EM Clerkship

Tank. Clogged Pipes. Broken Pipes. Pump. Introduction * “Tank”* Hypovolemic shock* Hemorrhagic shock* “Clogged Pipes”* Cardiac tamponade* Tension pneumothorax* Pulmonary embolism* “Broken Pipes”* Septic Shock* Neurogenic Shock* Anaphylactic Shock* “Pump”* Cardiogenic Shock Step 1: Fill the Tank * Establish an IV* IO line alternative in emergent situations Step 2: Consider Clogs * Cardiac tamponade* Diagnosis: Ultrasound* Treatment: Pericardiocentesis* Tension pneumothorax* Diagnosis: Clinical/Xray/Ultrasound* Treatment: Needle decompression and tube thoracostomy* Pulmonary embolism* Diagnosis: Clinical/CTA* Treatment: Thrombolytics Step 3: Squeeze the Pipes * Administer vasopressors* Most common: Norepinephrine* Alternatives: Epinephrine, Phenylepherine Step 4: Analyze the Pump * Get an EKG* Ischemia = Aspirin/Heparin/Cath lab* Dysrhythmia = Electricity Additional Reading * Airway Part 1 – Immediate Actions (EM Clerkship)* Breathing (EM Clerkship)* RUSH Exam (EMCrit)

Today is episode C, the final episode in our 3 part podcast series on the approach to a crashing patient. In previous episodes we covered AIRWAY: how the first thing we need to do is suction and move the posterior portion of the patient’s tongue. We covered BREATHING: how we need to fix hypoxia by increasing FiO2 and adding PEEP. And today we are covering CIRCULATION. With circulation, it all comes down to tank, clogged pipes, broken pipes, and pump. Which is a fancy way of saying… We fix all of the different types of SHOCK. So pay close attention, because the treatment of shock is a hugely important topic in Emergency Medicine. It is a topic that you need to master if you want to pass your shelf and do well on your SLOE.

Hypoxemia fixed by only TWO things: FiO2 and PEEP Step 1: Add FiO2 * If the patient is breathing…* Nasal cannula* Non-rebreather mask* If the patient is NOT breathing…* Bag-valve mask Step 2: Add PEEP * *Cannot be completed in 60 seconds, but equipment can be requested* If patient is breathing…* BiPAP* If the patient is NOT breathing…* Intubation Additional Reading * Ventilator Basics (EM Clerkship)* Airway Part 1 – Immediate Actions (EM Clerkship)* Circulation (EM Clerkship)

Today is episode B in a series about our approach to the crashing patient. As we discussed in the previous episode, at some point during your clerkship, you will have a patient that starts dying right in front of your eyes. And it will be very scary! In Emergency Medicine, we fall back onto the “A-B-Cs” whenever this happens. We fall back onto an algorithm that lets us take control of virtually any situation in less than 60 seconds. In this episode, we cover B-Breathing. In medical school, we learned that breathing equals both oxygenation and ventilation. However, between the two of these, oxygenation is BY FAR the most important in the acute setting. Hypoxia kills patients immediately, so you need to fix hypoxia immediately. As we will discuss in this episode, there are only two ways to do this. You either add FiO2, or you add PEEP.

“Airway” does not necessarily mean “Intubation” Introduction * In emergency medicine we are taught “A-B-Cs”* These are actions that can be accomplished in first 60 seconds of patient encounter* Intubation takes several minutes to accomplish* Intubating a crashing patient might even KILL them!* Resuscitate THEN intubate Step 1: Suction * Immediately suction if patient is…* Altered and vomiting* Gurgling Step 2: Move the Tongue * Bedside maneuvers* Head tilt* Chin lift* Jaw thrust* Adjunct equipment* Oropharyngeal airway* Nasopharyngeal airway Additional Reading * Airway Part 2 – BVM Adjuncts (EM Clerkship)* Airway Part 3 – Rapid Sequence Intubation (EM Clerkship)* Airway Part 4 – What to Do If Intubation Fails (EM Clerkship)* Laryngoscope As A Murder Weapon – Hemodynamic Kills (EMCrit)

During your clerkship, you will be encountering sick patients. This is obvious. However, I promise that at least one of these patients will catch you VERY off guard. It usually goes like this, you are walking into a room, ready to take a history from (what sounded like) a straight-forward patient. But as soon as you open that door… WHAM! You see an unconscious, hypoxic, hypotensive patient. Maybe they are simultaneously vomiting and pooping blood. Maybe they are limp, blue, and not breathing. Maybe they seize, fall on the floor, and smash their head. Your heart rate speeds up. A lump crawls into your throat. What do you do? Easy. You start with the A-B-Cs. In this episode, we cover A (Airway). And here is a hint, the algorithm does NOT start with intubation. Will you be able to intubate 5 minutes from now? Maybe. If the patient lives that long. But you need to act now. So what I plan on teaching you is an algorithm that allows you to take control of literally ANY situation in 60 seconds or less. I plan on giving you a FEAR algorithm. A plan for when soft, brown, mushy stool flies through the proverbial fan and sloshes all over your patient’s hemodynamic status.

Don’t forget to wear protective gear. Gown up! Initial Encounter * History* Anticoagulants* Easy bleeding/bruising* Lightheadedness* Exam* Pallor* Tachycardia/Hypotension Step 1: Put on Personal Protective Equipment * Gown* Gloves* Mask* Eye Protection Step 2: Clear Nose and Visualize Bleeding * Have patient blow out/remove any clot and look for source of bleed* Kiesselbachs plexus* “Anterior” epistaxis* Sphenopalatine artery* “Posterior” epistaxis* Most severe/dangerous form Step 3: Spray In Oxymetazoline (Afrin) * Hold pressure for 15 minutes after initial application Step 4: Cauterize With Silver Nitrate * Avoid bilateral cauterizations* Can cause septal perforation* Anesthetize as necessary* 4% lidocaine on gauze and leave in nose for 10 minutes prior to cauterization Step 5: Pack the Nose * Multiple commercial products available for this* The utility of antibiotic prophylaxis at this step is unclear* Patient goes home with packing in place Additional Reading * Epistaxis Management (EM:RAP)

If you listened to the introduction episode, you heard my story about the patient with a bleeding nose. I had NO IDEA what to do. It was embarrassing. And that specific situation is what inspired the creation of this episode. Nosebleeds can be scary! You will probably have a patient with this during your clerkship, and the approach requires a completely different mindset than when we just articulate the differential diagnosis for a Core 4 medical complaint. Epistaxis requires a plan with a series of interventions as opposed to labs and imaging, and it WILL throw you off balance if you aren’t prepared.

There are six cardiopulmonary causes of chest pain that you need to know. The SIX Causes * Cardiac* Acute coronary syndrome (ACS)* Pericarditis with tamponade* Pulmonary* Pneumonia* Pneumothorax* Vascular* Pulmonary embolism* Aortic dissection Step 1: Core Measures * Aspirin* EKG Step 2: Look for the “King” (Acute Coronary Syndrome) * Four high yield symptoms* Radiation to the RIGHT shoulder* Vomiting* Worsens with exertion* Diaphoresis Step 3: Look for the “Queen” (Pulmonary Embolism) * Wells score* PERC rule Step 4: Print a Previous Cath Report * Major bonus points with attending!* Other useful information* Previous echocardiograms* Previous stress tests* Previous CTAs for PE Step 5: Basic Testing Plan * If concerned for cardiac causes* Troponin* If concerned for pulmonary causes* Chest x-ray* If concerned for vascular causes* CTA of the chest Additional Reading * STEMI (EM Clerkship)* Pulmonary Embolism (EM Clerkship)

Patient presentations are the single most important skill to develop for your Emergency Medicine rotation. General Principles * Stay focused, thorough, and organized* Write out the basic 8-step presentation for reference The 8-Step Patient Presentation * Summary statement* Demographics* Risk factors/Past medical history* Chief complaint* History* OPQRST* Try to give at least 4 descriptors* This is for billing reasons* Pertinent positives/negatives* Give approximately 5 most pertinent symptoms* Vitals* Physical exam* Give approximately 3 MOST pertinent findings * Differential diagnosis* Briefly argue for/against* Include both most likely and most dangerous* Testing plan* Treatment plan* This is the most commonly forgotten step of presentation Additional Reading * Abdominal Pain Presentation – History (EM Clerkship)* Abdominal Pain Presentation – Exam, Plan, and Disposition (EM Clerkship)* Patient Presentations in Emergency Medicine (EMRA)

Today I would like to teach you about the biggest, awesomest, most stereotypical chief complaint that there is in all of Emergency Medicine: chest pain. This is a huge topic on your shelf exam, and you really need to have an in-depth understanding of it to do well on your clerkship. HOWEVER, you have to start with the basic approach, and that is what this episode covers.  

We are going to discuss a very important topic today. How do you give a good patient presentation to your attending?  This is the single most important skill you need to develop on your clerkship. Your presentations need to be FOCUSED, THOROUGH, and ORGANIZED. Don’t be nervous. There is a gold-standard presentation format that was published for all EM students by the Society for Academic Emergency Medicine. This is the format I highly recommend and will teach you in this episode. You just need to remember the 8 steps…

To Do Well On WRITTEN Exam * Study the “Core 4” body systems* Neurology* Headache* Strokes* Meningitis* Cardiology* Chest pain* ACS* EKG interpretation* Pulmonary* Shortness of breath* PE* GI* Abdominal pain* Nausea/vomiting* Appendicitis To Do Well In the DEPARTMENT * Study the “other stuff”* Epistaxis* Foley catheter issues* Rectal bleeding* Laceration repair* Rashes* Geriatric falls* Suicidal ideation* The list goes on and on… Additional Reading * Emergency Medicine Advanced Clinical Subject Exam Content Breakdown (NBME Website)

Today, I am very excited to announce that The Emergency Medicine Clerkship Podcast (and its affiliate website) are officially LAUNCHED!!! Over the next several weeks, I plan on streamlining and simplifying the technical side of my publishing process. I anticipate that I will finish this soon, and that the podcast itself will be posting episodes at full speed early this summer. I hope you enjoy the content. Please let me know if you have any feedback. I do plan on growing and adapting as I gain experience. With that said, if you have any constructive criticism or encouraging feedback, I would love to hear from you. ~~~~ Email: zack@emclerkship.com Twitter: @emclerkship