162 episodes

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.

EM Clerkship Zack Olson, MD and Michael Estephan, MD

    • Helse og trening
    • 4.5 • 2 Ratings

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 26

    Deep Dive – Round 26

    Cardiac Tamponade







    Cardiac Tamponade – A physiological state caused by a pericardial effusion in which the pressure in the pericardial sac is higher than the pressure inside the right sided chambers of the heart, leading to impaired filling, decreased cardiac output, and hemodynamic collapse.







    Pericardial Effusions – Can be caused by infections, rheumatologic diseases, malignancy, uremia, hypothyroidism, trauma, aortic dissections, etc







    Diagnosis on Exams:







    * Becks Triad – Hypotension, JVD, Muffled Heart Sounds* Pulsus Paradoxus – SBP drops >10mmhg during inspiration* Electrical Alternans on ECG







    Diagnosis in Real Life:







    * Mix of clinical and cardiac ultrasound* Clinically patients usually complain of dyspnea, sometimes chest pain. They can have ALL, SOME, or NONE of the features of Beck’s Triad!* On ultrasound, RIGHT VENTRICULAR COLLAPSE DURING DIASTOLE is most specific for tamponade.* On ultrasound, a PLETHORIC IVC is most sensitive for tamponade (but is totally non-specific as we see this with many other conditions including CHF, PE, PNTX, etc)







    Treatment:







    * Initial fluid bolus (stop if they worsen clinically)* Vasopressors if needed to bridge unstable patient to definitive treatment* Definitive treatment is pericardiocentesis.







    Further Reading:







    NEJM – Diagnosis of Cardiac Tamponade and how to perform pericardiocentesis

    • 16 min
    Round 26 (Stridor, Vomiting, Shock)

    Round 26 (Stridor, Vomiting, Shock)

    Case Introduction







    You are working a shift at your local free-standing emergency room when a family of three checks in to be seen (a father and his two sons).







    Initial Vitals#1 (Chris, 18mo with stridor)







    * Temp 100.4F* HR 120* RR 40* O2 93%







    Critical Actions#1 (Chris, 18mo with stridor)







    * Check pulse oximetry (hidden)* Administer PO Steroids* Administer Racemic Epinephrine* Reassess patient after therapy* Discharge patient







    Initial Vitals#2 (Ronnie, 3yo with vomiting)







    * Temp 98.0F* HR 140* RR 38* O2 98%







    Critical Actions #2 (Ronnie, 3yo with vomiting)







    * Identify Iron overdose* Obtain abdominal XR * Obtain Iron level* Administer IVF bolus* Administer deferoxamine







    Initial Vitals#3 (Carson, 55yo with shock)







    * Temp 98.0F* HR 130* RR 28* BP 82/68* O2 92%







    Critical Actions#3 (Carson, 55yo with shock)







    * Obtain ECG* Identify pericardial tamponade* Administer IVF Bolus (tamponade is preload dependent)* Perform pericardiocentesis* Consult CT Surgery/CVICU







    Further Reading







    Life in the Fast Lane – Iron Toxicity







    EMDocs – Croup







    EMDocs – Pericardial Tamponade

    • 47 min
    Deep Dive – Round 25

    Deep Dive – Round 25

    Hyponatremia in the ED







    Four questions to ask yourself:







    * Is the patient symptomatic from their hyponatremia (confusion, nausea/vomiting, ams, seizures, etc)?* If not, outpatient followup (unless super low)* Is the patient having severe neurologic symptoms from their hyponatremia? (seizures, AMS)* If yes, treat with hypertonic saline (3%)* Is the patient going to be admitted from their hyponatremia?* If yes, obtain serum osmolarity to rule out pseudohyponatremia* Is the patient dehydrated/hypovolemic?* If yes, treat with NS bolus* If euvolemic/hypervolemic, treat with fluid restriction







    Further Reading:







    EMCrit – Hyponatremia







    EMDocs – Critical Hyponatremia

    • 12 min
    Round 25 (Seizure)

    Round 25 (Seizure)

    CAUTION: THESE NOTES CONTAIN SPOILERS!!







    Case Introduction







    You are working a shift at EM Clerkship General when you are called to the waiting room by the charge nurse for a seizing patient.







    Initial Vitals







    * Temp 99.0F* HR 97* RR 16* BP 120/80* O2 90%







    Critical Actions







    * Perform airway maneuvers to clear obstruction* Administer IV Benzodiazepines * Administer Hypertonic Saline* Diagnose Anterior Shoulder Dislocation* Perform & Describe Shoulder Reduction Procedure







    Further Reading







    EMDOCs – Anterior Shoulder







    ALiEM – Park Method for Anterior Shoulder Dislocation







    EMCrit – Hyponatremia

    • 33 min
    Deep Dive – Round 24

    Deep Dive – Round 24

    Acetaminophen Overdose & Toxicology Pearls







    * History: Figure out how much was taken, what time the ingestion occurred, and if any other toxins were ingested* Physical Exam: Perform a regular physical exam, and in addition, perform the toxicologic physical exam!* Check pupil size* Assess neuromuscular status for rigidity/clonus* Perform the “toxicologist handshake”* Listen to bowel sounds* Workup:* Accucheck* ECG* CBC, CMP, VBG* Acetaminophen Level (now and at four hours); Salicylate Level* UDS* Consider specific drug levels (eg digoxin, lithium, valproic acid, etc) ; consider ammonia level for valproic acid OD* Management:* ABCs first* Consider decontamination (remove clothes, hose down with water if chemical exposure, consider activated charcoal or gastric lavage for early ingestions)* Consult poison control/toxicology* Consult psychiatry if it was an attempt at self harm* Administer NAC if considered to be a “toxic ingestion of acetaminophen”* Definition of an “Acetaminophen Toxic Ingestion”* Single ingestion of acetaminophen greater than 150mg/kg* Data point on Rumack-Matthew Nomogram that is above the treatment line* If UNKNOWN amount / UNKNOWN timing of ingestion, treat if LFTs are elevated or if serum acetaminophen level is above normal limits* Rule of 150* Toxic Ingestion is considered to be a single ingestion greater than 150mg/kg* Toxic Ingestion is considered to be if the acetaminophen level at the four hour mark is >150ug/mL (this would be above the treatment line on the Rumack-Matthew Nomogrom)* Dose of NAC is 150mg/kg IV







    Further Reading:







    Rumack-Matthew Nomogram (MDCalc)

    • 14 min
    Round 24 (Altered Mental Status)

    Round 24 (Altered Mental Status)

    CAUTION: THESE NOTES CONTAIN SPOILERS!!







    Case Introduction







    You are working a shift at EM Clerkship General when you receive a radio call from EMS who are bringing in a young female who was found unresponsive.







    Initial Vitals







    * Temp 98.0F* HR 97* RR 16* BP 120/80* O2 98%







    Critical Actions







    * Obtain collateral history from EMS/friends* Administer Naloxone as needed for respiratory depression* Obtain 0-hour and 4-hour acetaminophen levels* Administer N-acetyl-cystine * Obtain psychiatry consult for suicidal ideation







    Further Reading







    Acetaminophen Toxicity (EMCrit)

    • 30 min

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