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Hypertensive Emergencies of Pregnancy PreEclampsia, Eclampsia, HELLP syndrome Diagnosis: BP >140/90 plus end organ dysfunction * Acute Kidney Injury * Proteinuria * Thrombocytopenia * Transaminitis * Hemolysis * Pulmonary Edema * Cerebral Edema / Hemorrhage * Headache refractory to tylenol * Visual Changes * RUQ Pain not attributable to another diagnosis Treatment * Loading Dose: IV Magnesium 4-6g over 20-30 min OR 5g IM in each buttock * Maintenance Dose: 1g/hr IV * Antihypertensives (goal 20% reduction): Labetalol, Nicardipine, Hydralazine * Delivery of fetus and placenta

You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache. Initial Vitals: HR: 56 BP: 172/93 Temp: 98.8F RR: 18 O2: 97% Critical Actions: * Check a Blood Glucose * Diagnose Preecclampsia/Ecclampsia * Administer Magnesium * Treat the Hypertension * Discuss with OBGYN and Admit

Diagnosing PE: Step 1: Consciously consider the diagnosis Step 2: Risk Stratify into low, intermediate, and high risk Step 3: Choose appropriate testing based on pre-test probability Classification of PE * High Risk/Massive PE: Hemodynamic Instability * Intermediate Risk/Submassive PE: Right Heart Strain without instability ; or PESI Class 3+ * Low Risk/Non-Massive PE: Everything else (no instability, no heart strain, PESI Class 1-2) Treatment of PE * High Risk/Massive PE: Thrombolytics and often thrombectomy * Intermediate Risk/Submassive PE: Heparin and sometimes intervention * Low Risk/Non-Massive PE: Either discharge with DOAC or admit with heparin

You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.” Initial Vitals: HR: 122 BP: 75/40 Temp: 100.1 RR: 24 O2: 74% Critical Actions: * Obtain full set of vital signs * Treat the patient’s pain * Diagnose PE without imaging * Stabilize patient prior to imaging * Transfer the patient for thrombectomy

Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion * Hypovolemic Shock * Hemorrhage * Volume Loss (vomiting/diarrhea, dehydration) * Cardiogenic Shock * ACS, Myocarditis, CHF, Valve failure, Endocarditis, etc * Obstructive Shock * Massive PE, Tension Pneumothorax, Cardiac Tamponade * Distributive Shock * SIRS (Septic Shock, Pancreatitis, Severe Burns) * Anaphylactic Shock * Neurogenic Shock * Adrenal Crisis

You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision” Initial Vitals: HR: 65 BP: 88/50 Temp: 97.0F RR: 20 O2: 96% Room Air Critical Actions: * Apply Cervical Collar * Treat the Patient’s Pain * Give Antibiotics for Open Fracture * Identify and Prioritize Etiologies of Shock in Trauma * Start Vasopressors for Neurogenic Shock

* Differential * Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter * Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors * Work-up * XRay * Labs to evaluate for septic arthritis – CBC BMP ESR CRP * Kocher Criteria * Non-weight bearing * Fever >38.5C * ESR >40 * WBC >12 * Kocher Criteria Statistics * 0 points: 0.2% (or 2% in prospective studies) * 1 point: 3% (or 9% in prospective studies) * 2 points: 40% * 3 points:93% * 4 points: 99% * Septic Arthritis DX * >50,000 WBC * Age 0-3mo : group B strep * Age 3mo – 12 years: Staph Aureus * Age 12-18 years: Gonorrhea * Sickle Cell Disease: Salmonella

You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury. Initial Vitals: HR: 112 BP: 97/67 Temp: 99.2F RR: 20 O2: 97% Room Air Critical Actions: * Consider Non-Accidental Trauma * Evaluate for Septic Arthritis * Treat the Childs Pain * Diagnose Lyme Disease * Prescribe Antibiotics (Avoid Doxycycline)

* Focused Physical Exam * Tachypnea and Hypoxemia * Able to speak in complete sentences * Accessory muscle use/retractions * Moving air or quiet on auscultation * Basic Treatment Algorithm * Albuterol Inhaler * Albuterol/Ipratropium Nebulized (Duoneb) * Steroids * IV Magnesium * Non Invasive Ventilation (CPAP or BiPAP) * Decreases Work of Breathing * Epinepherine * Less Common Treatments * Benzodiazepines * Ketamine * Heliox * Intubation (Last resort) * Use a large ETT (8.0) * Increase the Expiratory Time * “Permissive Hypercapnea” * Appropriate ventilator management of asthma frequently results in mild hypercapnia and respiratory acidosis. IT’S OK * Air Trapping * Results in decreased preload, obstructive shock and pneumothorax * Suspect with high airway pressures and when waveform doesn’t return to zero (see media) * Treat by briefly unhooking ventilator and gently pressing on the patient’s chest to get out the trapped air * Ventilator Settings * Decrease the respiratory rate (ex 10) * Increase the tidal volume (although some hypercapnia is permitted) * Increase I:E ratio (1:4 or greater)

You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes” Initial Vitals: HR: 123 BP: 142/78 Temp: Unknown RR: 36 O2: 97% (NonRebreather) Critical Actions: * Give Albuterol, Steroids, and Magnesium * Give either Epinephrine or Terbutaline * Post Intubation Checklist: Sedation, Tubes, and Xray * Choosing Appropriate Vent Settings * Allow permissive hypercapnia

Introduction * Used as pesticides * Used as weapons (nerve agents) * Sarin Gas, VX Gas, Novichok * Transdermal, Inhalation, Ingestion Clinical Presentation * Muscarinic Activation (Dumbels Mnemonic) * Defication * Urination * Myosis * Bradycardia, Bronchospasm, and Bronchorrhea * “The Killer B’s” * Emesis * Lacrimation * Salivation and Sweating * Nicotinic Activation * Muscle weakness and paralysis * CNS Activation * Respiratory Depression * Altered Mental Status * Seizures Treatment * Atropine * Reverses Dumbels * Keep giving and doubling the dose until brochorrhea and bradycardia resolve * Pralidoxime * Only works before ‘aging’ occurs * Diazepam * Stops the seizures

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General. We are bringing you an unresponsive 6-year-old female found foaming at the mouth by her babysitter. ETA 2 minutes.” Initial Vitals: BP: 125/80 HR: 62 RR: 34 O2: 81% (Non Rebreather) Critical Actions: * Grab the Broslow! * Fingerstick Glucose * Choose Endotracheal Tube Size * Administer Atropine until bronchial secretions stop * Pralidoxime