EM Clerkship

Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!! Three Stages of Appendicitis * Stage 1: ~12 hours of “gastroenteritis” like symptoms* Stage 2: Direct somatic irritation* This is when pain over McBurney’s develops!* Stage 3: Perforation* Patient is now sick and septic Approach to Appendicitis * Step 1: Consider getting labs* Always remember “The white blood cell count is the last refuge of the intellectually destitute”* The WBC count has both low sensitivity and low specificity for acute appendicitis* Step 2: Get a detailed history* When did the pain start? * How many HOURS into their syndrome are they (remember stages of appendicitis)* Is the pain migrating?* Objective fever?* Did the pain start before the vomiting started?* Does the patient have decreased appetite?* Step 3: Perform a physical exam* Pain over McBurney’s point* Right lower quadrant* 1/3 the distance from the ASIS to the umbilicus* Peritoneal signs (Rigidity, Rebound, Guarding)* Psoas sign* Lie patient on left side with legs extended* Extend their hip behind them* Pain = Suspected retroperitoneal inflammation* Obturator sign* Have patient lie on back with hip/knee flexed at 90 degrees* Internally rotate hip (move ankle away from body)* Pain = Suspected obturator internus inflammation* Step 4: Imaging* Most adults* CT scan +/- IV contrast* Pregnant women* MRI abdomen* Pediatric patients* RLQ ultrasound* Step 5: Disposition* Perform a repeat abdominal exam* Even if CT is negative, consider followup in ED in 12-24 hours Additional Reading * McBurney’s Point (Wikipedia)* Psoas Sign (Wikipedia)* Obturator Sign (Wikipedia)

Before you can learn the different eye diagnoses and how to treat them, you need to have a basic understanding of the ophthalmologic exam. Only after having this foundation can you finalize your approach to the red eye, acute vision loss, or eye trauma (which will be covered in future episodes). https://www.youtube.com/watch?v=w9wMJ6job_0&t=62s

Common Complaints * Red Eye* Decreased Vision* Trauma to the Eye Approach to a Vision Complaint * Step 1: Assess visual acuity* Visual acuity is the “vital sign of the eye”* Snellen eye chart is best* If patient unable to see chart…* Count fingers?* Able to see light?* Step 2: Examine the conjunctiva/cornea with fluorescein* How to apply fluorescein* Recline patient 45 degrees* Pull down on lower eyelid to create pocket* Place anesthetic eye drops in pocket (ex. tetracaine) * Wet the fluorescein strip with eye drops and apply to pocket* Have the patient blink to distribute the dye* Look under woods lamp for bright “uptake” areas that don’t move with blinking* These represent abrasions, ulcers, etc* This step is also a good opportunity to evert the eyelids and examine for foreign bodies if appropriate* Step 3: Examine the anterior chamber with slit lamp * “Cell and flare” (example HERE)* Representative of iritis, uveitis* This is also a good opportunity to examine any other abnormal areas of the eye under magnification!!! * Step 4: Check intraocular pressure* Pressure >20mmHg (especially when unequal) is concerning for acute angle closure glaucoma* Multiple tools to measure pressure on market, ask somebody to show you how to use* Step 5: If appropriate, use ultrasound to evaluate posterior eye* Multiple things can be diagnosed with ultrasound of the eye* Retinal detachment* Optic neuritis* Papilledema* Foreign bodies Additional Reading * Introduction to Slit Lamp (YouTube)* Cell and Flair (TimRoot.com)

The approach to bradycardia is very simple and straightforward. The most important thing is to remember you differential diagnosis. After that, it’s a simple algorithm that you’ll never forget.

Differential Diagnosis * Mnemonic: HE DIES* Hypothyroidism* Elevated intracranial pressure (ICP)* Cushings reflex* Bradycardia* Increased blood pressure* Irregular breathing* Drugs* Beta blockers* Calcium channel blockers* Digoxin* Ischemia* Electrolytes* Especially potassium!!!* Sick Sinus Syndrome Approach to Bradycardia * Step 1: Get an EKG* Ischemia?* Heart block?* 1st degree = PR interval >200ms (5 small boxes)* 2nd degree type 1 = PR gradually prolongs until dropped beat* 2nd degree type 2 = Intermittent dropped beats* 3rd degree = None of the atrial beats result in a ventricular beat* Evidence of hyperkalemia?* Step 2: Determine if patient is SYMPTOMATIC* Hypotension* Chest Pain* Syncope* Lightheadedness* Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications* Step 3: If patient is having symptoms… Give atropine!* Typical dose is 0.5mg IV atropine* Step 4: If patient still having symptoms… Give epinephrine!* Step 5: If patient still having symptoms… Cardiac pacing!* If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology* Transcutaneous pacing* Sometimes difficult to get mechanical capture* Transvenous pacing* Place through the right internal jugular vein Additional Reading * How to Read an EKG (EM Clerkship)* Transcutaneous Pacing Procedure (EM Clerkship)

Anaphylaxis is total body chaos resulting from massive, inappropriate degranulation of mast cells when exposed to an antigen. When this happens, you have to remember airway and epi. It will save a life.

Airway and Epi! Airway and Epi! Airway and Epi! Introduction * Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen”* The antigen causes extensive mast cell and basophil cross-linking/activation* Common antigens* Foods* Drugs* Insect venoms Basic Approach * Step 1: Diagnose anaphylaxis* Consider anaphylaxis if the patient has TWO body systems involved* Dermatologic symptoms* Flushing* Rash* Urticaria* Pulmonary symptoms* Shortness of breath* Wheezing* Cardiovascular symptoms* Hypotension* Lightheadedness* Gastrointestinal symptoms* Nausea/Vomiting* Diarrhea* Step 2: Give epinepherine* A major pitfall in the treatment of anaphylaxis is delay of epinephrine!!!* Normal adult “EpiPen” contains 0.3mg epinephrine* Normal dosing of IM epinephrine is 0.01mg/kg* Step 3: Consider intubation* The second biggest pitfall in the treatment of anaphylaxis is delaying intubation until it’s extremely difficult to intubate!!!* Step 4: Give adjunct medications* H1 blocker* Diphenhydramine* H2 blocker* Ranitidine* Steroids* Prednisone, dexamethasone, etc* Step 5: Send the patient home with an EpiPen prescription* Education them on this* Articulate this part of the plan to your attending* Bonus* Refractory anaphylaxis* Beta-blockers? * Treat with glucagon Additional Reading * Round 10 – Allergic Reaction (EM Clerkship)* How to Use an EpiPen (YouTube)

IV fluids are something we deal with everyday in the emergency department. This podcast will teach you what you need to know about giving fluids.

IV fluids are something we deal with everyday in the emergency department. This podcast will teach you what you need to know about giving fluids.

There are 6 core apps that I’m currently using while running around the emergency department during my shifts, and we’ll cover the list in this episode. Also, we will soon be launching The EM Clerkship Pocket Guide which will replace the current, outdated, episode summaries. No specific date yet, but I already have the user interface designed and the content is now being written.  Stay tuned.

There are 6 core apps that I’m currently using while running around the emergency department during my shifts, and we’ll cover the list in this episode. Also, we will soon be launching The EM Clerkship Pocket Guide which will replace the current, outdated, episode summaries. No specific date yet, but I already have the user interface designed and the content is now being written.  Stay tuned.

One of the most difficult aspects of Emergency Medicine is shift work. Specifically, surviving overnights and the constant circadian chaos our body goes through by constantly rotating through morning, evening, and and overnight shifts. It happens to all of us, and in this episode I’m going to give you some personal strategies I’ve developed while in training.

O→ Episode Summary

EM doctors specifically look for two things every time they see an EKG. Ischemic changes (STEMI, ST depressions, inverted T waves), and dysrhythmias (bradycardia and tachycardias). In this episode, we cover the 5 categories of tachycardias and a basic approach to each one.

Basic Approach * Step 1: Is this SINUS tachycardia? * P before every QRS? * Treat the underlying condition* Step 2: Is this a NARROW and REGULAR rhythm?* SVT* Treat with vagal maneuvers or adenosine* Another new trend is treating with calcium channel blockers!! * ORTHOdromic Wolf Parkinson White* Treat with adenosine* Atrial flutter with fixed block* Treat with AV blockers (diltiazem)* Slows the heart rate* Step 3: Is this a NARROW and IRREGULAR tachycardia?* Almost always atrial fibrillation* Treat with AV blockers (diltiazem)* Other (less common) diagnoses* Atrial flutter with variable block* Multifocal atrial tachycardia* Step 4: Is this a WIDE and REGULAR tachycardia?* Assume ventricular tachycardia until proven otherwise* Treatment is immediate cardioversion if unstable* May try chemical cardioversion if stable* Procainamide* Amiodarone* Lidocaine* Other diagnoses* ANTIdromic Wolf Parkinson White* Narrow complex tachycardias PLUS aberrancy* Step 5: Is this a WIDE and IRREGULAR tachycardia?* Atrial fibrillation with bundle branch block* Extremely fast and bizarre in appearance? * Consider atrial fibrillation with Wolf Parkinson White Additional Reading * Calcium Channel Blockers for Stable SVT (ALiEM)* Atrial Fibrillation in WPW – Pearls and Pitfalls (County EM)