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.
Deep Dive – Round 23
* Make SURE the patient isn’t having symptoms of end organ dysfunction, which could make this hypertensive emergency (confusion, severe headache, blurry vision, weakness, chest pain, shortness of breath, seizures during pregnancy, etc). * ACEP clinical policy states, that in the patient with true asymptomatic hypertension who presents to the emergency department, no routine testing or treatments are indicated. * You risk causing HARM to your patients by treating these asymptomatic patients. For example, if you push IV hydralazine for asymptomatic hypertension in a patient who chronically lives at a BP of 230/120 and their blood pressure drops precipitously, you may cause a stroke/watershed infarcts. * ACEP clinical policy also states that in a patient who has poor access to followup (eg homeless), you may consider routine testing or initiation of long term anti-hypertensive treatment.
ACEP Clinical Policy – Asymptomatic Hypertension
EM Docs – Hypertensive Emergency
Round 23 (High Blood Pressure)
CAUTION: THESE NOTES CONTAIN SPOILERS!!
You are working a shift at EM Clerkship General when you are handed the next chart, a 60 year old male presenting with high blood pressure.
* Temp 98.0F* HR 90* RR 18* BP 220/120* O2 98%
* Perform thorough neurological exam (and find papilledema)* Diagnose Hypertensive Emergency* Start anti-hypertensive drip (usually Nicardipene)* Recheck patient’s blood pressure after intervention* Admit to ICU
Hypertensive Emergency (EMCrit)
Deep Dive – Round 22
*THIS IS A BASIC FRAMEWORK AND IS NOT COMPREHENSIVE*
* EVALUATE* Is the newborn crying/breathing spontaneously? Does the newborn have good tone? Is the newborn a term infant?* If YES, hand baby to mom for direct skin-to-skin.* If NO, proceed to step 2.* INTERVENE* STIMULATE – dry vigorously* WARM – place cap on head, place in warmer* OPEN AIRWAY – sniffing position, oral/nasal airway, suction if necessary* ASSESS HR (manually)* If HR>100, continue above interventions and move to PPV if not improving/if pulse ox low* If HR 60-100, attach to telemetry and pulse oximetry and begin PPV with room air at a rate of 60.* If HR60, this is a CODE situation. Chest compressions and ventilations in a 3:1 ratio (“one and two and three and breath”), use PPV with 100% FiO2. Obtain access via UC or IO line, and intubate. Use epinephrine / fluid bolus if no improvement in 60 seconds. Check glucose, supplement with dextrose if necessary.
PEARL: At one minute of life, we expect an SpO2 of 60%. Every minute afterwards, we expect the SpO2 to increase by 5%, so by 5 minutes of life it should be around 80%.
Neonatal Resuscitation – Emergency Medicine Cases
Round 22 (Cardiac Arrest)
CAUTION: THESE NOTES CONTAIN SPOILERS!!!
You are working a shift at EM Clerkship General when the triage nurse runs and grabs both you and your attending for a patient in triage who has active CPR in progress.
* Temp 98.0F* HR 0* RR 0* BP unmeasurable* O2 70%
* Identify pregnancy by exam, POCUS, or history* Place patient in left lateral decubitus* Perform resuscitative hysterotomy* Resuscitate the neonate
Neonatal Resuscitation (EMCases)
Resuscitative Hysterotomy (EMCases)
Deep Dive – Round 21
Torsades de Pointes (TdP)
A type of polymorphic ventricular tachycardia that is inherently unstable and often quickly degrades into ventricular fibrillation. It usually occurs in the setting of a prolonged QT interval, which can either be genetic or acquired.
* Defibrillation – per ACLS, ventricular tachycardia with a pulse should receive synchronized cardioversion. But in real life, the defibrillator often isn’t able to “sync” with TdP, forcing you to perform unsynchronized cardioversion (aka defibrillation).* IV Magnesium – treats and prevents TdP, even when magnesium levels are normal* Overdrive Pacing – by preventing bradycardia, we help prevent TdP (bradycardia prolongs the QT interval). * Electrical Overdrive Pacing – transcutaneous or transvenous pacemaker* Chemical Overdrive Pacing – beta agonist therapy (isoproterenol)* Lidocaine – anti-arrhythmic therapy that does not prolong QTc.* Fix underlying cause – congenital long QT syndrome, hypokalemia, hypocalcemia, medication induced (psych meds, anti-emetics, methadone, fluoroquinolones, many more)
Defibrillation and IV Magnesium are used for patients who are ACTIVELY in TdP. Once you shock/mag them into a stable rhythm, you can use Overdrive Pacing / Lidocaine / Treat Underlying Cause to PREVENT them from going back into TdP.
Round 21 (Drowning)
CAUTION: THESE NOTES CONTAIN SPOILERS!!!
You are working a shift at EM Clerkship General when EMS calls you on the radio… “Hey doc we’re bringing a young female who drowned in a pool ETA 1 minute”.
* Temp 95.0F* HR 55* RR 5-6* BP 110/82* O2 90%
* Evaluate for traumatic injury (and/or place C-Collar)* Intubate the patient* Identify Long QT Syndrome on ECG* Treat Pulseless Polymorphic VTach with defibrillation and IV magnesium* Treat Polymorphic VTach (pulse present) with overdrive pacing (transcutaneous pacing or isoproterenol)
Torsades de Pointes – EMCrit