EM Clerkship Zack Olson, MD and Michael Estephan, MD

You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen.







Initial Vitals:







HR: 101







BP: 138/85







Temp: 98.0F







RR: 20







O2: 99% (Room Air)







Critical Actions:









* Diagnose Retrobulbar Hematoma







* Diagnose Subdural Hematoma







* Reverse Anticoagulation







* Perform a Lateral Canthotomy Procedure







* Administer Tetanus Shot







* Elevate the Head of Bed

Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.  







The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags. 







Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’s paralysis.  







Management/treatment – thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (185/110 if treating, 220/120 if no treatment). 







Remember that time is brain, so move fast! 







AAEM tPA Infographic







AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.”







Initial Vitals:







HR: 51







BP: 201/98







Temp: 98.0F







RR: 18







O2: 99% (Room Air)







Critical Actions:









* Check a Blood Glucose







* Activate a Stroke Alert







* Assess Contraindications to tPA







* Consent for tPA







* Transfer via Air for Thrombectomy

* Common during the first year of life as well as during puberty







* Presents with nausea/vomiting, abdominal pain, and/or testicular pain







* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)







* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex







* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound







* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US







* Attempt manual detorsion if there will be a significant delay to surgery

You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting







Initial Vitals:







HR: 119







BP: 104/63







Temp: 98.0F







RR: 20







O2: 99% (Room Air)







Critical Actions:









* Finger Stick Blood Glucose







* Treat Patient’s Pain







* Diagnose Testicular Torsion







* Immediate Urology Consult







* Perform Manual Detorsion









References:







Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

Phase One: CNS









* Ataxia, Slurred Speech, Confusion, N/V, Seizures









Phase Two: Cardiopulmonary









* CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS









Phase Three: Renal









* Flank pain, Hematuria, Oliguria, Renal Failure









Diagnosis:









* HIGH INDEX OF SUSPICION







* Ethylene Glycol Serum Level







* Elevated Osmolar Gap







* Serial Anion Gap Measurements









Treatment:









* Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid







* Hemodialysis







* Consider Bicarb drip, pyridoxine, and thiamine

















Further Reading:







EMCrit Toxic Alcohols