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) Anaphylaxis: always consider in patients with undifferentiated shock. Skin findings are not needed for diagnosis. Laboratory testing is not necessary. Identification, administration of epinephrine, and airway management are key; the same can be said for angioedema minus epinephrine (unless allergic-type).

2) Acid-base disturbances: stop calculating numbers with memorized formulas. Learn common scenarios and develop your clinical gut (i.e., this patient has profuse vomiting, I expect to find a metabolic alkalosis; this is a patient with COPD and acute alteration of mental status, I expect to find an acute on chronic respiratory acidosis with inadequate metabolic compensation; etc.).

Along the same lines if you’re using blood gases, they shouldn’t override your clinical gut; remember, they’re just a single snapshot in time.

3) Hyponatremia: really the only number that matters for an emergency physician is one that’s accompanied with significant neurologic abnormality. Otherwise, leave it alone, admit the patient, and allow the inpatient team to collect meaningful data they desire (we must accept that there are many nuances and pitfalls in testing).

4) Hypokalemia: look for dysrhythmias, consider rhabdomyolysis. Avoid several QT-prolonging agents. Replace orally over intravenously, if possible. K and Mg are friends.

5) Know the limitations of empiric broad-spectrum antibiotic regimens (vancomycin/piperacillin-tazobactam or vancomycin/cefepime). Common one that’s overlooked: no atypical coverage.

6) Think about triggers of vomiting beyond the GI system (i.e., intracranial, cardiac, infectious, etc.).

7) Traumatic shock and where did my patient lose their blood volume: chest, abdomen, retroperitoneum, pelvis, femur, street. Don’t forget about peripheral vascular injuries; this is why tourniquets save lives.

8) Run through a differential diagnosis prior to disposition for unexplained chills/body aches + covid or flu mimic. Here’s ours: meningitis, pneumonia, HIV/acute retroviral syndrome, bacteremia / endocarditis, spinal epidural abscess, myocarditis, toxic shock syndrome, occult sepsis, CO toxicity.

9) When admitting someone for “dehydration”, think about the driver for hyponatremia / hypokalemia / acute kidney injury / ketonuria. Dehydration is easy to fix. Certain etiologies will need specific treatment.

10) When you order the less ideal study but stumble into a serious diagnosis (e.g. CT head with findings of cerebral venous thrombosis or CT abdomen/pelvis with findings of mesenteric ischemia), ask yourself if the initial study was negative would you have pursued the diagnosis. Take a mental snapshot of patient’s presentation and tweak your future care.


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