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


“One Pill Can Kill”

Steven Walsh, M.D.

  • Methadone causes QTc prolongation
  • All possible/confirmed sulfonylurea ingestions should be admitted for overnight glucose monitoring
  • Propranolol is the most dangerous beta-blocker; it can result in QRS prolongation, seizures, and other manifestations more typical of BB toxicity (i.e., bradycardia, hypotension)
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Ligamentous Injuries of the Knee

Katherine Mahoney, MD

  • When injury to the knee causes immediate joint dysfunction, the injury will almost always be to the ACL or PCL.
  • Lateral collateral ligament injury will take up to 24 hours to swell and cause dysfunction.
  • In PCL injuries and knee dislocations, careful assess for neurovascular injury.
  • Unhappy triad: ACL, MCL, Medial Meniscus
    • Evaluate for associated injuries in the presence of any of the three injuries.

Board Review: Cardiology and EMS

Mike Runyon, MD

  • Level of personal protective equipment (PPE):
    • Level A: a self-contained breathing apparatus and a totally encapsulating chemical-protective suit.
    • Level B: a positive-pressure respirator and nonencapsulated chemical-resistant garments, gloves, and boots.
    • Level C: consists of an air-purifying respirator and nonencapsulated chemical-resistant clothing, gloves, and boots.
    • Level D: consists of standard work clothes without a respirator.
  • Vesicants, also known as blistering agents, initially cause erythema and itching. They quickly progress to blisters that appear similar to those of second-degree burns.
  • Accelerated idioventricular rhythm should not be treated with anti-arrthymics

EKG Masterclass

Sean Fox, MD

  • Wide regular tachycardia is VT until proven otherwise
    • Shock if unstable vital signs
  • Wellen's Sign
    • Biphasic T-wave in V2-3
    • Highly specific for LAD occlusion
  • Be cautious of right ventricular MI in the setting of an inferior STEMI
    • Will be pre-load dependent
    • Stay away from nitrates
    • EKG Changes:
      • ST Depression in V2 and ST Elevation in V1
      • ST Depression in V2 with isoelectric V1 and V3
      • ST Elevations of Lead III > II
      • Can also try right sided leads (STEMI in rV4)
  • Hypertrophic Cardiomyopathy
    • LVH is the most common and sensitive sign
    • Look for large narrow Q waves in the lateral leads
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Pediatric Textbook Review – Lower Extremity Fractures and Upper Airway Management

Lee Garvey, MD

  • Toddler’s fractures may be missed on the normal two views. Consider getting an oblique view.
  • Pediatrics upper airway management requires significant forethought. Have your second and third backups ready.
  • For suspected epiglottitis, do NOT agitate the child until ENT/anesthesia available. NO IVs, NO meds, just transfer.
  • Proper documentation for likely viral URI
    • Position of uvula
    • Erythema of tonsillar pillars
    • Symmetry of tonsils
    • No pain on external manipulation of larynx
    • No trismus

Pediatrics M&M

Maneesha Agrawal, MD

  • For new diagnosis of leukemia, watch for:
    • Neutropenic fever
    • Disseminated Intravascular Coagulopathy (DIC)
    • Hyperviscosity syndrome
    • High output cardiac failure
  • Life threatening diagnoses on new born screen at 1 week of life
    • Congenital adrenal hyperplasia
    • Galactosemia
    • Maple Syrup Urine Disease
  • Henoch-Schonlein Purpura
    • Risk for ileo-ileo intussusceptions as opposed to the more common ileo-cecal intussusceptions because of intramural hematoma

The Art of Calling a Consult

Matthew D. Sullivan, MD

  • Succinct Consultation is a required skill set for Emergency Physicians
  • In order to maximally improve your communications in consultation you must practice.
  • Pitfalls in consultation include: consultation at night, cross-covering physicians, change of shift.
  • Anticipating stumbling blocks in consultation is the best way to avoid consultative miscues.

Obstetric Emergency

Mosey Nuccio, MD

  • Premature Rupture of Membranes
    • True ferning has branched appearance versus cervical mucosa that has linear appearance
  • Cord Prolapse
    • Do not remove your hand on the fetal presenting part
    • CALL OB for stat cesarean section
  • Shoulder Dystocia
    • Start the clock! Complications increase after 6 minutes.
    • Call Ob for help
  • Uterine Atony
    • Start oxytocin: 10 units IM or 20 units IV

Pediatric Abdominal Pain

Michael Preis, DO

  • FAST scan in trauma for children is controversial.
    • Sensitivity of 66-83%
  • In appendicitis, the positive likelihood ratio of WBC and CRP combined is 7.75 but only between 4-5 individually.
  • Time is testicle – Salvage rate related to time.
    • 4 hours – 96%
    • 12 hours – 20%
    • 24 hours – 10%
  • Intussusception
    • Imaging modality depends on clinical suspicion
      • High likelihood: Air contrast or barium enema
      • Moderate or low likelihood: ultrasound
        • Have to be aware that ultrasound may miss diagnosis especially if the child doesn’t have pain during exam

Airway Management Case Studies

Michael Gibbs, MD


  • To easily find the cricothyroid membrane in patients with poor landmarks, try placing 4 fingers in a row on the anterior neck with the pinkie finger in the sternal notch.  Your other 3 fingers should be positioned up the neck and your index finger should then fall on the membrane.
  • Nasotracheal Intubation: Try putting the tube in the nose first part way down then load the fiberoptic scope through the tube and you will be looking directly at the glottis.
  • If your nasopharyngeal scope is not long enough to pass through the cords then put the scope in one nostril and put the tube through the other nostril. This will still allow you to visualize the cords and intubate under direct visualization.
  • If you must intubate an asthmatic then make sure to maximize preload with IV fluids. Bag slowly to allow for complete exhalation.
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