PERC rule: low risk (<1.

8%) if AFib
1. age <50 - unstable or < 48hrs: sync cardiovert (200J)
2. HR <100 - >48hrs, stable and narrow: diltiazem 0.25mg/kg
3. O2 sat > 94% IV over 2mins
4. No unilat leg swelling - if wide complex use procainamide 15mg/kg over Lacerations
5. No hemoptysis 30min Uncomplicated UTI Max dose 1% lidocaine:
6. No surg/trauma in past 4wks - medicine to see Can be treated without dip or culture if • With epi = 7mg/kg = 50cc; lasts 2-6h
7. No hx of DVT/PE Cardioversion: convincing. Treatment will be finished before • w/o epi = 5mg/kg = 30cc; lasts 45-60 mins
8. No estrogens (even vaginal) AF: start 100-200J, then ! to 360J culture results are in. How long should sutures stay in situ?
AFlut/SVT: start 50J, then ! to 100J
Well’s Criteria for DVT: VT with pulse: 50-100J, then ! to 200J
Septra DS 1 tab BID x 3/7
Macrobid 100mg BID x 5/7
Face = 5 days
Most areas = 7-10 days
1. Active cancer (tx w/in last 6mos) Over joint = 14 days
2. Unilat calf swelling (>3cm diff.) Acute MI:
3. Swollen unilat superfic veins ASA 160mg chewed DKA Tx
4. Unilat pitting edema ticagrelor 180mg or plavix 300-600mg Pneumonia (CAP): Lab def’n of DKA:
5. Hx of documented DVT fonda/enox/UFH Confusion, RR ≥ 30, sBP<90, age >65 • BG > 14, ketosis, pH < 7.3, bicarb < 18
6. Swelling of entire leg STEMI? – PCI + stent (<24hrs) or TNK (<12hrs) * score: 0: OP tx; 1-2: consider; ≥3 inpt tx
7. Local TTP along DV sys Nitro 0.4mg sl q3-5mins (caution in inf. STEMI) * if O2 sat < 92% consider admission In DKA, there is increased urinary excretion of K
8. Paralysis, paresis or recent cast morphine 2-4 mg q3-5mins as well as insulin-mediated shift of K to the ECF.
9. Major surg or bed-ridden in 12 wks 15 lead: Consider RV/post involvement if inf. MI Meningitis: So, while hydration and insulin are mainstays of
10. Alt dx at least as likely or STD in V1-V3 Empiric tx: vanco + ceftriaxone. treatment, you must be careful not to drive the
*d-dimer if low pre-test prob Add ampicillin if EtOH/age>50/immunodeficient patient into hypokalemia
Sgarbossa Crit. (use LBBB or paced)
Well’s Criteria for PE: -LBBB by itself not a STEMI equivalent
- if hemodyanamic instab. or acute CHF then
Bacterial: >1000 WBC/mm3, gluc decr, prot incr
Viral: <100 WBC/mm3, lymph, gluc N, prot incr
Aggressive IV fluid resuscitation, AND
K < 3.3, no insulin, give 40mmol KCl
1. Clinical signs + symptoms of DVT STEMI equiavlent K 3.3-5.2 give insulin regular with 20mmol KCl
2. “PE is #1 dx or equally likely” A. concordant STE in any lead (>1mm) K > 5.2, can just give insulin
3. HR > 100 B. concordant STD in V1-V3 (>1mm) If BG < 16, give glucose alongside insulin
4. Immobilization x 3/7 OR Surgery past 4/52 C. discordant STE with ratio > 25% Migraine Mx:
5. Previous, objectively dx’d PE or DVT IV fluids Resolution: Bicarb > 15, pH > 7.3, anion gap
6. Hemoptysis metoclopramide 10mg IV closed, glucose < 11.1
7. Malignancy wishing 6/12 OR palliative Stroke Mx: ketorolac 30-60mg IV (d/c with NSAID)
- check glucose. Status Epilepticus
GCS: - CT Head – r/o bleed
- consider t-PA if ischemic stroke w/in 4.5hrs
Renal Colic Mx:
UA, imaging
Airway, IV access
Stat labs (glucose/na/cr/drug levels/ca)
Motor:
- CAEP does not recommend or U/S can’t see stone, but can see clinically-relevant 100mg thiamine IV
6 – follows commands
condemn the use of tPA. hydronephrosis 1 amp d50
5 – localizes pain
- if no t-PA, give ASA 160-325mg PO chewed analgesia (NSAID +/- opioid) Terminate seizure
4 – nonpurposeful movement to pain
- permissive HTN tamsulosin 0.4mg PO QHS x 28d (evidence?) First try ativan (give PR diazepam if no IV)
3 – flexes upper ext to pain
Syncope: ?abx: ie. cipro 500mg PO BID Then phenytoin, Then phenobarb
2 – extends all ext to pain
Then GA with propofol (If under GA need
1 – no response to noxious stim Cardiac Hemorrhage Others Acute Psychosis/Agitation emergency EEG to r/o non-
Verbal:
Arrhythmia GI Meds olanzapine 10-15mg PO/IM convulsive status)
5 – orientated x3
haldol 5mg + lorazepam 2mg PO/IM/IV
4 – converses but confused
MI Ectopic Orthostasis benztropine 0.5-2mg PO/IM/IV for dystonia Anaphylaxis
3 – replies w/ inapp words
ABCs
2 – makes incomprehensible sounds
Valvular Dz AAA PE Epinephrine is far more important than any other
1 – no response
drug in anaphlaxis. Give 0.5mg IM
Eyes:
WPW Trauma SAH After that, can give prednisone, benadryl,
4 – spontaneously
ranitidine and/or ventolin
3 – to speech Brugada
2 – to pain
1 – no eye opening HOCM

LQTS

Canadian CT Head: (GCS 13-15)

1. Take all advice with a grain of salt, including the advice written here.
2. Own your patients. Know them well and make sure you follow-up on their labs/imaging in a timely manner. Since you will be caring for multiple patients
concurrently, a tracking method is super useful. I take a sticker from each patient chart I’m managing and stick it in a clipboard or notebook I keep with me.
This lets me make running to-do lists (“f/u CXR” “r/a post-ventolin” “consult medicine”) right on the page, and the page can be thrown in the confidential bin at
the end of shift. Having a system helps you make sure you understand and remember everything that needs to be done for all your patients.
3. At the end of presenting your patient assessment to your supervisor, they will invariably ask you some variation of the following two questions: “What do you
think is going on, and what do you want to do?”. Ask yourself these questions before someone else does. Another helpful question to know the answer to:
“Where is this patient going?”. (i.e. discharge now or after xyz test vs. possible consult vs. almost certain admission). These questions are helpful because
they will help you figure out what the most efficient/useful first steps of your care might be.
4. We have all seen patients in the ED who probably don’t need to be in the ED. Try to resist the urge to be flippant or dismissive. In the real world, these are as
much your patients as the trauma/ACS/laceration patients and, until they walk out your door, you are their doctor. Make sure all your patients have a good
doctor, not just the “fun” ones.
5. If you wanna invest in gadgets to keep with you while on shift, I recommend a cheap penlight and a cheap pair of trauma shears. These are handy but not
crucial. One of the best “tools” you can bring is a sizeable volume of good-enough pens.
6. From a coffee lover: do not underestimate the power of keeping a water bottle on the go to get you through an 2300-0700 shift. Thoughts of an unhealthy
post-shift breakfast can also be quite motivating.
7. If a nurse is giving you pushback about one of your orders, listen to what they have to say. I have stopped counting the number of times a nurse’s question/
suggestion/concern about my orders has saved me and my patient’s bacon.
8. Ask for help. I am a PGY3 in Emergency Medicine, and if I have serious concerns about my patient, I have zero qualms about pulling a staff out of a room to
get help. I have also never had a staff be angry with me about doing that, even in situations where things were less acute than I initially thought they were. If
you are concerned, let someone know. If you are being asked to do something that you know you don’t know how to do, let someone know. Your staff is way
more reassured by you being openly safe and teachable than by you trying to minimize the appearance of your knowledge gaps.
9. If you see someone else doing a procedure you find interesting, ask them if you can assist or observe. The answer will almost invariably be “yes”.
10. Although it’s really more of an expectation than a tip, being nice to everyone you meet in the ED will serve you very well in the long run, I promise you.

Please feel free to ask me any questions you can think of, even the little ones, and even the general/non-emerg questions. I would be humbled if you considered
me a general resource during your clerkship. My email address is [email protected] and you can text me at 647-965-2563.

The ED cheat sheet on the opposite side was adapted by me from a sheet made by the fantastic Dr. Lincoln Foerster. Again, take it with a grain of salt as an
unvalidated resource and let me know if you find any errors.

All the best on this and future rotations.

-Joe

Joe Gabriel, MSc, MD, CCFP