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 collection will provide important considerations for the practice of emergency medicine.

1) Anaphylaxis buys you epinephrine. Think beyond airway and breathing. Rash may not be present. Undifferentiated shock may be it.

2) When interpreting a VBG or ABG, it’s not about mastering math but about putting the data in the context of your patient’s presentation. Lungs and kidneys are at the core of it with several other contributors impacting them.

3) Perfect is the enemy of good. Sometimes a less sensitive study may get your patient moving in the right direction. If you order ‘the more perfect’ study, it may delay the definitive intervention. Understand the strengths and weaknesses of all ancillary testing at your disposal.

4) When the patient is reporting shortness of breath yet has clear lung fields, consider the following differential diagnosis: myocardial infarction, anemia, metabolic acidosis, pericardial tamponade, pneumothorax, and pulmonary embolism.

5) Before sending the patient to advanced imaging, make sure he/she can lie flat for necessary amount of time. Also ask yourself if the imaging will significantly impact management.

6) With head & neck / pulmonary complaints, the patient may be sitting in an odd fashion. While this may be uncomfortable to you, leave the patient alone in his/her position of comfort.

7) When to give 2 grams of ceftriaxone: meningitis, septic arthritis, and community-acquired pneumonia (due to increasing resistance).

8) Know the difference between vasopressor and inotrope. Master evidence-based scenarios of when to use each one. Norepinephrine is the right answer in many cases.

9) Hyperkalemia pearls/pitfalls: EKG rules in, not out; get the lab test. The absolute level of potassium isn’t the whole story; consider the rate of rise. EKG predictors of decompensation include QRS widening, sinus bradycardia, and junctional rhythm; basically, anything wide or slow. Unusual EKG rhythm in an unstable patient, consider hyperkalemia and treat empirically. Treatment comes down to cardiac membrane stabilization (Ca), shifting of K (beta agonist, bicarb, insulin/glucose), or elimination of potassium (dialysis). There are more nuances, but this is a good start.

10) Fournier’s gangrene: sepsis without source => examine the perineum. For patients with groin/perineal “cellulitis”, think about FG. Risk factors: immunosuppression, obesity, diabetes. Lack of severe pain/crepitus doesn’t rule it out! Get them to the OR with Urology; advanced imaging may delay definitive management.

References / Further Reading:

An Emergency Medicine Mindset

Emergency Medicine Cases – Anaphylactic Shock

emDOCs – Pressors Part I and Part II

emDOCs – Hyperkalemia Controversies and Insulin/Glucose Dosing

First10EM – Hyperkalemia

emDOCs – Fournier’s Gangrene

IBCC – Antibiotic Selection


Journal of EM – Rash and Shock

Internal and Emergency Medicine – Antibiotics for MRSA PNA

REBEL EM – Macrolide Resistance in CAP

Iran J Microbiol

Lancet Infect Dis

Antimicrob Agents Chemother

Int J Antimicrob Agents

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