Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.


EKG Masterclass

Sean Fox, MD

  • Hyperkalemia
    • Peaked T-waves are narrow and symmetric.
    • Wide and irregular QRS morphology.
    • Strongly consider when QRS duration greater than 200 ms.
    • Give calcium early on in the management course.
  • Wellen's Sign
    • Classically, deep symmetric T wave in V1-4.
    • Less commonly, ST elevation with biphasic T wave in V2-3.
    • Highly specific for proximal LAD occlusion.

Aortic Dissection

Erin Noste, MD

  • Aortic dissection is a "chest pain and ______ syndrome", think about the diagnosis when you have a patient who presents with chest pain and: headache, back pain, abdominal pain, syncope, neuro symptoms, renal failure, leg pain, or arm pain
  • Think dissection when patients present with sudden and severe pain, 84.8% of patients in the IRAD study presented with abrupt onset of pain and 90.6% of patients presented with severe pain
  • Check and document bilateral pulses (carotid, radial, femoral, DP, PT), even though 15.1% of patients in IRAD had a documented pulse deficit
  • When dissection is highly suspicious or diagnosed treat hypertensive patients aggressively, consider treating before sending for imaging. Goal SBP 100-120 mmHg and HR < 60 bpm. Treat first with a beta blocker (esmolol), then, if needed add a vasodilator such as nitroprusside

Hagan P. et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA. 2000;283:897-903

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Michael Koehler, MD

  • SBP is the most common bacterial infection in patients with cirrhosis
  • Suspect SBP in a patient with known ascites who presents with any abdominal discomfort, worsening ascites, encephalopathy, or ileus
  • Fever is present in only half of SBP cases
  • A diagnostic peritoneal tap is a quick and easy procedure with rare complications
  • First-line treatment for SBP is 2g of cefotaxime IV
  • Renal failure is the largest predictor of mortality in SBP
  • Strongly consider giving your SBP patient 1.5g/kg of albumin IV, as it has been shown to decrease renal failure and mortality in patients admitted with SBP
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Thyroid Disorders

Dave Ahlers, MD

  • Myxedema coma and thyroid storm are a clinical diagnosis, start treatment without testing if suspicious.
  • For thyroid storm give beta blocker (propanolol or esmolol) then thionamide (methimazole) followed by iodide solution (SSKI or Lugols) 1 hour later.
  •  Myxedema coma patients need hormone replacement ASAP (ie: T4 +/- T3)
  •  All thyroid disorder patients in crisis should get stress dose steroids
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M&M – PE and Airway Management

Kelley Cardeira, MD

  • 13% prevalence of thromboembolic disease in all COPD patients.  30% prevalence in atypical presentations.
  • Those at high risk of contrast "allergy" are those with previous reactions, asthma, or ANY severe allergy (not more likely with seafood allergy).
  • Pre-treatment only works if given at least 12 hours prior to contrast load.
  • When using fiberoptic scope for intubation, place the ETT in the nare almost all the way before putting the scope in - will place your view right above the cords from the start.
  • Use lots of nebulized and spray lidocaine for awake intubations.


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Finding the Appendix

James Cao, MD

  • Negative ultrasound doesn’t rule out disease
  • Non-visualized appendix without inflammation is reassuring on CT
  • Equivocal CT does not rule out disease
  • Consider MRI in pregnant patients after ultrasound

Board Review: Dermatology and MSK

David Pearson, MD

  • Unlike older children, neonatal impetigo may present with bullae
  • Spectrum of disease
    • Erythema multiforme major - <10% total body surface area (TBSA)
    • Stevens Johnson's Syndrome - 10-30% TBSA
    • Toxic epidermal necrolysis - >30% TBSA
  • Cervical disc herniation occurs at C6-7 in approximately 70% of cases
  • Base of thumb fractures
    • Rolando - comminuted and intra-articular
    • Bennett - intra-articular and dislocation of the base of 1st metacarpal

Electrolyte Emergencies

John Marx, MD

  • For hyperkalemia, calcium chloride and gluconate (former contains 3x more Ca++ per amp) are the only agents that act directly on the heart. Multiple doses are often required. Treatment is usually indicated at levels 6.5 or higher.
  • The EKG changes in hyperkalemia are peaked T waves, small or indiscernible p waves, widening of the QRS and eventually a sinusoidal rhythm.
  • Hyponatremia can be categorized into the following; sample error, pseudo, hypervolemic, euvolemic and hypovolemic.
  • The treatment for hypernatriema is usually fluid restriction; for hyponatriema is usually NS.
  • The serum sodium goes down 1.6mEq per 100mg rise in glucose over 100.
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Listwa’s “Fail proof” method of Lumbar Puncture and use of the Schiotz Tonometer

Todd Listwa, M.D.


Lumbar Puncture

  • Atraumatic needles (Gertie Marx/Whitacre) have a lower rate of post LP headache compared to Quincke needle (beveled/cutting)
  • 22 g needle has a lower rate of post LP headache than larger needles. We should always request a 22g as the kit has a 20g needle.
  • Assess the anatomy and never adjust your needle position blindly. Consider depth if hitting bone, and adjust cranially or caudally if suspecting spinous process is obstruction. When deeper, adjust to pt left or right suspecting lamina or articular facet is struck by the needle.

Lavi R, Yarnitsky D, Yernitzky D, Rowe JM, Weissman A, Segal D. Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial. Neurology. Oct 24 2006;67(8):1492-4

Lavi R, Rowe JM, Avivi I. Traumatic vs. atraumatic 22 G needle for therapeutic and diagnostic lumbar puncture in the hematologic patient: a prospective clinical trial. Haematologica. Jul 2007;92(7):1007-8


The Schiötz Tonometer

  • The Schiötz is a non electronic, reliable measure of intraocular pressure that you should be familiar with.
  • The weights are needed to ensure reliability and to measure higher intraocular pressures
  • You cannot use the tonometer without the conversion chart


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Mike Koehler, M.D

  • An abnormal QRS width or magnitude presents a confounding variable in diagnosing a STEMI
  • Classic LVH with strain pattern has concave up ST elevation in the anterior leads with ST depression in lateral leads
  • Nasal tamponade devices are easier and faster than gauze packing in persistent epistaxis
  • Treatment of anastomotic leaks includes broad spectrum antibiotics, volume resuscitation, and immediate surgical consultation
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