EM Clerkship

Get your attending! Step 1: Obtain Last Known Well * Stroke treatments including tPA and thrombectomy both require last known well* <3-4.5 hours for tPA* <24 hours mechanical thrombectomy Step 2: Finger Stick Blood Glucose * Hypoglycemia is classic mimic of CVA* Results can be obtained immediately Step 3: STAT Head CT Without Contrast * Poor sensitivity for ischemic stroke* Primary use is identification of hemorrhagic stroke* Required prior to administration of tPA! Step 4: Perform NIHSS * Use calculator (MDCalc) Step 5: Give tPA (If No Contraindications) * Follow department protocol and contraindications* Frequently being updated Additional Reading * tPA Basics (EM Clerkship)* 2013 AHA Stroke Guidelines (AHA)* NIH Stroke Scale/Score (MDCalc)

Today we are talking about the critical diagnosis of stroke. Specifically, we need to discuss what to do during ischemic strokes. And the most important thing to remember is that TIME IS BRAIN. If you ever suspect that your patient is having a stroke, you need to get your attending immediately. After that, stroke protocols follow a very regimented pattern that we will be overviewing today.

You need an organized, anatomical approach. Step 1: Consider Differential Diagnosis * Upper airway* Angioedema* Foreign body* Abscess* Lower airway* COPD* Asthma* Alveoli* Pneumonia* Pulmonary edema* Blood* Anemia* Acidosis* DKA* Sepsis (lactic acid)* Toxins (salicylic acid)* Blood vessels* Pulmonary embolism* Aortic dissection* Heart* Myocardial infarction* Acute heart failure* Cardiac tamponade Step 2: Examine Anatomically * Upper airway* Stridor* Voice changes* Lower airway* Wheezing* Alveoli* Crackles* Blood* Pallor* Heart* Dysrhythmia* Jugular vein distension (JVD)* Edema Step 3: Testing Plan * Common tests* Chest x-ray* EKG* CBC* Electrolytes* Less common tests* Blood gas* Troponin* BNP* D-Dimer Step 4: Calculate Wells Score and PERC * Wells Score (MDCalc)* PERC Rule (MDCalc) Additional Reading * Pulmonary Embolism (EM Clerkship)* Shortness of Breath (SAEM)

The most important thing to remember about shortness of breath is that you need to keep your thoughts and actions focused by using an organized approach. I recommend thinking anatomically. The differential diagnosis for this complaint is huge, and it’s really easy to make mistakes if you don’t develop a system. Also, you MUST calculate a Well’s Score and PERC criteria for your patients with shortness of breath. This is how you determine what tests to pick when you evaluate for pulmonary embolism. Learn this now, because your attendings will quiz you on this frequently during your clerkships.

6 EKG Findings. 6 Risk Factors. 6 Mimics. Step 1: Get an EKG * This is the only “required” test for a patient with syncope* Other common tests* CBC* Evaluate for anemia* hCG* If patient might be pregnant Step 2: Look For 6 High Risk EKG Patterns * Mnemonic: QT-BRIDE* QT prolongation* Especially QTc >500* Brugada pattern* Right heart strain* Tachycardia* S1Q3T3* Inverted T waves precordial leads* Ischemic changes* ST segment elevation/depression* T wave inversion* Delta waves* Seen in Wolf-Parkinson White (WPW)* Epsilon waves* Seen in arrhythmogenic right ventricular dysplasia (ARVD) Step 3: Ask the 6 High Risk Historical Questions * Mnemonic: CHESS +1* Cardiac history* CHF* Structural heart disease* Hematocrit <30%* “Elderly”* Shortness of Breath* Systolic BP <90* (+1) Family history of sudden cardiac death Step 4: Consider 6 Deadly Syncope Mimics * 15% of the following diseases reportedly present as “syncope”* AKA “Rule of 15s”* Subarachnoid hemorrhage* Myocardial infarction* Pulmonary embolism* Aortic dissection* Abdominal aortic aneurysm* Perforated GI* Ulcers* Ectopics Additional Reading * QT Intervals (LITFL)* Brugada Syndrome (LITFL)* Right Heart Strain (LITFL)* Delta Wave (LITFL)* Epsilon Wave (LITFL)

The key to understanding syncope is understanding who is at high risk and who can go home. Over the years, numerous different studies have been done looking at this topic. The easy way to remember the approach to syncope is 6-6-6. There are 6 high risk EKG findings. 6 important risk factors, and 6 deadly syncope mimics (aka the “Rule of 15s”). Patients with these are at high risk for sudden death and typically need to be admitted, even if they sound like a “simple” case of “orthostatic” syncope.

Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone. Oral Acetaminophen (Tylenol) * Give every 4-6 hours* Regular strength – 325mg* Extra strength – 500mg* Maximum Daily Dose – 3000mg Oral Ibuprofen (Advil) * NSAID* Give every 4-6 hours* Regular strength – 200mg* Therapeutic Ceiling – 400mg Oral Hydrocodone-Acetaminophen (Vicodin, Norco) * Give ever 4-6 hours* Common doses – 5-325mg, 7.5-325mg, and 10-325mg IV/IM Ketorolac (Toradol) * NSAID* Common dosing – 15-30mg* Therapeutic ceiling – 10mg IV/IM morphine * Classic dose (0.1mg/kg)* This would be 7-10mg in adults!* More COMMON dosing is 4mg* Repeat as needed IV/IM Hydromorphone (Dilaudid) * COMMON dosing – 0.5-1mg * This drug is notorious for bringing you to peer-review/MM conference* Be careful! Contraindications to NSAIDS * Pregnant patients* Elderly patients* Renal disease patients* Cardiac patients* GI/ulcer patients Side Effects of Opiates * Sedation* No driving* Do not mix with alcohol* Do not mix with other sedatives* Constipation* Opiate dependency/addiction Additional Reading * Pain Management In the Emergency Department: A Review (PubMed)* Myths in EM: The Anti-Inflammatory Properties of NSAIDS (ACEP Now)

It’s definitely not the most exciting topic in emergency medicine, but it’s easily one of the most important. Every single shift you will be required to manage a patient’s pain. In this episode, we will be covering the 6 major pain medicines that you need to know for your clerkship- including doses. Those medicines are PO acetaminophen, PO ibuprofen, PO hydrocodone-acetaminophen, IV/IM ketorolac, IV/IM morphine, and IV/IM hydromorphone.

You have 90 minutes to restore blood flow. Step 1: Obtain EKG and Call STEMI Alert * This activates ED resources as well as cath lab, interventional cardiology, etc Step 2: Stop the Platelets * Dual anti-platelet therapy* Aspirin 325mg chewed (or PR)* Plavix 600mg (not usually given in ED)* Complicates management if patient needs CABG Step 3: Stop the Coagulation Cascade * Heparin 60 units/kg (MAX 4000 units) Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now * If you DON’T have cath lab* Option 1: 30 minutes to give thrombolytics* Option 2: 120 minutes to get them to a different hospital with cath lab Sgarbossa Criteria * Left bundle branch block (LBBB)* PLUS* Concordant ST elevation (>1mm) in leads with positive QRS* OR* Concordant ST depression (>1mm) in leads with negative QRS* Typically V1-V3* OR* Severely discordant ST elevation (>5mm) in leads with negative QRS “MONA” * Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain* Oxygen has been shown to worsen outcomes if given indiscriminately* Not ideal to be giving supplemental O2 when SaO2 is 100%* Nitroglycerine* Nitroglycerine 0.4 mg SL q5min* OR* Nitroglycerin 10mcg/min drip (will need to be titrated UP)* For comparison… * 0.4 mg SL nitroglycerine releases approximately 80mcg/min* Contraindications* Inferior/Right heart infarction* Patients usually preload dependent* Nitro drops preload* Sildenafil (Viagra)* Can cause sudden/severe drop in blood pressure* Hypotension Additional Reading * Round 3 – Chest Pain (EM Clerkship)* The Death of MONA in ACS: Part 1 – Morphine (REBEL EM)* The Death of MONA in ACS: Part 2 – Oxygen (REBEL EM)* The Death of MONA in ACS: Part 3 – Nitroglycerine (REBEL EM)* The Death of MONA in ACS: Part 4 – Aspirin (REBEL EM)

We get hundreds of EKGs every day looking for ST elevation myocardial infarction. And when you finally see it, you have to know what to do. In 2013, the American Heart Association updated their STEMI management guidelines, and that is what we are learning about today. Make sure you understand the material in this episode, because you will only have 90 minutes to run through the algorithm when this EKG gets handed to you during your clerkship.

Mnemonic: AEIOU-TIPS Step 1: Evaluate the Airway * General principles* “If they can’t speak, they can’t control their airway”* “If GCS is <8, intubate”* In the real world, it’s a clinical judgement call* Postictal patients?* Intoxicated patients? Step 2: Point of Care Labs * Finger stick blood glucose* EKG* Dysrhythmia?* Ischemia? * Abnormal intervals?* Pregnancy test Step 3: Consider Naloxone * Classic dose – 0.4 to 2mg IV/IM* Many start with lower doses to lower chance of severe withdrawal* Can also be given intranasal (2-4mg) Step 4: Consider Differential Diagnosis * Mnemonic: AEIOU-TIPS* *Note: You don’t need to order all of these tests on every patient with altered mental status!!!* Alcohol* Blood alcohol level* Thiamine* Endocrine/Electrolytes* Includes* Hypoglycemia* Hepatic encephalopathy* Myxedema coma* Hyponatremia* Obtain* Electrolyte panel* Hepatic panel* TSH* Ammonia* Ischemia (Cardiac)* EKG* Troponin* Opiates* Uremia* Trauma* CT head without contrast* CT cervical spine without contrast* Infection* Urinalysis* Chest x-ray* Lumbar puncture* CBC* Lactic acid* Blood cultures* Poisoning* Stroke* CT head without contrast* Neuro exam for focal deficits Additional Reading * Round 1 – Altered Mental Status (EM Clerkship)* Approach to Altered Mental Status (SAEM)

AEIOU TIPS. This is easily one of the most important mnemonics of emergency medicine because it represents the differential diagnosis for altered mental status. Obviously, this is not meant to be an exhaustive list, but it certainly provides a good framework to start with. Even as a resident, I still will write out this differential when I’m placing orders on a complicated, altered mental status patient. It keeps me from  missing something obvious, and it’s crucial for your training as a medical student.

Poison Control Hotline: 1-800-222-1222 Step 1: Evaluate the Airway * General principles* “If they can’t speak, they can’t control their airway”* “If GCS is <8, intubate”* In the real world, it’s a clinical judgement call Step 2: Toxicology History * What did they take? * How much did they take?* Why did they take it?* When did they take it? Step 3: Toxicology Exam * Vital signs* Pupils* Skin Step 4: Medication List * Make note of all bottles with patient* Make EXTRA note if any pills seem to be missing* Bonus points if you bring your attending a med list Step 5: Common Toxicology Tests * Assessing for damage* Electrolytes* Liver function test* EKG* Pregnancy* Assessing for co-ingestion* Serum acetaminophen* Serum salicylate* Serum alcohol* Urine drug screen The “Big 5” Toxidromes * Anticholinergic* Increased vitals* Big pupils* Dry skin* Treatment – Physostigmine (rarely given)* Cholinergic* Decreased vitals* Small pupils* Moist skin* Treatment – Atropine* Opioid* Decreased vitals* Small pupils* Dry skin* Treatment – Naloxone* Sedative/Hypnotic* Decreased vitals* Normal pupils* Dry skin* Treatment – Flumazenil (rarely given)* Sympathomimetics* Increased vitals* Big pupils* Moist skin* Treatment – Benzodiazepines Additional Reading * NBME Shelf Review – Ophthalmology and Toxicology (EM Clerkship)* Toxidromes (Admin EM)

Welcome to clerkship season! Over the next few months we will be going through the biggest, hugest, most important topics in emergency medicine. And today, we will be starting off with toxicology. After covering the general approach to a toxicology case, we will also be overviewing the “Big 5” toxidromes of emergency medicine: anticholinergic, cholinergic, opioid, sedative, and sympathomimetic.  And the one thing I want you to remember is… Vitals, Pupils, Skin.

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