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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Round 21 (MW) Geriatric Fall
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 -
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