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Asymptomatic Bradycardia – usually don’t treat Symptomatic Stable Bradycardia – atropine, further workup Symptomatic Unstable Bradycardia – SIMULTANEOUS treatment with medications and electricity * Meds: Trial of atropine, then either epinephrine, dopeamine, or isoproterenol* Electricity: Transcutaneous Pace –> TVP DDX of Bradycardia – BRADIE Blocks (av blocks) Reduced vital signs (hypoxemia, hypothermia, hypoglycemia) Acs (acute coronary syndrome/ischemia) Drugs (beta blocker, calcium channel blocker, digoxin, organophosphate) Infection/Inc ICP (Lyme, myocarditis // cushings reflex) Electrolyte/Endocrine (hyperkalemia, hypermagnesemia, hypocalcemia // myxedema coma)

What is most important to programs from ERAS? SLOEs, clinical grades on EM rotations and residency interviews. How do you look good on interviews? Have a thorough ERAS application that gives interviewers lots to ask about! On ERAS, there are four sections in the curriculum vitae portion: * Education – honorary societies, medical school awards, other awards/accomplishments (e.g. college, volunteer, previous career awards)* Experiences –* Work (paid, unpaid clinical or teaching)* Volunteer (public service, leadership, clubs and organizations)* Research (labs, projects)* Licensure – only if previous medical career, legal history* Publications – papers, presentations, online publications Don’t forget to add some personality to your application with the hobbies section! Further Reading

ERAS Pt 1: The 8 Parts of the ApplicationThere are 8 parts to the application: * Personal and Biographic Information – mostly self-explanatory* Curriculum Vitae (Resume) – keep an updated CV throughout medical school to makethis easy to fill out, be concise but specific* Personal Statement – start early* Letters of Recommendation – should ideally have two SLOEs from rotations in EMdepartments plus one extra letter* Test Scores – transfer reports from USMLE or COMLEX* MSPE or Dean’s Letter – submitted by your school* Medical School Transcript – submitted by your school* Photo – business professional headshot with neutral background Further Reading: CordEM – SLOE 1 CordEM – SLOE 2

You are working at Clerkship General when you are called to see a 70 yo male who is presenting with shortness of breath. Initial Vitals * Temp 98.0* HR 36* RR 28* BP 80/35* O2 82% Critical Actions * Interpret ECG Correctly (3rd degree AV block)* Order a troponin* Perform and Describe transcutaneous pacing* Perform and Describe transvenous pacing* Treat NStemi (ASA, Heparin gtt, nitro if BP improved after pacing) Further Reading Complete Heart Block – EMDocs Bradycardia – EMCrit

DOPES D-Displacement – endotracheal tube dislodges from trachea, or falls into right mainstem bronchus O-Obstruction – Mucous plugging, bronchospasm, patient biting tube P –Pneumothorax – Look out for pneumothorax, it can be subtle E – Equipment – Disconnected/unpowered equipment, ensure everything is powered on and connected appropriately S – Stacking – common in asthma/COPD due to inadequate expiration resulting in air trapping between breaths Further Reading LITFL – Post-Intubation Hypoxia CanadiEM – Approach to the Alarming Vent

Brainstorming ideas – how to make it personal * What makes me unique? 2. What are some specific experiences I’ve had in my life that have either made me want to do EM or given me the skills that will prepare me well for training in EM? 3. If a family member or a friend were to describe me to a stranger, what would they talk about first? Brainstorming ideas – how to make a statement * What do I bring to the table? 2. What am I looking for in a training program? 3. Where do I see myself in 5-10 years? Further Reading: Personal Statement Library

Welcome to EM Clerkship Maddie Watts! The personal statement should be *personal* and should *make a statement*. * Start early* Use solid organizational structure* Address the big three questions – who? what? why?* Check for grammar mistakes* Explain any red flags Further Reading: EMRA / CORD Advising Guide NRMP Program Director Survey ALiEM Match Advice Series

You are working at Clerkship General when you are called to the resuscitation bay for a 55yo M presenting in respiratory distress. Initial Vitals * Temp 99.9* HR 110* RR 22* BP 122/82* O2 82% on BiPAP 10/5 100%FiO2 Critical Actions * Correctly interpret CXR #1 (multifocal PNA)* Correctly interpret CXR #2 (bilateral PNTX)* Treat with Oseltamivir* Troubleshoot vent alarm#1 (increase sedation)* Troubleshoot vent alarm#2 (place bilateral chest tubes) Further Reading: Acute Exacerbation of COPD – EMCrit COPD – EM@3AM

Cardiac Glycoside containing plants : Foxglove, Lilly of the Valley, Oleander, Squill * Contain cardiac glycosides, which act as a negative chronotrope as well as a positive inotrope.* Patients present with nausea, vomiting, visual changes, bradycardia/arrhythmia, and may develop hyperkalemia – a poor prognostic factor* Treatment is Digibind/DigiFAB – look out for the side effects of hypokalemia as well as anaphylaxis. Anticholinergic Alkaloid containing plants: Jimson Weed, Angels Trumpet, Deadly Nightshade * Contain alkaloids that act as anticholinergics ; often used recreationally* Patients present with delirium/hallucinations, pupillary dilation, anhydrosis, hyperthermia, skin flushing, urinary retention* Treatment is support care, with physostigmine for severe cases – remember to go low and slow! Toxic Mushrooms * Important to distinguish between acute onset symptoms (6hours) or delayed onset (6-24 hours)* Inocybe : acute onset ; cholinergic crisis; treat with atropine* Amanita Muscarina: acute onset; CNS toxicity – delrium, myoclonus, seizures ; supportive care and benzos as needed* Amanita Phalloides: delayed onset ; treat with NAC and maybe Silibinin* Phase 1: 6-24 hrs after ingestion, nausea vomiting diarrhea* Phase 2: transient recovery, 24-60 hours after ingestion* Phase 3: Hepatic / multisystem organ failure* Gyromitra: delayed onset; causes acute B6 deficiency leading to refractory seizures, treat with pyridoxine (vitamin B6) as well as usual seizure care. Further Reading: Stone Heart Syndrome – LITFL Gyromitra – Indiana Poison Center Anticholinergic Intoxication – EMCrit

You are working at Clerkship General when you see your next patient : a 3 year old male accompanied by his father with chief complaint of vomiting.  Initial Vitals * Temp 98.6* HR 50* RR 20* BP 95/55* O2 100% Critical Actions * Identify the history of ingestion* Check a blood glucose* Call Poison Control* Treat with DigiBind* Treat subsequent anaphylaxis Further Reading: EMCrit – Digoxin Toxicity The Tox and the Hound – Digoxin: to bind or not to bind

* Opioid overdose is the number one leading cause of death in adults under the age of 50. * Many ED Physicians fail to recognize that offering MAT (medication assisted therapy) to victims of opiate overdose is one of the most effective interventions we can offer in medicine.* 1 in 2 using high-dose buprenorphine (≥ 16 mg) had retention in treatment – meaning NNT of 2! Further Reading: TheNNT – Opioid Use Disorder

Critical Actions: * Administer Naloxone* Minimize Unnecessary Testing* Discuss options for Rehab* Offer opioid replacement therapy* Provide Social Support Further Reading: Buprenorphine – EMDocs Naloxone – EMDocs Initiating Opioid Treatment in the ED – ACEP