EM Thinker: Pearls from the Frontlines

Authors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome back to The EM Thinker series. This series will provide important considerations for the practice of emergency medicine.


1) Multiple visits for nephrolithiasis: CT renal colic is not needed each and every time. What’s the patient history like – co-morbidities with higher risk for kidney diseases, type of stone, antibiotic courses, complications, interventions, etc.? What it boils down to is severe sepsis/septic shock +/- in setting of obstruction. Consider serious mimics when appropriate. Master interpretation of lab work and urinalysis, and know their limitations. Bedside ultrasound can be helpful, but also has its limitations. Bottom line: it’s not a one-size-fits-all disease.

2) Female with abdominal pain + you’re obtaining a CT. Did you consider OB/Gyn pathology and do a complete exam? The answer may lie there and a CT may be unnecessary.

3) When should you obtain stool studies: ill patient in front of you with systemic sympotms, immunocompromised, grossly bloody diarrhea, > 1 week of symptoms and not improving. There are nuances to antibiotics and antimotility agents; look them up each time. With a WBC > 20 in patient with no source, consider C. diff colitis.

4) If you’re able to obtain a cohesive patient story, it will likely jive with your work-up. If not, consider expanding what you’re doing. Language/communication barriers add a lot of complexity.

5) If pneumomediastinum is identified => consider esophageal and pulmonary sources. The major conditions to not miss include esophageal perforation and tracheal perforation.

6) Small puncture wound in vicinity of fracture, give a dose of antibiotics and don’t look back. Type I is what burns emergency physicians along with not considering the environment the injury occurred in.

7) Beware reflexive use of propranolol in patients with thyroid storm, especially in cases of undiagnosed cardiomyopathy. We likely over-diagnose this entity as Burch-Wartofsky scale has its limitations. Perform a bedside echocardiogram and save a life. Esmolol may be a better option, but we don’t have great data.

8) Don’t anchor on equivocal or contaminated urinalysis as source of infection in patients with diabetes. Do a thorough history and exam and consider the list of sneaky infections.

9) Find a way that works for you to stay up-to-date on meaningful clinical changes. 1 recent example: https://www.cdc.gov/std/treatment-guidelines/urethritis-and-cervicitis.htm and https://www.cdc.gov/std/treatment-guidelines/pid.htm

10) ECG with slow or wide rhythm: consider hyperkalemia. Management approach to bradycardic periarrest includes electrical and medical arms. Simplify your approach to etiology and look up the rest: DIE (Drugs, Ischemia, Electrolytes).


Further reading:

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