EM Clerkship

A→ Episode Summary

In this episode we will be discussing a laceration repair procedure. Don’t overcomplicate things. Keep it nice and simple. And you will be successful.

Step 1: Pain Control * Local anesthesia* Most common agent is lidocaine (frequently already in laceration repair kits)* Inject through wound edges (not through epidermis)* This decreases pain* Alternative is digital/regional nerve block Step 2: Irrigation * Laceration repair is not a sterile procedure* Copious irrigation is the best method to decrease chance of wound infection* Faucet/sink vs saline Step 3: Alternative Wound Closure Techniques * Dermabond/Tissue Adhesive* Works best on easily approximated wound edges and little tension* Commonly used in pediatrics and geriatrics* Staples* Sometimes leaves a poor cosmetic outcome* Commonly used for scalp wounds* Rapidly stops bleeding* Quickest and easiest closure method to perform Step 4: Choose a Suture Type * Absorbable (Gut, Monocryl) * Pros: Patient doesn’t need to return for removal* Cons: Loses tensile strength* Non-Absorbable (Prolene)* Pros: Good cosmetic outcomes, easy to see (bright blue)* Cons: Patient must have them removed Step 5: Repair the Wound * Gently approximate wound edges* You are not trying to “seal” the wound closed* Primary goal is to improve cosmetic outcome* Keep it simple* Simple interrupted sutures* Instrument tie Additional Reading * Laceration Evaluation (EM Clerkship)* Wound Closure for the Emergency Practitioner (LacerationRepair)

Laceration Repair is one of your core 3 procedures and is critical to master if you want to get a good SLOE. You have to very carefully consider if the wound should even be repaired at all! Otherwise it might get infected and the patient will have a bad outcome. However, if your presentation is strong, they will let you repair the wound, which will get you great scores on your SLOE.

Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!! To Close or Not To Close? * Closing a wound with sutures, etc = Healing by “primary intention”* INCREASES risk of infection but DECREASES scar* Leaving a wound open = Healing by “secondary intention”* DECREASES risk of infection but INCREASES scar Step 1: History * Does patient have comorbidities that increase risk of infection/poor healing?* Diabetes* Renal Failure* Obesity* Smoking* Immunosuppression* How long since injury happened?* Any concern for foreign body? Step 2: Identify Tetanus Status * Has patient EVER been immunized against tetanus?* Has it been >5 years since last tetanus shot? Step 3: Tetanus Prophylaxis * Give tetanus booster (Tdap) if >5 years since last tetanus shot* Give tetanus immunoglobulin (IG) if patient has never had tetanus immunization Step 4: Give Specific, Objective Description of Laceration * EXACT length* Must use a ruler* Most important BILLING categories* 2.5 cm or less* 2.6 cm to 7.5 cm* 7.6 cm to 12.5 cm* Description* Shape* Linear* Stellate* Flap* Depth* Superficial* Muscle* Bone* Neurovascular exam* Sensation* Motor* Cap refill Step 5: Rule Out Foreign Body * Consider X-Ray* Not all foreign bodies will show up on x-ray* Especially organic material, clothing, etc* Consider bedside ultrasound* (You are not expected to know how to do this, only to consider this) Additional Reading * Laceration Repair (EM Clerkship)* Wound Closure for the Emergency Practitioner (LacerationRepair)

During my clerkship, every time a patient came in with a sore throat, my attending would ask me, “Zack, what are the 4 life threatening causes of sore throat!?”  I could never remember the answer, but after the episode today you will. Also, extra special thanks to Dr. O’Connell and Elsevier for allowing us to use the book USMLE Step 2 Secrets during this episode. We will be incorporating these questions into future shows as well. I hope you find it useful.

You must know the FOUR emergent causes of sore throat! Step 1: Apply the Centor Criteria * Determines if patients is at risk for Group A strep (“strep throat”)* 4 Criteria* Fever* No cough* Tonsiller exudates* Lymphadenopathy* Interpretation* If patient has ALL of the criteria* Treat for strep throat* If patient has NONE of the criteria* Don’t even test for strep throat* If patient has SOME of the criteria* Consider testing for strep throat Step 2: Prescribe Antibiotics * B-lactams work best* Penicillin* Amoxicillin* If patient has allergy, consider alternative agent* Azithromycin* Clindamycin Step 3: Pain Control * NSAIDS* Steroids Step 4: Consider EBV (Epstein-Barr Virus) * Consider in patients not getting better on antibiotics* Examine for splenomegaly* If present, no contact sports Step 5: Consider the FOUR Emergent Causes of Sore Throat * Ludwigs angina* Airway emergency* Infection UNDER the tongue* Peritonsillar abscess (PTA)* Complication of bacterial pharyngitis* Causes “trismus” (difficulty opening mouth)* Frequently need to be drained* Retropharyngeal abscess* Airway emergency* Difficult to diagnose by exam alone* Infection is BEHIND airway* Seen on lateral neck xray* Epiglottitis* Airway Emergency* “The Triad”* Drooling* Dysphagia* Distress (respiratory)* Lateral neck xray shows “thumbprint sign” Additional Reading * Peds O- Oxygen, Airway, and Respiratory Disorders (EM Clerkship)* Airway Infectious Disease Emergencies (UNM)

In this EM Bolus we will be discussing the future of trauma resuscitation with Dr. Sam Tisherman, a professor of trauma surgery at the University of Maryland. He is currently conducting a very interesting study that has the potential to drastically change our approach to trauma forever. What if we cool trauma patients after they have died? What if we make them VERY cold, like those stories of cold water drownings who recover after being underwater for over an hour? What if we fill our dead trauma patients with icy saline and take their body to the OR so we have time to fix their injuries? Will it be too late? Today we take you to the fringe of medical discovery and address all of these questions.

I→ Episode Summary

One of the most common procedures we do in the emergency department is procedural sedation. One doctor does the primary procedure, one doctor pushes meds and watches airway. There are 5 common medications that I have seen used in the ED. We will cover these as well as the general approach today.

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship Common Scenarios * Cardioversion* Orthopedic reductions* Painful procedures Three Step Approach to Procedural Sedation * Step 1: Risk stratify the patient* Mallampati score (aka “How visible is the uvula?”)* Level 1: Can visualize THE WHOLE uvula* Level 2: Can visualize MOST of the uvula* Level 3: Can visualize SOME of the uvula* Level 4: Can NOT visualize the uvula* ASA (aka “How healthy are they?”)* Level 1: Healthy* Level 2: Mild illness* Hypertension* Hyperlipidemia* Anemia* Level 3: Major illness* Diabetes* Coronary disease* COPD* Chronic renal disease* Level 4: Extremely unhealthy* Dialysis patient* Severe heart failure* Chronically debilitated* Level 5: Dying* Patient needs operation to live* Intracranial hemorrhage with midline shift* Ruptured aortic aneurysm* Ruptured papillary muscle with cariogenic shock* Dissecting aortic aneurysm* Step 2: Informed consent* Patients sign a GENERAL CONSENT to treat when registering to the department* Many emergency scenarios require physician to operate with IMPLIED CONSENT* Many patients have an ADVANCED DIRECTIVE* In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required* Varies by hospital* Typically required for procedural sedation in stable patients* Step 3: Gather supplies* Nurse and nursing supplies* IV* Cardiac monitor* Respiratory therapy and respiratory supplies* Capnography* Bag-valve mask* Airway box Top 5 Procedural Sedation Medications * Midazolam (“Versed”) – 0.02 mg/kg IV* Reduces anxiety prior to procedure* Provides no analgesia* Fentanyl – 1 mcg/kg IV* Reduces pain* Useful for painful procedures* Incision and drainage* Simple reductions* Propofol – 0.5-1mg/kg IV* General anesthetic* Best given “low and slow”* Short acting* Causes respiratory depression and hypotension* Etomidate – 0.15 mg/kg IV* General anesthetic* Less hypotension than propofol* Can cause myoclonus* Ketamine – 1-2mg/kg IV* “Dissociative”* Provides both amnesia AND analgesia* Can cause emergence reactions* Can cause laryngospasm and secretions Additional Reading * Mallampati Score (Wikipedia)* ASA Physical Status Classification (Wikipedia)

Lets talk about oxygen. Hypoxia is bad, and we need to know how to help these patients. However, giving TOO much oxygen is also bad. In this episode we will review the basics of oxygen administration as well as review the current literature so you can impress your attendings when they try to pimp you.

Lets talk about oxygen. Hypoxia is bad, and we need to know how to help these patients. However, giving TOO much oxygen is also bad. In this episode we will review the basics of oxygen administration as well as review the current literature so you can impress your attendings when they try to pimp you.

Similar to patients with a headache, patients with back pain typically require very little testing. Rather, these encounters are focused entirely around a search for red flags. I LOVE these types of cases. These cases are straightforward, and you have the potential to sound REALLY smart in front of your attending if you remember the life threats and red flags during your presentation.

Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses * Aortic Dissection and Abdominal Aortic Aneurysm (AAA)* Age >50* Hypertension* “Ripping” or “Tearing” pain* Absent pulses in lower extremities* Spinal Infections* Fever* Immunocompromized* HIV* Diabetes mellitus* Transplant patients* Spinal cord compression (especially cauda equina)* Urinary retention* Consider obtaining post-void residual* Saddle anesthesia* Fecal incontinence/decreased rectal tone* Fracture* Recent trauma* Advanced age* Cancer* History of cancer* Night sweats* Weight loss Step 2: Testing Plan (If Patient Has Red Flags) * X-ray or CT scan if concerned for fracture* MRI if concerned for infection, cord compression, or cancer Step 3: Symptom Management * NSAIDS* Naproxen* Ibuprofen* “Muscle relaxants” * Cyclobenzaprine* Other agents* Opiates* Topical therapy* Lidocaine patches Step 4: Counseling * Remain active* Avoid heavy lifting* Red flags = immediate return to ED Additional Reading * Round 6 – Back Pain (EM Clerkship)* Back Pain Red Flags (WikEM)