EM Clerkship Zack Olson, MD and Michael Estephan, MD
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- Health & Fitness
The purpose of this podcast is to help medical students crush their emergency medicine clerkship and get top 1/3 on their SLOE. The content is organized in an approach to format and covers different chief complaints, critical diagnoses, and skills important for your clerkship.
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Ischemic Stroke (Deep Dive MW R20)
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” -
Round 20 (MW) Stroke Symptoms
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 -
Testicular Torsion (Deep Dive MW R19)
* 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 -
Round 19 (MW) Tummy Ache in Child with Diabetes
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. -
Ethylene Glycol (Deep Dive MW R18)
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 -
Round 18 (MW) Drunk Man Wants Pizza
You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again
Initial Vitals:
HR: 116
BP: 150/70
Temp: 98.8
RR: 26
O2: 85% (Room Air)
Critical Actions:
* Recognize Hypoxemia
* Diagnose Toxic Alcohol Ingestion
* Consult Nephrology Emergent Dialysis
* Administer Fomepizole
* Workup Anion Gap Metabolic Acidosis