EM Clerkship

Basic Categories * Upper GI Bleed* Symptoms* Coffee ground emesis* Melena* Black tarry stool* Digested blood* Common causes* Peptic ulcer disease* Varices* Lower GI Bleed* Symptoms* Bright red blood per rectum (BRBPR)* Maroon/bloody stools* Common causes* Diverticulosis* Colon cancer* Angiodysplasia* AV Malformations History * Ask about risk factors for upper GI bleed* Peptic ulcer risk factors* NSAIDS* Steroids* History of ulcers* Varices risk factors* Heavy alcohol use* History of liver disease Exam * Abdominal exam* Usually minimal tenderness* If patient has severe tenderness/peritoneal signs consider alternative diagnosis* Perforation* Rectal exam* Identify stool color* Guaiac testing* Hemorrhoids* Are they bleeding* Anal fissures Testing Plan * CBC* Looking for anemia* Electrolytes* Elevated BUN* Commonly present in upper GI bleed* Coagulation panel* Type and screen Treatment Plan * Proton pump inhibitor (upper GI bleeds)* “-prazoles” such as pantoprazole* Octreotide/Antibiotics if varies suspected Disposition * Most upper GI bleeds get admitted* Lower GI bleeds depend on risk factors* Comorbidities* Clinical findings/stability* Vital signs* Hemoglobin/Hematocrit Additional Reading * GI Bleed Emergencies (EM Cases)* GI Bleed (emDOCs)

Type and Screen? Type and Rh? Type and Cross? Emergency Release? I never received a talk in medical school about how to give blood to patients. So when I started residency, I was surprised and confused by how many options I could select when placing orders for blood! This episode covers the basic terminology you need to know so that you can sound smart on your clerkship.

Type and Rh * What information it provides* Blood type (A, B, AB, O)* Rh status (Rh positive or negative)* When to order* Pregnant patients with vaginal bleeding* Need if Rh negative (prevents hemolytic disease of newborn) Type and Screen * What information it provides* Blood type (A, B, AB, O)* Rh status (Rh positive or negative)* PLUS* Antibody status* Looks for all possible antibodies that may cause transfusion reaction* When to order* When the patient needs/might need a blood transfusion* Test typically takes 30 minutes to run… ORDER EARLY! Type and Cross * What information it provides* Blood type (A, B, AB, O)* Rh status (Rh positive or negative)* Antibody status* PLUS* Specifically tests against patients blood* This blood is then set aside and officially “matched”* Acts as a final safety step before transfusion Emergency Release Blood * Universal donor is O negative* Order if you can’t wait 30 minutes because the patient is dying Additional Reading * Straight Talk with an ER Doc with Scott Weingart (BBGuy Podcast)

This week we are having the talk… The PE talk. It will be one of the most high yield episodes we will ever have on the show. Before listening, please look up the Well’s Score and the PERC rule for reference, and email me with any questions. ~~~~~ Kline, J. A., & Kabrhel, C. (2017). Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. Journal of Emergency Medicine, 49(1), 104–117. https://doi.org/10.1016/j.jemermed.2014.12.041

Introduction Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries Can cause pulmonary infarction (which mimics pneumonia on chest x-ray) Basic Approach to the Diagnosis of PE * Step 1: Consider PE in any patient with signs or symptoms consistent with the disease* Common signs/symptoms* Shortness of breath* Chest pain* Syncope* Tachycardia* Hypoxemia* Hypotension* Step 2: Do not do additional testing for PE in patients with a CLEAR alternative diagnosis* Common alternative diagnoses* COPD exacerbation* Acute coronary syndrome* Pneumonia* Keep in mind that these diagnoses are also the most frequent misdiagnoses in cases of missed PE!!! Be careful.* Step 3: Calculate Wells Score and PERC criteria* Wells score* (I personally use Wells’ Criteria for PE by MDCalc)* Define patient as either “Low” “Medium” or “High” risk* PERC criteria* I use the PERC Rule for PE by MDCalc for this as well* If patient is both low risk wells and meets all PERC criteria…* No additional testing needed!!!* Step 4: Get a D-Dimer* IF… * Low risk Wells but fails PERC criteria* Medium risk Wells score* Step 5: Get a CTA* IF…* Wells score is high* Elevated d-dimer* (Update: it is now established that you can safely use AGE ADJUSTED D-DIMER)* ACEP’s clinical policy supporting this can be found HERE Final Thoughts * Bilateral lower extremity ultrasounds not sensitive enough to rule out PE* The classic EKG finding is S1Q3T3 Additional Reading * Emergency Evaluation of PE: Diagnosis (Journal of Emergency Medicine)* Wells Criteria (MDCalc)* PERC Criteria (MDCalc)* Age Adjusted D-Dimer Policy (ACEP)

This week we are going to talk about the 3 types of hemoptysis, the differential diagnosis, and a basic approach.

There are 3 main “categories” of hemoptysis… Mild, “Streaky” Hemoptysis * Most common diagnosis* Bronchitis* Testing plan* Chest xray* Rules out alternative causes of hemoptysis* Pneumonia* Cancer* Pulmonary Embolism* Vasculitis Scary but Stable Hemoptysis * Patient is coughing up frank blood* Testing plan* CTA of the chest* CBC* PTT/PT/INR* Electrolytes* Need renal function if giving IV contrast Oh-My-God-That’s-A-Lot-Of-Blood!!! * Intubate the patient* Consult cardiothoracic surgery/interventional radiology Additional Reading * Hemoptysis: An EM Primer (emDOCs)

Aspirin overdoses are the great mimicker, and the queen of both intentional and unintentional overdoses. This week we will discuss a basic approach to this critical diagnosis.  

Salicylate toxicity is the great toxicologic mimicker!!! Step 1: When to Suspect Salicylate Overdose * Signs of CNS stimulation* Tachypnea* Hyperthermia* Altered mental status* Signs of GI irritation* Nausea/Vomiting* Abdominal pain* Common “mimicker”* Sepsis* Acute abdomen Step 2: Testing Plan * Electrolyte panel* Anion gap metabolic acidosis* Sodium – Chloride – Bicarb* Normal anion gap (AG) is <10* Caused by salicylic acid and lactic acid* Blood gas* Mixed respiratory ALKALOSIS and metabolic ACIDOSIS Step 3: Obtain Serum Salicylate Level Step 4: Treatment Plan * Mild salicylate toxicity* Alkalinize urine with sodium bicarbonate (NaHCO3) drip* Severe salicylate toxicity* Dialysis Additional Reading * Salicylate Poisoning (LITFL)

The king of all overdoses is acetaminophen. In this episode we will discuss an approach to this overdose with an emphasis on the life-saving antidote, N-Acetylcysteine (NAC).

Acetaminophen is the most important overdose in toxicology Step 1: Check a Serum Acetaminophen Level * Common situations where testing is ordered* Suicidal ideation* Severe depression* Overdose Step 2: Consult the Rumack-Matthew nomogram * Only works for acute/single ingestions of acetaminophen* Loses reliability if patient is on drugs that affect bowel motility* If the time of ingestion is KNOWN* Measure acetaminophen level 4 hours post-ingestion* Plot on nomogram and treat if above line* If time of ingestion is UNKNOWN* Determine earliest possible time of ingestion* Plot on nomogram and treat if above line Step 3: Order hepatic labs (LFTs) * AST* ALT* Alk Phos* PTT/PT/INR Step 4: Identify Phase of Toxicity * Phase 1/Day 1* High acetaminophen levels* Normal LFTs* Minimal symptoms* Phase 2/Day 2* Acetaminophen level starts decreasing* LFTs level starts increasing* Mild GI symptoms develop* Abdominal pain* Nausea/vomiting* Phase 3/Day 3* Acetaminophen levels are normalized* LFTs are peaking* Phase 4* Recovery Step 5: Give N-Acetylcysteine (NAC) * If patient meets criteria on Rumack-Matthew nomogram* If patient is in phase 1, 2, or 3 Additional Reading * Acetaminophen Overdose and NAC Dosing (MDCalc)

This special episode is dedicated to Tyler who wants to know more about the process for getting into medical school. It’s been several years since I’ve done this myself, and alot has changed over the years. But some advice is timeless, and so this week we will cover the basics that you will need to understand before applying.

T→ Episode Summary

This week we will discuss some Emergency Medicine 101. This is my personal approach to the initial management of crashing patients. Not only does this algorithm work well in real life, it also works well in sim, and during verbal cases with my attendings. Listen to the old ABC episodes if you want to go more in depth.

This week we will discuss some Emergency Medicine 101. This is my personal approach to the initial management of crashing patients. Not only does this algorithm work well in real life, it also works well in sim, and during verbal cases with my attendings. Listen to the old ABC episodes if you want to go more in depth.