Ottawa’s Clerkship Guide To Emergency Medicine First Edition
Ottawa's clerkshipguide to emergencymedicineFirst edition2017Department of Emergency Medicine, University of OttawaOmar AnjumLaura OlejnikShahbaz Syed
Authors and EditorsOmar Anjum, BSc, MD CandidateAuthor and EditorClass of 2018, Faculty of Medicine, University of OttawaLaura Olejnik, BSc, MD CandidateCo-Author and Associate EditorClass of 2019, Faculty of Medicine, University of OttawaShahbaz Syed, MD, FRCPC(EM)Faculty Lead and Associate EditorDepartment of Emergency Medicine, University of OttawaStaff ContributorsStella Yiu, MD, CCFP(EM)K. Jean Chen, MD, CCFP(EM)Edmund Kwok, MD, MHA, MSc, FRCPC(EM)Brian Weitzman, MDCM, FRCPC(EM)Department of Emergency Medicine, University of OttawaFirst edition, March 2018.This book can be downloaded from https://emottawablog.comAll rights reserved. This work may not be copied in whole or in part withoutwritten permission of the authors. While the information in this book is believedto be true and accurate at the time of publication, neither the authors nor theeditors nor the contributors can accept any legal responsibility for any errors oromissions that may be made. Readers are advised to pay careful attention to druginformation or equipment provided herein. The primary intended reader is amedical student and as such it is expected that a supervising physician isconsulted prior to initiation of treatment and management discussed in thishandbook.
PrefaceIntroductionDear readers,This handbook is a student-driven initiative developed in order tohelp you succeed on your emergency medicine rotation. It providesconcise approaches to key patient presentations you willencounter in the emergency department. This guide has beenpeer-reviewed by staff physicians to make sure evidence is up-todate and accurate. Based out of Ottawa, our hope is that thisresource will benefit clerkship students and help bridge theemergency medicine knowledge gap from pre-clerkship to clinicalpractice.Sincerely,Omar Anjum, BSc, MD Candidate (2018)Author and EditorHow to use this GuideTopics are subdivided according to background, assessment,investigations, and management.BackgroundThis section provides common definitions, pathophysiology,etiology or risk factors for certain conditions. Differentialdiagnoses are also discussed (“Symptoms Approach” section).AssessmentCommon historical and physical exam features are mentionedhere. Diagnostic criteria or techniques/methods used to aid indiagnosis may also be noted.InvestigationsRelevant labs, radiological evaluation and adjunctive tests arementioned for consideration of diagnostic workup.ManagementGeneral and disease-specific management approaches arediscussed. Disposition and discharge criteria may also benoted.Key references: Used for further reading. Some sources areprovided because they are deemed useful to a reader seekingadditional information.
Table of umaSymptoms ApproachSyncopeAltered Mental StatusHeadacheShortness of BreathChest PainChest Pain Risk StratificationAbdominal PainPelvic PainBack PainMedical EmergenciesAnaphylaxisAsthmaChronic Obstructive Pulmonary DiseaseMyocardial InfarctionCongestive Heart FailureCardiac DysrhythmiasVascular EmergenciesDeep Vein Thrombosis and Pulmonary EmbolusGastrointestinal BleedingTIA and StrokeDiabetic EmergenciesSepsisElectrolyte DisturbancesENT EmergenciesUrological EmergenciesEnvironmental injuriesCommon fracturesToxicologyDrugs and dosagesClinical decision rulesRisk stratification scalesACLS
Resuscitation
AirwayDecision to IntubateFailure to maintain or protect airway (ie. low GCS, airway trauma)Failure to ventilate/oxygenate (ie. low or declining SpO2, rising pCO2)Anticipatory (ie. trauma, overdose, inhalation injury, AECOPD, CHFe)AssessmentDifficult bag-valve mask ventilation “BOOTS”B Beard; O Obese; O Older; T Toothless; S Snores/StridorDifficult intubation “LEMON”L Look for gestalt signsE Evaluate the 3-3-2 rule: 3 fingers mouth opening, 3 fingers hyo-mentaldistance, 2 fingers from thyroid cartilage to floor of mouthM Mallampati scoreO Obstruction or ObesityN Neck mobility (ie. ankylosing spondylitis, rheumatoid arthritis)Airway techniquesTemporizing MeasuresChin lift/jaw thrust, BVM,suctioning, nasal airway, oralairway, LMADefinitive AirwayOrotracheal/nasotrachealintubation, surgical airway(percutaneous or open cric)Airway methodsRapid Sequence Intubation (RSI)Blind nasotracheal intubationAwake oral intubationOral intubation without anyagents (ie. “crash” airway)Rapid Sequence Intubation (6Ps)PreparationPrepare equipment and medicationsPre-oxygenation100% O2 x3 mins OR ask pt to take deep breaths on 100% O 2Pre-treatment (optional)Reactive airways: /- lidocaine 1.5mg/kgCardiovascular disease: fentanyl 3mcg/kgIncreased ICP: fentanyl 3mcg/kgParalysis with inductionAdministration of sedative (ie. ketamine, propofol, etomidate) followed bymuscle relaxant if indicated (ie. succinylcholine or rocuronium)Place tube with proofIntubate patient and confirm tube placementPost-intubation managementCXR, ongoing analgesia and sedation, ongoing resuscitationKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 1. Emergency Medicine Journal 2005; 22(2): 99-102.
BreathingDefinitionsAcute respiratory failure pO2 50mmHg /- pCO2 45mmHgType 1 respiratory failure without hypercapniaDiffusion problem: pneumonia, ARDSV/Q mismatch: PEShuntLow ambient FiO2: high altitudeAlveolar hypoventilationType 2a respiratory failure with hypercapnia, normal lungsDisorder of respiratory control: overdose, brainstem lesion, CNS diseaseNeuromuscular disorders: muscular dystrophy, GBS, Myasthenia Gravis, ALSAnatomic: trauma, ankylosing spondylitis, kyphosis/severe scoliosisType 2b respiratory failure with hypercapnia, abnormal lungsIncreased airway resistance: AECOPD, asthma exacerbationDecreased gas exchange: scarring, IPFAssessmentLookMental status, color,chest wall movement,accessory muscle useListenFeelAuscultate for breathsoundsSigns of obstructionAir entering or escapingTracheal deviation,crepitus, flail segments,chest woundsInvestigationsLabs: CBC, electrolytes, cardiac enzymes /- D-dimer, VBGTests: Chest X-ray /- Chest CTManagement of breathingSpontaneously breathing patientNasal prongsFace mask, Non-rebreather face maskTemporizing measures for inadequate ventilationBag-valve mask /- nasal airwayHigh flow nasal oxygenation (ie. Mastech)CPAP/BiPAP: acute exacerbations of CHF, COPD, asthmaDefinitive measures for inability to maintain/protect airwayOro-tracheal intubationSurgical airwayAdditional modalitiesNeedle thoracostomy for tension pneumothoraxTube thoracostomy to drain pleural effusions or hemothoraces, andto treat pneumothoracesKey References: Journal of Critical Care 2016; 34: 111-115. Rosen’s Emergency Medicine:Concepts and Clinical Practice – 8th ed, 2014; Chapter 2.
CirculationCauses of shockHypovolemic shockObstructive shock(intra-thoracic)Distributive shock(vasodilation)Cardiogenic shockHemorrhageGI lossesPulmonary embolismCardiac tamponadeTension pneumothoraxSeptic shockAnaphylactic shockNeurogenic shockACSCardiomyopathyThird spacingValvular dysfunctionCongenital heart diseaseAir embolismDrug overdoseAdrenal crisisCardiac structural damageDysrhythmiasAssessmentRosen’s empirical criteria for circulatory shock ( 4/6)Ill appearance or AMSHR 100 bpmRR 20 or paCO2 32Base deficit -4 or lactate 4Urine Output 0.5mL/kg/hr Arterial hypotension 30min continuousInvestigationsLabs: CBC, electrolytes, BUN, Cr, LFTs, TnI, VBG, lactateTests: CXR, ECG, POCUS – RUSH exam (cardiac, IVC, lungs, aorta)ManagementHemorrhagic hypovolemic shockControl hemorrhage (tourniquets, direct compression, pelvic binders)Aggressive fluids (IV warm crystalloids), blood product transfusion (1:1:1pRBCs:platelets:FFP)Obstructive shockTension pneumothorax: needle decompression then chest tubeCardiac tamponade: IV crystalloids, pericardiocentesisPE: IV crystalloid, inotropes, thrombolysisAnaphylactic shockEpinephrine IM, IV crystalloids, antihistamines, corticosteroidsSeptic shockBroad-spectrum antibiotics, IV crystalloids /- norepinephrineGoals: Urine Output 0.5mL/kg/h, CVP 8-12mmHg, MAP 65mmHg, ScvO2 70%, lactate clearanceCardiogenic shockMaintain MAP 65 with fluid boluses to optimize preloadNorepinephrine 5mcg/min, dobutamine 2.5 mcg/kg/min,Treat underlying cause: cath lab, ECMO support, heart transplantCellular ToxinsAntidotes for various toxins (see toxicology)Key References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 6.
Trauma ResuscitationPrimary Survey1 Airway3 CirculationAssess patency of airway, look forobstruction (blood, emesis, teeth,foreign body), ensure C-spineprecautions, RSIAssess LOC, signs of shock (HR, BP,skin color, urine output, base deficits)Estimate degree of hemorrhagic shock2 Breathing4 DisabilityExpose chest, assess breathing,auscultate for breath soundsRule out tension pneumothoraxGCS assessmentNeurological evaluation5 Exposure/EnvironmentFully expose patient, logroll patient to inspect for injuries, spine tendernessand rectal exam for high-riding prostate and tone.Keep patient warm and dry to prevent hypothermiaSecondary SurveyFull physical exam: head and neck, chest, abdomen, MSK, neuroSAMPLE history, collateral historyFAST exam: subxiphoid pericardial window, perisplenic, hepatorenal(Morison’s pouch), pelvic/retrovesicalInvestigationsThe Deadly TriadBloodwork: CBC, lytes, BUN, Cr, glucose, lactate,CoagulopathyINR/PTT, fibrinogen, B-hCG, tox bloodwork (EtOH,HypothermiaASA, APAP), T C, U/AAcidosisLabs: Full portable X-rays (spine, chest, pelvis)CT – for stable patients; unstable patients may require urgent ORManagementResuscitation partsBlood component ratios: 1 pRBCs: 1 FFP: 1 plateletsTranexamic acid: 1g IV over 10 minutes then 1g IV over 8 hoursHead traumaSeizure management, treat suspected raised ICP, neurosurgical interventionfor severe head injury/bleedsSpinal cord traumaImmobilize, treat neurogenic shock, consult spine serviceChest traumaAirway management, thoracotomy for blunt vs. penetrating trauma as perEAST guidelines, surgical intervention for life-threatening pulmonary,diaphragmatic, esophageal, aortic, myocardial injuriesAbdominal traumaLaparotomy for hemodynamically unstable and hollow organ injuriesOrthopedic injuriesReduce and immobilize when possible, adequate analgesia, consult orthoKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 36. ATLS Manual, ACS – 9th ed, 2012.
Symptoms Approach
SyncopeDefinition: sudden and transient loss of consciousness with loss ofpostural tone accompanied by a rapid return to baselinePathophysiology: dysfunction of both cerebral hemispheres or thebrainstem (reticular activating system), usually from hypo-perfusionDifferential DiagnosisCardiacNonCardiacRhythm disturbances: dysrhythmias, pacemaker issuesStructural: outflow obstruction (aortic stenosis, HOCM), MIOther CV diseases: dissection, cardiomyopathy, PEVasovagal: sensory or emotional reactionsOrthostatic: postural related, volumeReflexdepletion(neurallySituational: coughing, strainingmediated)Carotid sinus pressure: shavingSubclavian steal: arm exercisesCCBs, B-blockers, digoxin, insulinMedicationsQT prolonging medsDrugs of abuseFocal CNSHypoxia, epilepsy, dysfunctional brainstemhypoperfusionAssessmentHistory: syncope character (ask about exertion!), cardiac risk factors,comorbidities, medication/drug use, family history, orthostatic symptomsRule out seizure/stroke/head injuryPhysical: cardiac exam (murmurs, rate), CNS examInvestigationsLabs: CBC, glucose, lytes, extended lytes, BUN/Cr, CK/TnI, B-hCGECG intervalsECG ratesShort PR: WPWLong PR: conduction blocksDeep QRS: HOCMWide QRS: BBB, Vtach, WPWQT intervals: Congenital QT syndromeTachydysrhytmias: SVT, Afib, Vtach, VfibBradyarrhytmias: AV conduction blocks,sinus node dysfunctionManagementGeneralABCs, monitors, oxygen, IV accessCardiogenic syncopeConsult cardiology for workup, pacemaker considerationNon-cardiogenic syncopeBenign causes or low-risk syncope: discharge with GP follow-upConsider outpatient cardiac workupRisk stratification prediction rulesCanadian Syncope Risk ScoreKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 15. CMAJ 2011; 183(15): 1694-1695. CMAJ 2016; 188(12): E298.
Altered Mental StatusDefinition: decrease in LOC caused by either diffuse CNS dysfunction(toxic/metabolic causes) or primary CNS diseaseDifferential DiagnosisDrugsAbuse: Opiates, benzodiazepines, alcohol, illicit drugsAccidental: Carbon monoxide, cyanidePrescribed: Beta-blockers, TCAs, ASA, acetaminophen, digoxinWithdrawal: Benzodiazapines, EtOH, SSRIsInfectionCNS: meningitis, encephalitis, cerebral abscessSystemic: sepsis, UTI, pneumonia, skin/soft tissue, bone/joint,intraabdominal, iatrogenic (indwelling lines or catheter), bacteremiaMetabolicKidneys: electrolyte imbalance, renal failure, uremiaLiver: hepatic encephalopathyThyroid: hyper or hypothyroidPancreas: hypoglycemia, DKA, HHSStructuralBleeds: ICH, epidural hematoma, subdural hematoma, SAHBrain: Stroke, seizures, surgical lesions, hydrocephalusCardiac: ACS, dissection, arrhythmias, shockAssessmentHistory: Collateral from family/friends/EMS, onset and progression,preceding events, past medical history, medications, history of trauma,comparison to baselinePhysical: ABCs, primary survey, vital signs including temp and glucose,rapid neurological exam (GCS and focal neurological deficits)InvestigationsLabs: CBC, lytes, glucose, BUN, Cr, LFTs, INR/PTT, serum osmolality,VBG, troponin, urinalysis, drug levels.Tests: ECG, CXR, CT headManagementGeneralMonitors, oxygen, vitals, IV accessTreatmentTreat underlying cause, universal antidotes (dextrose, oxygen,naloxone, thiamine), broad-spectrum Abx, warm/cool, BP controlDispositionConsider admission for working up underlying causeKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 16.
HeadacheCommon TypesMigraine: POUND (pulsatile, onset 4-72hrs, unilateral, N/V, disablingintensity), photophobia/phonophobia, chronic, recurrent, /- auraCluster: unilateral sudden sharp retro-orbital pain, 3hours usually atnight, pseudo-Horner’s symptoms, precipitated by alcohol/smokingTension: tight band-like pain, tense neck/scalp muscles, precipitatedby stress or lack of sleepDifferential DiagnosisIntra-cranialBleed: epidural, subdural, subarachnoid,intracerebral hemorrhageInfection: meningitis, encephalitis, brainabscessIncreased ICP: mass, cerebral venoussinus thrombosisExtra-cranialAcute angle closure glaucomaTemporal arteritisCarotid artery dissectionCO PoisoningAssessmentHistory: Red flags (sudden onset, thunderclap, exertional onset,meningismus, fever, neurological deficit, AMS), symptoms of increasedICP (persistent vomiting, headache worse lying down and in AM)Physical: vitals, detailed neuro exam (cranial nerves, gait,coordination, motor/sensory, reflexes), neck for meningeal irritation,eye exam (slit lamp, IOP), temporal artery tendernessInvestigationsNeuroimaging to rule out deadly causes. Most benign headaches do NOTneed further investigation. Refer to Ottawa SAH Rule.LP: if CT head negative ( 6h from onset) but suspicion of SAHESR/CRP: if suspect temporal arteritisManagementCommon benign headache regimenFluids: No clear evidence, but consider in dehydrated patientAntidopaminergic agent: Metoclopramide 10mg IVAnalgesic: Acetaminophen 1g poNSAIDs: Ketorolac 15-30mg IV or Ibuprofen 600mg poSteroids: Dexamethasone 10mg po/IV (rebound migraine prophylaxis)Non-traditional usesOxygen, sumatriptan, verapamil – used for cluster headachesMagnesium, lidocaine, propofol, ketamine – for refractory headaches,emerging evidenceNerve blocks: limited efficacyKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 20. Headache 2016; 56: 911-940.
Shortness of BreathDefinitionsTachypnea: RR 18 in adultsHyperpnea: high minute ventilation to meet metabolic demandsOrthopnea: dyspnea lying flatParoxysmal Nocturnal Dyspnea: sudden dyspnea at nightDifferential DiagnosisPulmonaryAirway obstructionRespiratory failure (refer to Type 1vs Type 2 in “Breathing” section)AnaphylaxisPulmonary embolismTension pneumothoraxToxic-metabolicToxin ingestion (organophosphates,CO poisoning)SepsisDKACardiacPulmonary edemaMyocardial infarctionCardiac tamponadePericardial illain-Barre syndromeAmyotrophic lateral sclerosisMultiple sclerosisAssessmentHistory: OPQRST, recent travel, trauma, PE risk factors (Well’s criteria,PERC rule), sick contactsPhysical: appearance, signs of respiratory distress, cardiac/resp examInvestigationsBlood work: CBC, lytes, BUN/Cr, VBG, cardiac enzymes /- D-dimerTests: ECG, bedside U/S, CXR (portable if unstable)ManagementGeneralMonitors, oxygen, vitals, IV access, ABCsIntubateIf not protecting airway or significant respiratory distressEmpiric treatmentTrauma: ATLS guidelinesAnaphylaxis: epinephrine, antihistamines, steroids, fluidsCardiac causes: see various cardiac sections belowAsthma/COPD: oxygen, bronchodilators, corticosteroids /antibioticsInfection: antibiotics, consider broad-spectrum if septicKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 25.
Chest PainDifferential DiagnosisDeadly Six (PET MAC)Pulmonary embolismEsophageal rupture/mediastinitisTension pneumothoraxMyocardial infarctionAortic dissectionCardiac tamponadeRespiratoryPneumoniaPleural effusionAcute chest syndrome (sickle cell)Lung or mediastinal massMSKIntramuscular painRib sGIEsophagus – Mallory-Weiss tear,esophageal spasmStomach – GERD, dyspepsia/PUDPancreas - pancreatitisGallbladder - biliary colic,cholecystitis, cholangitisOtherPanic attackHerpes ZosterAssessmentHistory: character of pain, cardiac risk factors (see HEART score), PErisk factors (see PERC rule), recent trauma, neuro symptomsPhysical: appearance, cardiac exam, resp exam, neuro screen, vitals pulse deficitsInvestigationsTests: ECG, CXR /- CTPALabs: CBC, lytes, abdo panel, CK/TnI /- ionpneumothoraxTamponadeDissectionDispositionABCs, monitors, oxygen, vitals, IV access, equipmentASA, nitro (avoid in RV infarct), clopidogrel/ticagrelor,LMWH, code STEMI (PCI vs. thrombolytics)Anticoagulation /- thrombolysis for massive PEUrgent thoracics consult, IV antibiotics, NPO, furtherimagingNeedle decompression (2nd ICS at MCL) then chest tube(4th or 5th ICS)PericardiocentesisUrgent vascular consult, reduce BP and HR with IVlabetalol, surgery vs. medical managementDiagnosis and risk stratification dependentKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 26.
Chest Pain Risk StratificationHEART scoreInclusion CriteriaPatients 21 years oldpresenting with symptomssuggestive of ACSExclusion CriteriaNew STEMI 1mm or other new ECG changes,hypotension, life expectancy 1 years,noncardiac medical/surgical/psychiatric illnessH History0 slightly suspicious 1 moderately suspicious 2 highly suspiciousE ECG0 normal 1 No ST depression but LBBB, LVH, repolarization changes 2 ST depression/elevation not due to LBBB, LVH, or digoxinA Age0 age 45 1 age 45 – 64 2 age 65R Risk factorsRisk factors HTN, hypercholesterolemia, DM, obesity (BMI 30), smoking(current, or smoking cessation 3 months), positive FHx (parent/sibling withCVD 65yo), atherosclerotic disease (prior MI, PCI/CABG, CVA/TIA, or PVD)0 No known risk factors 1 1-2 risk factors 2 3 risk factors or history of atherosclerotic diseaseT Troponin (initial)0 initial troponin normal limit1 initial troponin 1-2X normal limit2 initial troponin 2X normal limitInterpretationScores 0-3: 0.9 – 1.7% risk of MACEScore 4-6: 12-16.6% risk of MACEScore 7: 50-65% risk of MACEPERC RuleInclusion CriteriaPatients where pre-testprobability of PE isconsidered to be low-risk( 15%)Use the HEART Pathway (HEART score delta TnI) to further lower risk ofMACE (not prospectively validated but1% risk of MACE in retrospective data)Exclusion CriteriaModerate to high risk for PEPatients can be safely ruled out and do not require further workupif no criteria are positive:Age 50, HR 100, SaO2 95% on room air, unilateral leg swelling,hemoptysis, recent surgery or trauma ( 4 weeks ago), prior PE or DVT,hormone use (OCPs, hormone replacement, estrogen)Key References: Neth Heart J. 2008; 16(6): 191-6. J Thromb Haemost 2008; 6(5): 772-80.
Abdominal PainDifferential DiagnosisRUQEpigastriumLUQHepatitisBiliary niaPleural titis*Cardiac – ACS*Pancreatitis*GastritisPneumoniaPleural effusionPE*Right FlankUmbilicusLeft FlankColitisPerforation*Obstruction*Renal ion*Aortic l isEctopic pregnancy*PID, TOATesticular torsion,epididymitis, orchitisOvarian torsionRenal colicUTI (Cystitis)Renal colicObstructionDiverticulitis*Ectopic pregnancy*PID, TOATesticular torsion,epididymitis, orchitisOvarian torsionRenal colicCan’t-miss DiagnosesRisk FactorsRuptured ectopicHx of STI/PID, recent IUD, previous ectopic,smoking, fallopian tube surgery, tubal ligationElderly, hx HTN/DM, smoking, trauma hxAlcohol use, biliary pathologyCharcot’s Triad: fever, RUQ pain, jaundiceElderly, CAD, CHF, dehydration, infectionOperative or malignant history, elderlyRisk factors for diverticulitis or PUD, malignancyor instrumentation (ie. colonoscopy)Elderly, low-fibre diet, Western populationRuptured AAAPancreatitisCholangitisMesenteric ischemiaObstructionPerforated viscusComp. diverticulitisAssessmentHistory: OPQRST, associated symptoms (N/V, fever, chills, bowel movement,urinary symptoms, pelvic discharge/bleeding)Physical: abdominal exam /- pelvic exam, cardiac/resp examInvestigationsLabs: CBC, lytes, BUN/Cr, LFTs, lipase, lactate, B-hCG /- CK/TnITests: ECG, CXR, bedside US as indicatedFormal abdo U/S (biliary pathology, ectopic, AAA) /- CT abdo/pelvisManagementABCs, NPO, analgesics, anti emetics, consult surgery as neededKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 27.
Pelvic PainDifferential DiagnosisGynecologicalOvaries: Ruptured cyst, abscess, torsionFallopian tubes: Salpingitis, tubal abscess, hydrosalpinxUterus: PID, endometriosis, fibroidsPregnancy related (1st trimester): Ectopic pregnancy, threatenedabortion, ovarian hyperstimulationPregnancy related (2nd-3rd trimester): Placental abruption, roundligament pain, Braxton-Hicks contractionsOther: Bartholin abscessUrinary tractUrologicalOtherUrolithiasisTesticular torsionSexual or ssmentHistory: OPQRST, associated symptoms (vaginal bleeding, discharge,dyspareunia, bowel or bladder symptoms), pregnancy and sexual historyPhysical: vitals, abdominal examPelvic exam (assess cervical motion tenderness, adnexal tenderness)Speculum exam (look for discharge, blood, take samples as needed)Investigations:Labs: CBC, lytes, BUN/Cr, b-hCG, /- vaginal and cervical swabsTests: Bedside U/S – rule out ectopic, free fluid assessmentFormal abdo/pelvic ultrasoundManagementGeneralABCs, IV access, analgesia, antiemetics, /- admit and consultOvarian cystUncomplicated: analgesia with follow-upHemoperitoneum or hemodynamically unstable: surgeryOvarian torsion/Testicular torsionSurgical detorsion or removalPIDSevere infection: admit with IV antibiotics (cefoxitin 2g IV q6h IV doxycycline 100mg IV q12h x24hrs then switch to po)Mild-moderate infection: Ceftriaxone 250mg IM x 1 doxycycline100 po BID x 14 daysKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 33.
Back PainDeadly Differential DiagnosisSpinalCauda equina and spinal cordcompression:Spinal metastasisEpidural abscess/hematomaDisc herniationSpinal fracture with subluxationMeningitisVertebral osteomyelitisTransverse myelitisVascularAortic DissectionRuptured AAAPulmonary EmbolismMyocardial InfarctionAssessmentHistory: focus on red flags, fracture history, cancer risk, infection riskRed flags (BACK PAIN): bowel/bladder dysfunction, anesthesia (saddle),constitutional symptoms (night pain, weight loss, fever/chills), chronicdisease, paresthesias, age 50, IVDU/infection, neurological deficitsPhysical: vitals pulse deficits, inspect skin for infection/trauma, abdoexam for AAA, cardiac exam (aortic murmur), MSK lower back exam,neuro exam (lower extremity, reflexes, rectal tone), post void residualInvestigationsBloodwork: usually not indicated unless suspected infection (CBC, ESR,CRP)Bedside U/S: rule out AAA, look for bladder distention post-voidPVR: cauda equina syndrome (PVR 200cc has sensitivity of 90% for CES)ManagementCauda equina syndromeUrgent MRI, spine consult, analgesia, IV dexamethasoneAortic dissectionImmediate specialist consultation, IV labetalol to control HR and BPRuptured AAAFluid resuscitation, immediate OR if unstableEpidural abscess or vertebral osteomyelitisMRI to definitively diagnose /- bone scan (osteomyelitis), broadspectrum antibiotics, orthopedics consultMSK back painAnalgesia (WHO pain ladder)Multidisciplinary approach with GP follow-upKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 35.
Medical Emergencies
AnaphylaxisDefinition: life-threatening immune hypersensitivity systemic reactionleading to histamine release, vascular permeability and vasodilationCommon triggers: foods (egg, nuts, milk, fruits), meds (antibiotics,NSAIDs), insect bites, local anesthetics, occupational allergens,aeroallergensDifferential Diagnosis: shock (of any etiology), angioedema, flushsyndrome, asthma exacerbation, red man syndromeDiagnostic criteria:Acute onset (minutes to hours) ANY of the following three:Involvement of skin /- mucosa WITH EITHER respiratory difficulty or low BPExposure to likely allergen with 2/4 signs:Skin-mucosal involvement (urticarial, angioedema, flushing, pruritis)Respiratory difficulties (dyspnea, wheezing, stridor, hypoxemia, rhinitis)Low BP (hypotonia, syncope, pre-syncope, headache, collapse)GI symptoms (abdo pain, cramps, N/V)Low BP after exposure to known allergenAssessmentGeneral: TREAT FIRST, ABCs, monitors, oxygen, vitals, IV accessAppearance, respiratory distress, visualize swelling (lips, tongue,mucous membrane)History: exposure to any known or likely allergen, co-morbidities,recent medication use, family history, atopyManagementGeneral managementIf need to protect airway: ketamine as induction agentEpinephrine: 0.3-0.5 mg IM (1:1000 conc.) to anterolateral thigh q5-10 minsAntihistamines: Benadryl 50mg IV/PO, Ranitidine 50mg IV/150mg POSteroids: Methylprednisolone 125mg IV/prednisone 50mg poFluids: 0.5 – 1 L NS bolusRefractory hypotensionEpinephrine drip 1-10ug/min IV (titrate to desired effect)Consider norepinephrine 0.05 – 0.5ug/kg/minPatients with beta-blockersIF epinephrine unsuccessful, glucagon 1-5mg IV over 5-10 mins followed by 515ug/min infusionDispositionMay discharge as early as 2 hours if stable. Arrange follow-up with GP in 2448 hrs to watch for biphasic reaction.Education to avoid allergen, consider allergy testing, Epi-pen prescriptionMeds at discharge: Benadryl 50mg po OD, Ranitidine 150mg po OD andprednisone 50mg po OD x3 daysKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 109. The World Allergy Organization Journal 2011; 4(2): 13-37.
AsthmaDefinition: chronic inflammatory airway disease with recurrentreversible episodes of bronchospasm and variable airflow obstructionTriggers: URTIs, environmental allergens, smoking, exerciseClassification (CAEP/CTS Asthma Severity):Respiratory Arrest/FatalAppearance: altered mental status, cyanotic, decreased resp. effortVitals: low HR, high RR, low O2 sat 90% despite oxygenExam: Silent chest – consider preparing for intubationSevereAppearance: agitated, diaphoretic, labored respirations, difficulty speakingVitals: high HR, high BP, O2 sat 90-95%Exam: worsening resp. distress, exp/insp. wheezing, FEV1 40% predictedModerateAppearance: SOB at rest, cough, congestion, nocturnal symptomsVitals: O2 sat 95%Exam: exp. wheezing, FEV1 40-60% predictedMildAppearance: SOBOE, chest tightnessVitals: O2 sat 95%Exam: exp. wheezing, FEV1 60% predictedAssessmentHistory: triggers, recent infection, thorough asthma hx including priorexacerbations, hospitalizations interventions/ICU stays, family historyGood asthma control: daytime symptoms 2/week, no activity limitation, nonocturnal symptom, rescue puffer 2/week, normal PFTPhysical: vitals, sign of distress, accessory muscle use, respiratory examInvestigations: CXR, ECG /- VBG, /- PEFR (to estimate FEV1), bloodwork(CBC – infection, lytes – potassium)ManagementTreat exacerbation (“0.5 – 5 - 50”)Atrovent 0.5mg nebulized OR 4-8 puffs via MDI spacer q20mins x 3Ventolin 5mg nebulized OR 4-8 puffs via MDI spacer q20mins x 3Prednisone 50mg oralNOTE: MDIs are superior to nebs, however if patient too tachypneic use nebsSevere asthmaMgSO4 2g IV over 30 minsEpinephrine 0.3mg IM then 5mcg/min IV infusionKetamine 1mg/kg (in conjunction with BiPAP)Respiratory failureConsider NiPPV first (BiPAP)Intubate (LAST RESORT): ketamine 1mg/kg IV succinylcholine 1.5mg/kg IVInvolve ICU earlyKey References: Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed,2014; Chapter 73. CMAJ 1996; 155(1): 25-37.
Chronic Obstructive Pulmonary DiseaseRisk factors: smoking (#1
resource will benefit clerkship students and help bridge the emergency medicine knowledge gap from pre-clerkship to clinical practice. Sincerely, Omar Anjum, BSc, MD Candidate (2018) Author and Editor How to use this Guide Topics are subdivided according to background, assessment, investigations, and management. Background
Family Medicine Clerkship. is a 6-week core clerkship that focuses on ambulatory care and the principles of preventive medicine. 4. The . Internal Medicine Clerkship. is a 6-week core clerkship that includes both inpatient and outpatient care. 5. The . Obstetrics and Gynecology Clerkship. is a 6-week core clerkship that focuses on women’s .
Review of Year 3 Pediatrics Clerkship Clerkship occurs in Year 3 Clerkship Directors – Adam Weinstein and Alison Holmes Clerkship Coordinator – Sharon French Clerkship Length – 8 weeks, 6 cycles – 2 Weeks Inpatient, 1 Week Nursery, 4 Weeks Outpatient (change f
watch the Introduction to the Pediatrics Clerkship orientation video prior to the first day of the clerkship. In addition, students will meet the Clerkship Director for a general orientation to the clerkship, this meeting may take place prior to or during the first week of the clerkship.
Welcome to clerkship. Clerkship consists of Years 3 & 4 of the undergraduate medical education program. The clinical clerkship allows students to apply their basic knowledge and skills acquired in the first 2 years of medical school in
CLERKSHIP GOALS The Family Medicine clerkship is designed as a competency-based, community-centered learning experience. The goals of the clerkship are: 1. To provide opportunities that will help students develop knowledge of practices, skills, attitudes, and principals that are essential to the family physician. 2.
Carver College of Medicine Family and Community Medicine Clerkship (FAM:8302) 2021 Syllabus CLERKSHIP DIRECTOR Stacey Appenheimer, MD Pager 3043 stacey-appenheimer@uiowa.edu ASSISTANT CLERKSHIP DIRECTOR Emily Welder, MD Pager 3829 emily-welder@uiowa.edu CLERKSHIP COORDINATORS Bre Anna McNeill 1293-G
Aug 01, 2020 · clerkships plus 12 weeks of clerkship electives) listed below are taken only after the student has completed Years 1 and 2 and the Clinical Skills Clerkship (CSC). The seven core clerkships must be completed by the end of Year 3. Block Clerkships: 8 weeks, Clerkship in Internal Medicine 4weeks, Clerkship in Surgery
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