EM Clerkship Zack Olson, MD and Michael Estephan, MD

* 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

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

Hypertensive Emergencies of Pregnancy







PreEclampsia, Eclampsia, HELLP syndrome







Diagnosis: BP >140/90 plus end organ dysfunction









* Acute Kidney Injury







* Proteinuria







* Thrombocytopenia







* Transaminitis







* Hemolysis







* Pulmonary Edema







* Cerebral Edema / Hemorrhage







* Headache refractory to tylenol







* Visual Changes







* RUQ Pain not attributable to another diagnosis









Treatment









* Loading Dose: IV Magnesium 4-6g over 20-30 min OR 5g IM in each buttock







* Maintenance Dose: 1g/hr IV







* Antihypertensives (goal 20% reduction): Labetalol, Nicardipine, Hydralazine







* Delivery of fetus and placenta

You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache.







Initial Vitals:







HR: 56







BP: 172/93







Temp: 98.8F







RR: 18







O2: 97%







Critical Actions:









* Check a Blood Glucose







* Diagnose Preecclampsia/Ecclampsia







* Administer Magnesium







* Treat the Hypertension







* Discuss with OBGYN and Admit