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:

Round 18 (MW) Drunk Man Wants Pizza

Hypertensive Emergencies of Pregnancy PreEclampsia, Eclampsia, HELLP syndrome Diagnosis: BP &gt;140/90 plus end organ dysfunction Treatment

Pre-Eclampsia (Deep Dive MW R17)

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:

Round 17 (MW) Headache

Diagnosing PE: Step 1: Consciously consider the diagnosis Step 2: Risk Stratify into low, intermediate, and high risk Step 3: Choose appropriate testing based on pre-test probability Classification of PE Treatment of PE

Pulmonary Embolism (Deep Dive MW R16)

You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.” Initial Vitals: HR: 122 BP: 75/40 Temp: 100.1 RR: 24 O2: […]

Round 16 (MW) Leg Pain

Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion

Shock (Deep Dive R15 MW)

You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision” Initial Vitals: HR: 65 BP: 88/50 Temp: 97.0F RR: 20 O2: 96% Room Air Critical Actions:

Round 15 (MW) MVA

* Differential

* Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter



* Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors





* Work-up

* XRay



* Labs to evaluate for septic arthritis – CBC BMP ESR CRP





* Kocher Criteria

* Non-weight bearing



* Fever &gt;38.5C



* ESR &gt;40



* WBC &gt;12





* Kocher Criteria Statistics

* 0 points: 0.2% (or 2% in prospective studies)



* 1 point: 3% (or 9% in prospective studies)



* 2 points: 40%



* 3 points:93%



* 4 points: 99%





* Septic Arthritis DX

* &gt;50,000 WBC

* Age 0-3mo : group B strep



* Age 3mo – 12 years: Staph Aureus



* Age 12-18 years: Gonorrhea



* Sickle Cell Disease: Salmonella

Pediatric Septic Arthritis (Deep Dive R14 MW)

You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury. Initial Vitals: HR: 112 BP: 97/67 Temp: 99.2F RR: 20 O2: 97% Room Air Critical Actions:

Round 14 (MW) Leg Pain

* Focused Physical Exam

* Tachypnea and Hypoxemia



* Able to speak in complete sentences



* Accessory muscle use/retractions



* Moving air or quiet on auscultation





* Basic Treatment Algorithm

* Albuterol Inhaler



* Albuterol/Ipratropium Nebulized (Duoneb)



* Steroids



* IV Magnesium



* Non Invasive Ventilation (CPAP or BiPAP)

* Decreases Work of Breathing





* Epinepherine





* Less Common Treatments

* Benzodiazepines



* Ketamine



* Heliox





* Intubation (Last resort)

* Use a large ETT (8.0)



* Increase the Expiratory Time





* “Permissive Hypercapnea”

* Appropriate ventilator management of asthma frequently results in mild hypercapnia and respiratory acidosis. IT’S OK





* Air Trapping

* Results in decreased preload, obstructive shock and pneumothorax



* Suspect with high airway pressures and when waveform doesn’t return to zero (see media)



* Treat by briefly unhooking ventilator and gently pressing on the patient’s chest to get out the trapped air





* Ventilator Settings

* Decrease the respiratory rate (ex 10)



* Increase the tidal volume (although some hypercapnia is permitted)



* Increase I:E ratio (1:4 or greater)

Asthma (Deep Dive R13 MW)

You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes” Initial Vitals: HR: 123 BP: 142/78 Temp: Unknown RR: 36 O2: 97% (NonRebreather) Critical Actions:

Round 13 (MW) Respiratory Distress

Introduction Clinical Presentation Treatment

Organophosphate Poisoning (Deep Dive R12 MW)

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General. We are bringing you an unresponsive 6-year-old female found foaming at the mouth by her babysitter. ETA 2 minutes.” Initial Vitals: BP: 125/80 HR: 62 RR: 34 O2: 81% (Non Rebreather) Critical Actions:

Round 12 (MW) Respiratory Distress

Shoulder dystocia is an OB emergency. Remember McRobert’s maneuver and suprapubic pressure. For more information, take a look at the resources below. References ACOG- Shoulder Dystocia AAFP- Shoulder Dystocia

OBGYN: The Vaginal Delivery (Pt 2)

Maddie’s 7 Cardinal Movements of a Successful Delivery: 1. Head comes out 2. Head turns 3. Cord Assessment 4. Anterior shoulder delivered 5. Posterior shoulder delivered 6. Body delivered. 7. Baby on mom’s chest T’s of Postpartum Hemorrhage: 1. Tone 2. Trauma 3. Tissue 4. Thrombosis

OBGYN: The Vaginal Delivery (Pt 1)

The 6 STEMI Equivalents: Other atypical ischemic EKG findings: Further Reading (see photos in the article): ECG Diagnosis of Life-Threatening STEMI Equivalent’s: Journal of the American College of Cardiology

The Ischemic EKG (Deep Dive R11 MW)

You are working at Clerkship Rural when the nurse hands you your next chart to see. It’s a 59 year old farmer with chest pain. Initial Vitals: BP: 156/97 HR: 110 RR: 22 O2: 98% (Room Air) Temp: 98.8F Critical Actions:

Round 11 (MW) Chest Pain

Consider removing the terminology “Agitated Delirium” from your vocabulary, as there is significant racial bias behind this term.

Agitation (Deep Dive R10 MW)

You are working at Clerkship General when you hear an EMS call on the radio… “CLERKSHIP GENERAL – We are bringing you an agitated and combative 30 year old male, we’ll see you in 5 minutes.” Initial Vitals: BP: 192/105 HR: 134 RR: 22 O2: 99% (Room Air) Temp: 98.8 F Critical Actions: Dangerous Actions: […]

Round 10 (MW) Agitation

Indications for LP: CNS infection, SAH, Guillian Barree, IIH Contraindications for LP: Space occupying lesion with mass effect ; severe thrombocytopenia and coagulopathy; cellulitis over LP site or concern for epidural abscess ; traumatic injury to spine Complications for LP: Post LP Headache, spinal hematoma, brainstem herniation Technique for LP: Positioning is everything.  Use US […]

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