EM Clerkship

On occasion, seizures won’t stop, or a seizure lasts longer then 5 minutes. Unlike a simple, single, resolved seizure, status epilepticus is an emergency. In these scenarios, we add to the descriptive and diagnostic workup discussed last week, and move on to a focused treatment algorithm to stop the seizure as soon as possible.

Introduction * Simple seizure* Seizure ends in <5 minutes AND* Patient wakes up before next seizure* No meds required* Status epilepticus* Seizure lasts >5 minutes OR* Patient has a 2nd seizure before waking up from 1st* Initiate status epilepticus pathway Approach to Status Epilepticus * Step 1: Give a benzodiazepine* Lorazepam (IV)* Diazepam (IV or PR)* Midazolam (IV or IM)* Step 2: Give an anti epileptic* Levetiracetam (Keppra)* Fosphenytoin* Valproic Acid* Step 3: Continue attempting agents for 30 minutes* If seizure continues, you must move onto step 4… * Step 4: Sedate and intubate the patient* Propofol* Phenobarbital* Step 5: Start patient on continuous EEG* Detects non-convulsive status epilepticus* Usually started once patient is in ICU Additional Reading * Round 9 – Seizure (EM Clerkship)* Emergency Management of Status Epilepticus (EM Cases)

One of the most common neurologic complaints we encounter in the Emergency Department is seizure. Typically, a patient with epilepsy will have a breakthrough seizure, or somebody will try some drugs and get a seizure, or the seizure will be the first symptom of a dangerous medical condition. Regardless, 911 will almost always get called if the seizure is witnessed, and by the time the patient gets to you, the seizure is almost completely resolved or they are stable and post-ictal. It is our job to sort through these cases.

Basic Approach * Step 1: Describe the seizure* Did patient have an aura? * Was there loss of consciousness?* What did the movements look like?* Did they have postictal phase? * Did they have a trauma as well?* Step 2: Ask about TIME (mnemonic)* Tongue biting* Usually occurs on the lateral sides of tongue* Incontinence* Medication changes/adjustments* Ethanol use* Step 3: Do a FULL neurologic examination* Mental Status* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Reflexes* Gait* Step 4: Testing plan* Glucose* Pregnancy Test* CBC* Electrolyte panel* Urine drug screen* Drug levels of anti-epileptic agents* Step 5: Simple seizures (<5 minutes) do not require immediate treatment* Roll them on side* Suction Additional Reading * Approach to Status Epilepticus (EM Clerkship)

You will probably witness a few cardiac arrest cases during your clerkship. Sometimes these happen in the hospital, but usually these patient’s will be brought into the ED, CPR in progress, by EMS. Just like in trauma, we follow a very basic, logical algorithm when we resuscitate these patients, and this algorithm is called ACLS.

Hard, fast, unrelenting chest compressions are the core of ACLS!!! Step 1: Check the Patient’s Pulse * If the patient does not have a pulse, start CPR* Hard, fast, unrelenting compressions* Intubated patients* Continuous Compressions* Non-intubated adults* 30 compressions then 2 breaths… Repeat* Non-intubated pediatrics* 15 compressions then 2 breaths… Repeat Step 2: Determine if the Rhythm is Shockable or Non-shockable * Shockable rhythms* Ventricular Fibrillation (VF)* Ventricular Tachycardia (VT)* Non-shockable rhythms* Pulseless electrical activity (PEA)* Asystole Step 3: Start a Timer For 2 Minutes * Do a rhythm/pulse check every 2 minutes Step 4: Is the Patient in a Shockable Rhythm? * Repeat/coordinate shocks with every 2-minute pulse check* Give 1mg IV/IO epinephrine every 3-5 minutes* Give amiodarone* 300mg with first dose* 150mg with a repeat dose Step 5: Is the Patient in a Non-Shockable Rhythm? * Give epinephrine every 4 minutes (every other cycle) Quick Facts * Shockable rhythms (VT/VF) have best prognosis* Frequently related to myocardial infarction* Asystole has the worst prognosis* PEA has mixed prognosis (depends on diagnosis)* Two types (wide and narrow)* “Wide” PEA frequently caused by metabolic abnormalities* Consider bicarb and calcium chloride* “Narrow” PEA frequently caused by shock state* Perform bedside ultrasound in attempt to determine cause* “The H’s and T’s”* Hypoxemia* Hypovolemia* Hydrogen Ions* Hyper/hypokalemia* Tension pneumothorax* Tamponade* Toxins* Thrombosis (MI/PE) Additional Reading * When to Stop CPR (EM Clerkship)

It is really important to use the correct terminology when presenting a patient with right upper quadrant abdominal pain to your attending. If you want a good score on your SLOE, your differential diagnosis has to contain more than just “cholecystitis”. We will cover a basic approach today with a focus on the terminology to use in your differential diagnosis.

There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain. Cholelithiasis and Biliary Colic * Cholelithiasis = Gallstones in the gallbladder* Frequently seen on CT scan or RUQ ultrasound* Present in 15% of the population* Biliary colic = Intermittent episodes of pain if stone passes* Classically colicky/crampy/spasmy pain in RUQ* Frequently radiates to right shoulder/flank* Pain is intermittent and resolves after a few hours* Patients need pain control and outpatient follow up with general surgery Cholecystitis (Inflammation of the Gallbladder) * Caused by obstruction of the cystic duct* Increased pressure in the gallbladder results in ischemia/inflammation* Diagnosis* RUQ Ultrasound* Gallbladder wall thickening* Pericholecystic fluid* Cholelithiasis* CT of the abdomen and pelvis also has decent sensitivity/specificity* Admit for cholecystectomy Choledocolithiasis (Common Bile Duct Obstruction) * Terminology* Cholecystitis = Stone in CYSTIC DUCT* Choledocolithiasis = Stone in COMMON BILE DUCT* Symptoms similar to cholecystitis* Testing* LFTs will be elevated* Results from blockage of bile outflow from liver* RUQ Ultrasound* Shows dilation of the common bile duct* Treatment* GI Consult* Endoscopic Retrograde Cholangiopancreatography (ERCP) Cholangitis (Infection of Bile Duct/Liver) * Common complication of choledocolithiasis* Charcots triad* RUQ pain* Fever* Jaundice* Reynolds pentad* RUQ pain* Fever* Jaundice* Altered mental status* Shock/hypotension* Treatment* Fluids* IV antibiotics* ERCP Gallstone Pancreatitis * Gallstone obstructs PANCREATIC DUCT* Testing* Lipase will be elevated* LFTs will be elevated* RUQ will show dilation of the CBD* Treatment* Fluids* Pain medicine* ERCP Additional Reading * Biliary Diseases and Pancreatitis (EM Clerkship)* Biliary Anatomy (TeachMeAnatomy)

Not all patients with chest pain are having a STEMI, or massive PE, or aortic dissection. In fact, most patients with chest pain will have a set of normal labs, feel better, and we then have to decide what to do next. Admit or Discharge? What if we send this low risk patient, complaining of chest pain, home? What if they get home and die of a massive MI, and you had seen them the day before for chest pain? That’s why this is a huge topic that your attendings will want you to understand. In this episode we will talk low risk chest pain, and specifically, the HEART score.

Not all patients with chest pain are having a STEMI, or massive PE, or aortic dissection. In fact, most patients with chest pain will have a set of normal labs, feel better, and we then have to decide what to do next. Admit or Discharge? What if we send this low risk patient, complaining of chest pain, home? What if they get home and die of a massive MI, and you had seen them the day before for chest pain? That’s why this is a huge topic that your attendings will want you to understand. In this episode we will talk low risk chest pain, and specifically, the HEART score.

When most people think about trauma, they think about gunshot wounds. However, not all gunshots come in as a multi system trauma alert. Not all patients have been shot in the chest or belly and need to be rushed to the OR. Much more commonly, we are dealing with gunshot wounds to the extremities. In this episode, we will cover the basic approach to the extremity gunshot wound.

Evaluate 5 important structures when evaluating gunshot wounds in an extremity. Blood Vessel Injuries * 3 Categories* Hard-Signers* Mnemonic: HARD Bruit* Hypotension* Arterial/pulsatile bleeding* Rapidly expanding hematoma* Deficits (pulse)* Audible BRUIT/thrill* These patients likely need OR* Soft-Signers* Significant vascular oozing/bleeding* Large hematoma* These patients need to be screened with ABI (ankle brachial index)* ABI <0.9 or asymmetry between extremities is concerning for vascular injury* If abnormal, obtain a CTA* No-Signers* No additional management for vascular injury required Nerve Injuries * Relatively rare* Document neuro exam in the extremity* Consult if abnormal Bone Injuries * Relatively common* Diagnosed by x-ray* Consult orthopedics for fracture Soft Tissue Injury * Be sure to count/document number of holes* Typically do not need laceration repair unless cosmetic area* Don’t miss compartment syndrome* Mnemonic: “P’s”* Pain out of Proportion* Pain with Passive range of motion* Paresthesias* Pallor* Paralysis* Poikilothermia The Bullet: What To Do With It? * The bullet is almost never removed, unless…* Very superficial/cosmetic and easy to remove* In a joint Additional Reading * NBME Shelf Review Part 2- Trauma (EM Clerkship)

COPD and asthma exacerbations are two of the most common pulmonary diseases we encounter in Emergency Medicine, and the severity of these attacks can vary from mild and basic to severe. It’s a clinical diagnosis, but there are lots of treatments to consider. Don’t be overwhelmed, we will cover a basic approach today.

5 core treatments and 5 MORE treatments 5 Core Treatments * Albuterol* Beta agonist* Bronchodilator* Core treatment for asthma* Ipratropium* Anti-muscarinic* Relax muscles around the airways* Works synergistically with albuterol* Steroids* Decrease inflammation in the airways* Prednisone (PO)* Methylprednisone (IV)* BiPAP (COPD)* Decreases work of breathing* Decreases rates of intubation* Decreases mortality* Antibiotics (COPD)* Infection common cause of inflammation 5 More Treatments * Magnesium sulfate* Ketamine* Epinephrine (systemic beta agonist)* Heliox* LAST RESORT – Intubation* Decrease rate and volume* Increase expiratory time and inspiratory flow Additional Reading * Antibiotics in COPD (AAFP)* The Crashing Asthmatic (REBEL EM)

One of the most dangerous complaints in all of Emergency Medicine is the GI Bleed. Especially upper GI bleeds when patients are complaining of coffee ground emesis or black sticky poop. This week we will discuss the overall approach to anybody who comes in with a GI bleed.