Black stools from digested GI blood* Treatment* Proton pump inhibitor (PPI)* Pantoprazole* Octreotide* Antibiotics* Classic procedure* Blakemore tube (balloon tamponade)* Ascites with spontaneous bacterial peritonitis (SBP)* Symptoms* Abdominal pain/tenderness* Ascites* Fever* Testing plan* Diagnostic paracentesis* >250 neutrophils* High protein* Low glucose* Treatment* Antibiotics* Albumin Liver Failure Complications * Coagulopathy* Diagnose with abnormal coagulation studies* PT with INR* Patients can be BOTH hyper and hypocoagulable Additional Reading * How to Perform Paracentesis (Medscape)

For our series finale we will review the 5 mega abdominal emergencies in kids as well as briefly discuss non-accidental trauma.

Non-Accidental Trauma * Estimated 10% of pediatric patients are victims of abuse* Sexual abuse* Physical abuse* Neglect* Common red flags* Changing story* Story that doesn’t make since* Delays in seeking care* Unusual bruising locations* Torso* Ears* Neck* Common tests if non-accidental trauma suspected* Skeletal survey x-rays* Head CT* Especially if altered mental status* Abdominal CT* Especially if abdominal trauma* Report to child protective services (CPS) Tummy Ache * Necrotizing enterocolitis* Classic presentation* Premature baby* 1st month of life* Ill appearing* Classic finding on x-ray* “Pneumatosis intestinalis”* Volvulus* Classic presentation* 1st month of life but previously healthy* Distended abdomen* Bilious vomiting* Testing* Abdominal Xray* Upper GI Series (ideal test)* Toxic megacolon* Complication of Hirchsprung Disease* Seen on x-ray* Intussusception* Telescoping bowel resulting in ischemia* Classic presentation* 2 months – 2 years old* Intermittent abdominal pain followed by lethargy* Diagnose with abdominal ultrasound* Pyloric stenosis* Classic presentation* Projectile vomiting* Normal appetite/hungry* Palpable “olive” in epigastrium * Testing* Electrolyte panel* Hypokalemia* Hypochloremia* Alkalosis* Abdominal ultraound Additional Reading * Pediatric Abdominal Pain (EM Clerkship)

Don’t be scared of the inborn errors of metabolism and endocrinology. They are really quite simple to screen for. Focus less on knowing the details of each one, and more on the general concept of what byproducts are building up and what substance is missing.

Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!! Inborn Errors of Metabolism (IEM) * Almost always result in one of the following three clinical abnormalities* Buildup of toxins* Ammonia* To test for this, obtain an ammonia level* Buildup of acids* Methylmalonic acidemia* To test for this, obtain electrolyte panel and look for decrease CO2* Shortage of glucose* Glycogen storage disorders* To test for this, obtain a blood glucose level Congenital Adrenal Hyperplasia (CAH) * Decreased 21-hydroxylase enzyme* Physiologic abnormalities* Decreased aldosterone* Low sodium (hyponatremia)* High potassium (hyperkalemia)* Decreased cortisol* Low glucose level* Hyperpigmentation* INCREASED sex hormone (androgens)* Fused labia* Partial male genitalia Additional Reading * Congenital Adrenal Hyperplasia (Wikipedia)

Cyanosis, difficulty feeding, failure to thrive, and shock can all be the presenting symptom of a cardiac abnormality. We will briefly overview cyanotic heart lesions, ductal dependent lesions, and CHF today.