This document summarizes 10 common medical emergencies: 1. Pulmonary embolism (PE) - It discusses signs, symptoms, and PERC criteria to rule out PE. 2. Acute coronary syndrome (ACS) - It outlines the spectrum of ACS and characteristics that increase likelihood of AMI. 3. Hyperkalemia - It provides strategies for treating and shifting potassium intracellularly or eliminating it. 4. Subarachnoid hemorrhage (SAH) - It notes the acute onset and need to rule out SAH with CT or LP if symptoms present. 5. Sepsis - It emphasizes assessing vital signs, CBC, blood cultures, urine analysis, and evaluating

1. The 10 Medical
Emergencies
(You Can't Miss!)
John Bielinski MS PAC

2. The 10 Medical Emergencies You Can't
Miss
PE

3. DDx of Chest Pain
Who is Your PAPPA?
• P = Pericarditis
• A = Acute Coronary Syndrome
• P = Pneumothorax
• P = Pulmonary Embolism
• A = Aortic Aneurysm (Thoracic) 3
Acute onset

4. HORIDDon’t Make A HORID Mistake!
• H = Heart (CHF/ACS)
• O = Obstructive
• R = Reactive (COPD/Asthma)
• I = Infection
• D = Death! (From a PE/Pneumothorax)
4

5. Clots
•Heart attack Thrombus
•Stroke Emboli
•Pulmonary EmbolismEmboli
Thrombus vs.
Emboli?

6. Virchow’s Triad:
• Damage to extremity
• Stasis
• Hyper-coagulable State
• Estrogen/Cancer/Genetics
Venous Disease
Risk Factors

7. PERC
RulesPulmonary Embolism Rule Out Criteria
<50?

9. • Vital Signs:
– Heart rate <100 bpm
– O2 saturation ≥95%
• Virchow’s Triad:
– No estrogen use
– No surgery/trauma requiring hospitalization within the
prior four weeks
• No hemoptysis
• Age <50 yrs
• Leg findings:
– No prior DVT or PE
– No unilateral leg swelling
Raja AS, Greenberg JO, et al Ann Intern Med. 2015;163(9):701
PERC Rules

10. The PERC Rule:
ACEP
• For patients who are at low
risk for acute PE, use the PERC
rules to exclude the diagnosis
without further testing
Level B Recommendations = reflect “moderate clinical certainty”
ACEP Guidelines: Acute Venous Thromboembolic Disease

11. SOB 73
Pleuritic CP 66
Leg Complaints 44
Cough 37
Wheezing 21
Stein PD et al, Chest. 1991;100(3):598.
Symptoms of PE

12. Tachypnea 54
Leg Findings 47
Tachycardia 24
Rales 18
Fever 3
Signs of PE
Stein PD, et al Am J Med. 2007;120(10):871.

13. The 10 Medical Emergencies You Can't
Miss
PE
ACS

14. Spectrum of ACS
Unstable
Angina
NSTEMI STEMI
Positive Troponin

15. H

16. Characteristics that Increase Likelihood
of AMI
Pain Descriptor Positive Likelihood Ratio
Radiation to right arm or shoulder 4.7 (1.9-12)
Radiation to both arms or
shoulders
4.1 (2.5-6.5)
Associated with exertion 2.4 (1.5-3.8)
Radiation to left arm 2.3 (1.7-3.1)
Associated with diaphoresis 2.0 (1.9-2.2)
Associated with nausea or
vomiting
1.9 (1.7-2.3)
Worse than previous angina or
similar to previous MI
1.8 (1.6-2.0)
Describes as pressure 1.3 (1.2-1.5)
Swap CJ and Nagureney JT, JAMA, November 23/30, 2005—Vol 294, No. 20

17. Drive = Red Flag

18. Chest Pain with …
• D = Diaphoresis
• R = Radiation
• I = I won’t get burned!
• V = Vomiting
• E = Exertion
Swap CJ and Nagureney JT, JAMA, November 23/30, 2005—Vol 294, No. 20

19. H
E
A
R

20. • National Registry of Myocardial Infarction:
– >540,000 patients
– 1994 – 2006
– Presented with a first AMI with no prior
cardiovascular disease
• 86 percent had one of five major risk factors:
– HTN, smoking, dyslipidemia, DM, or + FHx
Canto JG et al. NRMI Investigators SO JAMA. 2011 Nov;306(19):2120-7
Cardiac Risk Factors

21. It’s a “SAD” Case of “CHF”
Cardiac Risk Factors
S = Smoking
A = Age
D = Diabetes
C = Cholesterol
H = Hypertension
F = Family History
21
Arterial Disease
Risk Factors

22. H
E
A
R
T

23. Heart Score
Interpretation
• Low Risk = Heart Score 0-3
• Risk of MACE 1.7%
• Intermediate Risk = Heart Score 4-6
• Risk of MACE 16.6%
• High Risk = Heart Score 7-10
• Risk of MACE 50.1%
• Interventional cardiologist?
B.E. Backus et al, International Journal of Cardiology, 168 (2013) 2153–2158

24. • The external, prospective demonstrated that
of 2,388 patients with chest pain:
–1.7%of patients with a score of 0-3 had a
major adverse cardiac event within 6 weeks.
– This was further reduced to <1%when a
second troponin was added 3 hours later.
Backus BE et al Int J Cardiol 2013;168:2153-2158.
Mahler SA et al Int J Cardiol 2013;168:795-802.
Mahler SA et al Circ Cardiovasc Qual Outcomes 2015;8:195-203.

25. Chest or Pulmonary
Symptoms?
• Document on every chart:
100% of the time!!!
• 1) Arterial risk factors - “SAD-CHF”
• 2) Venous risk factors - Virchow’s
Triad
• 3) Symmetrical legs - “No Homan’s
Sign”

26. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia

27. EKG Changes with Hyper
K+

28. Symmetrical T Wave

31. How do we treat
Hyperkalemia?
1) Stabilize (Ca+)
2) Shift into cell
3) Eliminate

32. Metabolic
Acidosis
H+
H+
K+
H+

33. “Osmol Shift”
33
Glucose
Glucose
Glucose
K+
K+

34. Shift Potassium
Intracellular
• 1) Sodium Bicarbonate
• 2) Insulin/Glucose
• 3) High Dose Proventil
34

35. • 1) Kayexalate PO/PR
• 2) Dialysis
• 3) Loops?
Get Potassium Out
Usually
need more
the one!

36. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH

37. Subarachnoid
Hemorrhage
• Acute Thunder Clap
• N/V
• Neck Pain
• Syncope
• 90-95% found on CT
• If not there  LP
• Yellow Color = Old Blood (Xanthochromia)

38. Acute
Onset?• Burst
• SAH/aneurysms/ovarian cyst
• Emboli
• Stone
• Kidney/gall
• Twist
• Torsion/cysts
It’s BEST to
evaluate
acute pain
carefully

39. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH
Sepsis

40. Septic Workup
• VS: Temp  VALID TEMP!
• CBC  Absolute number, Segs and
Bands
• Blood Cultures x 2
•VALID URINE and CXR
• If not, think “brain and belly”
–CT Abd?
–Meningeal signs?
– Kernig's and Brudzinski’s

41. Sepsis?
5 Body Compartments
•Wind & Water
•Brain & Belly
•Skin

42. QuickSOFA
(qSOFA):
•Brain
• Altered mentation
•Breathing
• Respiratory ≥ 22/min
•BP
• SBP ≤ of 100 mm Hg

43. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH
Sepsis
Appy

44. Appendicitis
44

45. Best Test to Dx
Appy?

46. Appendiciti
s• Classic = Periumbilical
pain
• P = Psoas Sign
• R = Rovsing’s Sign
• O = Obturator Sign
• M = McBurney's point
46

47. • Psoas sign
–  retrocecal appendix
• Sensitivity 13 to 42%; specificity 79 to 97%
• Rovsing's sign “indirect tenderness”
– Sensitivity 22 to 68%; specificity 58 to 96%
• Obturator’s sign
–  Pelvic appendix
– Sensitivity 8%; specificity 94%
• McBurney's point
– Sensitivity 50 to 94%; specificity 75 to 86%
Appendiciti
s

48. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH
Sepsis
Appy
Sick Kid

49. “Sick Kid?”
Also Known as “The Look”
• T = Tone (strong or weak?)
• I = Irritability
• C = Consolability
• K = “Kry” (loud and vigorous or wimpy)
• L = Labor (breathing)
• E = Environment (appropriate?)
• S = Suckling (eating/drinking history)

50. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH
Sepsis
Appy
Sick Kid
Epiglottis

51. Epiglottitis
Symptoms
Sick
Tripod Position
Fever
Stridor
High Pitch Voice
Drooling
Bug:
Group A Strep/Staph/H. Flu
Treatment: Antibiotics
51

52. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH
Sepsis
Appy
Sick Kid
Epiglottis
SI

53. Risk of Suicide?
• S: Male sex
• A: Age
• D: Depression
• P: Previous attempt
• E: ETOH/Substance use
• R: Rational thought loss
• S: Social supports lacking
• O: Organized plan
• N: No spouse
• S: Sickness 53

54. Organized plan
Anhedonia

55. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH
Sepsis
Appy
Sick Kid
Epiglottis
SI
Sick Eye

57. “Limbus Clear”
57

59. 59

60. 60

61. The 10 Medical Emergencies You Can't
Miss
PE
ACS
Hyperkalemia
SAH
Sepsis
Appy
Sick Kid
Epiglottis
SI
Sick Eye

62. Welcome to the
NCAPA
2018 Summer