EM Clerkship

Performing an emergency delivery is very intimidating. The good news is that in most scenarios, as long as you don’t drop the baby, it should go very naturally. However, there are exceptions to this which we will cover today.

P→ Episode Summary

EM physicians are the masters of EKG interpretation. We will cover an organized EKG interpretation system today with an emphasis on identifying life threats, and this will act as the foundation for your EKG interpretation skills for the rest of your career.

Always remember…1, 2, 3, get an old EKG!!! Step 1: Identify the Rate and Rhythm * Is it sinus rhythm?* P wave before every QRS* Is it one of the tachycardias? (Refer to THIS episode)* Is it one of the bradycardias? (Refer to THIS episode) Step 2: Look for Signs of Ischemia * Most consistent way is to examine by anatomic region of the heart* II, III, and aVF are “inferior” leads* I, aVL, V5, V6 are “lateral” leads* V1 and V2 are “septal” leads* V3 and V4 are “anterior” leads* Check for Q waves* Check for ST segment elevation or depression* Compare the J point with baseline (TP segment)* Check for peaked T waves and T wave inversions* T wave inversions in V1 and aVR are normal Step 3: Look at Intervals * PR interval* Wolf-Parkinson White Syndrome* 1st degree heart block* QRS interval* Left bundle branch block* Right bundle branch block* Sodium channel blockade* QT interval* Long QT syndrome* Hypokalemia* Risk of torsades de pointes Step 4: Get an Old EKG * If you find anything abnormal looking, compare to an old EKG Bonus: Scarbossa Criteria * Identifies ischemia in patients with a left bundle branch block* 1 lead with concordant ST elevation* 1 lead with concordant ST depression (V1-V3)* Severely discordant ST elevation (>25% preceding S wave) Additional Reading * Basic Approach to Tachycardias (EM Clerkship)* Basic Approach to Bradycardias (EM Clerkship)* EKGs for the Emergency Physician (Amazon)

Sick. Not sick. This week we will discuss the fundamental pediatric exam that you need to remember regardless of how the patient looks.

Mnemonic: ABCDEF Appearance * The ‘A’ in the pediatric assessment triangle* Interactive vs distant* Good tone vs floppy* Calm and happy vs inconsolable Breathing * The ‘B’ in the pediatric assessment triangle* Signs of respiratory distress* Nasal flaring* Retractions* Abnormal respiratory sounds Color/Circulation * The ‘C’ in the pediatric assessment triangle* Pink = good* Abnormalities* Pallor* Cyanosis* Mottling Distraction * Almost impossible to do a good peds exam in a crying kid* Easiest ways to keep kids distracted* Let parents hold/play with them* Toys* Stethoscope* Funny sounds/noises ENT * Many times the kids don’t localize the symptoms* May present with vomiting, fever, irritability, etc* If difficulty examining pharynx, consider triggering a gag reflex Fully Undress * Look for bruising, rash, blisters* Signs of non-accidental trauma* GU exam (especially in boys, check the testes!) Additional Reading * Peds Respiratory Disorders (EM Clerkship)* Pediatric Assessment Triangle (Wikipedia)

Really sick kids and babies are some of the scariest and most difficult cases we get in Emergency Medicine. This week we’re going to start with the general approach to the less-sick pediatric patient. We will use this as the groundwork for future episodes.

Always ask about pediatric patient’s ‘P-I-S-S’ status!!! Core Function Questions (P-I-S-S Status) * Peeing* Evaluates for dehydration* Number of wet diapers per day?* Same number as usual?* Intake* Rule of 3s* Estimates how much milk/formula an average infant should be taking* 3oz of milk or formula every 3 hours* Sleeping* Is the patient sleeping MORE than usual?* LESS than usual?* Stooling* Normal stool* Changes from dark meconium to tans/yellows Pediatric Medical History * Prebirth* Did the patient have prenatal care?* Any issues with the pregnancy?* Was mom GBS positive?* Peribirth* What gestational age was patient born at?* Vaginal delivery or c-section?* How long did baby have to stay in hospital after delivery?* Postbirth* Diagnosed medical/surgical problems* Immunization status Additional Reading * The Truth About Baby Poop (WebMD)

One of the topics that we typically DONT study much in Emergency Medicine is tropical medicine, and specifically fever in returning travelers. The reason this is important, is because MALARIA is a huge life threat in this patient population that can be easily missed. It is very important to ask about recent travel and then go through a simple approach when they say “yes”.

If a returning traveler has a fever, think malaria malaria malaria!!! Step 1: Ask your patient if they have traveled within the last year * If yes… You should at least CONSIDER malaria Step 2: If patient says yes, take a travel history * When did they go* Where did they stay* Where they exposed to anything concerning* Mosquitos* Animals* Weird foods* Sexual partners* Sick people* Where they in developed/tourist areas or “off the trail” Step 3: Ask about prophylaxis * Did they see a doctor before leaving?* Did they take any immunizations or medicines prior to departure?* Did they continue prophylaxis as instructed? Step 4: Go to the CDC website * Look up the country of concern* Will help establish your differential Step 5: Test for malaria * If you are concerned that patient has malaria…* Order thick and thin blood smear Additional Reading * CDC Yellow Book (CDC Website)

Diarrhea is almost always a benign complaint, especially in well appearing patients, with stable vitals, and a lack of red flags. This week we will cover those red flags as well as some basic treatments when a  patient is complaining of bad diarrhea.

If the patient is completely non-toxic and doesn’t have any red flags, they can usually go home without further testing!!! 3 Big (Non-Viral) Causes of Diarrhea * The Icky ‘I’s* Ischemia* Frequently require surgery consult* Infection* Frequently require antibiotics* Inflammatory bowel disease* Frequently require GI consult, steroids, or salicylates 5 Red Flags * Is it bloody? * Consider performing a guaiac test* Bloody diarrhea usually isn’t “just a virus”* Is it severely painful? * (Viral gastroenteritis may cause gas cramping but shouldn’t be tender or severely painful)* Bonus red flag!!!* POST-PRANDIAL pain* Consider mesenteric ischemia* Recent antibiotics or hospitalization?* Consider C. difficile* Treat with PO vancomycin* Recent travel? * ~80% travelers diarrhea is bacterial* Treat with ciprofloxacin* Note: See FDA black box for fluoroquinolones prior to prescribing* Do you have history of atrial fibrillation? * Increases risk for mesenteric ischemia and ischemic colitis Consider Testing if Patient is Ill or has Red Flags * CBC* Electrolytes* Stool studies* Stool WBCs* Stool culture* C-diff* Ova/Parasite* CT abdomen/pelvis with IV contrast Common Antidiarrheals * Loperamide (Imodium)* Bismuth (Pepto-Bismol)* Dphenoxylate (Lomotile) Additional Reading * Fluoroquinolone Black Box Update (FDA)

I’ve been getting lots of emails regarding which CT scan is the right scan to order in different situations. Contrast? No contrast? ORAL contrast? There are so many options! I recommend you know the core, high yield CT scans, and over time you’ll pick up the rest.

I’ve been getting lots of emails regarding which CT scan is the right scan to order in different situations. Contrast? No contrast? ORAL contrast? There are so many options! I recommend you know the core, high yield CT scans, and over time you’ll pick up the rest.

Everybody knows what appendicitis is (fever, migrating right lower quadrant pain, elevated WBC, pain with bumps in the road). Unfortunately, the issue is that appendicitis only sometimes presents in this classic fashion. Using history, exam, and imaging, it is always important to keep a high index of suspicion for appendicitis so that you don’t miss the diagnosis.