EM Board bombs
@EMBoardBombs
Followers
13,709
Following
654
Media
1,946
Statuses
9,621
Co-hosts @blakebriggsMD & @iltifatMD (Academic Faculty). We drop multiple podcasts a week in our podcast:
United States of America
Joined July 2018
Don't wanna be here?
Send us removal request.
Explore trending content on Musk Viewer
Can Can
• 3485767 Tweets
#Paris2024
• 662758 Tweets
#Paris2024
• 662758 Tweets
Olimpíadas
• 162410 Tweets
Macron
• 134699 Tweets
フランス
• 99363 Tweets
#OpeningCeremony
• 84229 Tweets
Lady Gaga
• 78576 Tweets
#4MINUTES_EP1
• 71063 Tweets
Seine
• 69145 Tweets
Snoop
• 67110 Tweets
オリンピック開会式
• 63443 Tweets
França
• 51998 Tweets
Sena
• 49847 Tweets
HAPPY TASTY CHEF
• 49260 Tweets
#ceremoniedouverture
• 46810 Tweets
Zico
• 46595 Tweets
対象作品
• 35266 Tweets
#CerimoniaDeAbertura
• 33746 Tweets
Rio 2016
• 24741 Tweets
Zidane
• 21477 Tweets
#GioHocayaTransfer
• 16044 Tweets
セーヌ川
• 12421 Tweets
Notre Dame
• 11002 Tweets
Pinned Tweet
What's your guess? 🤔
A new episode of
#EMBoardBombs
is out now wherever you get your podcasts.
🎧 Listen:
📺Watch:
2
0
3
Unless you're trying to make them more acidotic, resuscitating DKA with NS makes. no. sense.
#FridayFeelings
#MedTwitter
51
291
2K
Thyroid storm treatment has to go in this specific order:
1) Control unstable beta-adrenergic symptoms- Beta-blockers
2) Stop hormone release- Thionamides
3) Stop new hormone production - Iodine
4) Reduce inflammatory burden - Glucocorticoids
Stream episode 139 for more
1
119
627
IV calcium for hyperkalemia should ONLY be given when ECG changes are seen - otherwise you are just worsening renal failure (bc the elevated phosphate will precipitate with the calcium) without a balance of known benefit
#FridayFeelings
13
91
580
Alcohol Ketoacidosis occurs when a malnourished patient stops drinking, and falling ethanol levels stimulate ketogenesis. Ethanol itself suppresses gluconeogenesis as well, making hypoglycemia worse.
Keep this on your hypoglycemic differential!
1
72
360
Hypokalemia contributes to hyperammonemia by decreasing ammonia excretion; correcting hypokalemia is thought to decrease ammonia levels in patients with hepatic encephalopathy.
#FOAMed
2
67
317
Sulfonylureas respond to increased blood glucose by increasing endogenous insulin release - this is why, if a pt is hypoglycemic on one of these drugs, giving IV dextrose won't cut it. They need octreotide (~1-2mg/kg/hr) & admission!
1
59
297
Remember the "rule of 50s" for hypoglycemia treatment in kids- don't forget it for boards & life! Easy points right here:
>8 y/o= D50 x 1ml/kg
1-8 y/o= D25 x 2ml/kg
<1 y/o= D10 x 5ml/kg
#FOAMed
#Pediatrics
0
94
283
You're handed this EKG for "stroke alert". RN says patient is obtunded. BP 105/60, sat 96%. Next step?
46
36
286
Fibrillation waves are often best seen in the inferior & R sided precordial leads. If you're unsure, get Lewis leads to better focus on the atrial conduction.
3
92
278
If the guy who named the walkie-talkie also worked in
#medicine
...
Defibrillator= hearty starty
Phlebotomy= veiny drainy
TXA= gusher crusher
Keep it going!
#medtwitter
@reverendofdoubt
@Rick_Pescatore
@MDaware
@DocAroundThClok
@mcsassymd
@ResusMed
@EMinMiami
34
50
253
Repeat after us:
CXR does not rule out Aortic dissection
CXR does not rule out Aortic dissection
CXR does not rule out Aortic dissection
(your board exams agree)
1
18
254
The toe web-space is the most common sensory site involved in compartment syndrome since it is innervated by the deep peroneal nerve (in the anterior compartment).
0
36
229
Sulfonylureas respond to increased blood glucose by increasing endogenous insulin release - this is why, if a pt is hypoglycemic on one of these drugs, giving IV dextrose won't cut it. They need octreotide (~1-2mg/kg/hr) & admission!
8
54
212
The actual AKI definition:
o Increase in serum creatinine 0.3 mg/dL compared to 48hr prior
o Increase in serum creatinine 1.5x baseline or presumed baseline from within the last 7d
o UOP falling to < 0.5 ml/kg/hr for at least 6 hours
1
37
201
For an intubated asthmatic, PEEP needs to be as low as possible ~5, FiO2 can be low, targeting sat of 88-92%, and I:E ratio should be long! (1:3 or 1:4).
EM Rapid Bombs has an entire episode on intubating & ventilating these high risk patients.
2
48
187
Got a male patient whose chief complaint is that his pregnancy test was positive? 🤔
While seminomas only produce bhcg, nonseminomatous germ cell tumors produce bhcg and AFP. Get imaging to look for an anterior mediastinal mass!
#FOAMed
3
25
181
Our mnemonic for causes of
#Bradycardia
: “ATROPINE”
Anterior MI
Thyroid, Adrenal disorders
Rhythm disorder
Overdose- bblocker, CCB, digoxin
Pressure up- increased ICP
Inferior MI
Nippy- hypothermia
Electrolytes- K, Ca, Mg
5
49
181
ECG evidence of P pulmonale (ie R atrial enlargement) = P wave that is
> 2.5 mm in the inferior leads (II, III and AVF)
> 1.5 mm in V1 and V2
If a COPD patient has this on ECG they need home O2
2
29
177
NSAID dosing for gout flare can be any of the following for 7d:
-Naproxen 500 mg BID
-Indomethacin 50 mg TID
-Ibuprofen 800 mg TID
Perfect for those <60 years old who lack renal, cardiovascular, or ulcer disease
4
39
171
On a 12-lead, suspect RV infarction in the following:
-ST elev. in V1 or V1 > V2
-ST elev. in Lead III > II
-ST elev. in V1 with ST depression in V2 (most specific!)
!!!Most important lead is V4R. ST elev = 80% spec. & sens.
0
35
168
Peripheral effects in anticholinergic toxicity:
🦴 “Dry as a bone” = dry skin
😡 “Red as a beet” = flushed skin from hyperemia & anhidrosis
🌡️ “Hot as a hare” = hyperthermia
🦇 “Blind as a bat” = blurry vision due to mydriasis
⚗️ “Full as a flask” = urinary retention
4
61
161
Ketamine preserves airway reflexes, and it has proven itself to be a fantastic induction agent and bronchodilator for asthmatic patients. It can be used as part of an overall sedation and anxiolysis strategy for Bipap in struggling asthmatics
5
36
163
Don't let pediatric EKGs trip you up - you know more than you think!
In infancy, RV > LV (think about the in utero blood supply with high pulm vessel resistance). So basically, an infant EKG is that of RV hypertrophy!
1
33
156
Bidirectional Nystagmus means the direction of nystagmus changes based on direction tested, e.g. left beating nystagmus when looking left, but changes to right beating nystagmus when looking right. This is concerning for stroke!
2
21
152
EMS comes in with this strip and says "well doc, it looked like SVT so we gave adenosine" ...
What happened & why?
16
24
135
STOP giving Lasix early in Flash Pulm (o)edema (SCAPE). You are harming your pts. >50% pts are euvolemic. Nitro & Bipap saves lives, reduces intubation.
#FOAMed
#FridayThoughts
#medicine
#medtwitter
@emcrit
@amalmattu
@WakeEMresidency
@MahlerHEARTpath
#Cardiology
#cardiovascular
4
44
134
When is LMWH (lovenox) the preferred agent for treating VTE over a DOAC:
-Cancer
-Liver disease
-Pregnancy
11
25
134
If you fail to obtain an ABG and need to reposition: withdraw the needle to where the tip remains under the epidermis then redirect either medially or laterally to try again. DON'T REPOSITION THE NEEDLE WHILE IT IS FULLY INSERTED (this is how you dissect the artery)
4
33
126
When resuscitating a burn remember that your clock starts at the time of injury! Half your resus fluids need to happen in the first 8 hours from their injury, not from when you start the resus.
2
19
120
Quick initial vent settings for intubated asthmatic:
Rate 8-12
TV 6-8 mL/kg IDEAL body weight
I:E ratio 1:4
PEEP 5
FiO2 titrate to SpO2 >92%
Keep plateau pressure <30
*getting an idea of their MV prior to intubation can also help you here
5
29
122
No one should ever roll their eyes at getting a repeat EKG 🙄 Studies have shown 11-15% of STEMIs were diagnosed on REPEAT EKG. STEMIs can develop in the ED (or after triage). Be aware!
#FridayFeelings
5
26
119
Myastheic crisis can be precipitated by fluoroquinolones, beta blockers, doxy/tetracycline, procainamide. These pts can develop apnea really quickly so be ready! And remember your preferred paralytic in this case should be roc (a non depolarizing agent)
3
35
117
Hyponatremia? Check homeostatic mechanisms:
🍩 Serum osm>290 = hyperglycemia (remember corrected Na) or renal failure
💧 Urine osm<100 = primary polydipsia or malnutrition
🤕 Urine osm>serum osm = SIADH
0
18
119
A "DNR" in simplest form = do not perform CPR. It does NOT mean-
-withhold standard of care in ED
-not giving pain meds
-not giving antibiotics
-treating them grossly different from any other pt w/ a pulse
#FridayFeelings
1
42
116
Currently asymptomatic male, mid 20s, otherwise healthy. Had an episode of chest pain, dyspnea, palpitations at rest prior to presentation. What is going on here?
#MedTwitter
@smithECGBlog
@srrezaie
22
20
112
Trying to diagnose tamponade by physical exam?
-Beck’s Triad performs poorly (10% sensitivity)
-JVD is individual component that performs best (76% specificity)
-Pulsus paradoxus is most sensitive AND specific physical examination finding (82%)
1
14
114
"When you say dizzy, do you mean the room is spinning?" is the most useless question in the ED. Half of pts change the answer to their description of dizziness just minutes apart! Time course, provoking & aggravating factors are more useful questions.
#FridayFeeling
3
17
109
Cocaine blocks sodium channels & causes QRS widening similar to TCAs inducing life threatening dysrhythmias. Sodium bicarbonate works in cocaine-induced arrhythmias by flooding the sodium channels, overcoming blockade & narrowing the QRS.
#FOAMtox
0
26
110
Easy way to remember what meds can be given via ETT!
(But remember no vasopressin if pediatric patient)
#FOAMed
6
32
109
Who doesn't love a good table? This one is for the genital ulcers. Gross, but you gotta know 'em, especially for boards! Tx is diff for each.
1
33
109
What is the *first* sign of cauda equina? Urinary retention! The incontinence that you associate with this syndrome is overflow incontinences. Easy boards question!
2
17
110
@MikeGatMe
In short 🔺️plasma chloride ➡️ 🔻strong anion difference ➡️ 🔺️renal bicarb excretion. There are lots of great posts/papers out there on it - Here's an oldie but goodie from
@PulmCrit
2
19
106
Leukemoid reaction (not a leukemia)= response to severe infection; leukocytes >50,000! Differentiate from CML by presence of high alkaline phosphatase, higher number of late neutrophil precursors (metamyelocytes, bands) & lack of absolute basophilia. See: LAP score
#FOAMed
0
20
105
If a question stem presents you with a patient who appears to have Guillain-Barré but has a fever - think transverse myelitis instead
1
13
105
>80% of pts with cerebellar strokes lack classic stroke findings & present w/isolated vertigo, n/v, unsteady gait, & head motion intolerance. Watch out for these subtle clues in pts w/vertigo!
2
30
102
Pontine ICH = PinPoint Pupils, loss of horizontal gaze, quadriparesis (decerebrate posturing = rigid upper & lower extremities). These patients die rapidly, don't miss it!
0
34
98
Risk factors for ketamine induced laryngospasm
-Instrumentation or irritation of the vocal cords under light sedation
-Current or recent URI
-Young infants are at highest risk; generally more common in peds than adults (from 1.7-25%)
-Airway anomalies
1
17
100
Rapid high dose IV fentanyl carries the risk of glottic spasm & chest wall rigidity - these are not always reversible w/narcan. Be prepared!
5
16
95
Dexamethasone for meningitis? 0.15 mg/kg dex before or w/abx if strong suspicion for bacterial meningitis, but unknown bug. It should only be continued if bug is S. pneumoniae. There is no proven benefit if not Strep and it shouldnt be given after abx!
#FOAMed
2
16
96
Treatment with B12 in patients with moderate to severe megaloblastic anemia can result in hypokalemia. Ideally you should monitor serum levels for the first 48hr.
#FOAMed
0
8
90
EM doc? You've got to know tpa contraindications like the back of your hand! Here's our simplified list
3
15
93
Cerebral edema in DKA (a highly tested complication) more likely in pts w BG<250 still being treated w/insulin & esp in peds, usually 6-10 hrs following onset of tx. Give mannitol if a change in mental status is seen bc mortality is 90%!
0
16
92
Sick of mixing up tx for Shingles, Bell's palsy, & Ramsay Hunt? Check out this table made by
@blakebriggsMD
. This is what boards want as well.
#FOAMed
#MedTwitter
#medicine
@srrezaie
@EMinMiami
@grepmeded
@RosenelliEM
@KimiChernoby
@embasic
@emresidents
@reverendofdoubt
2
35
92
Updated mnemonic
#Bradycardia
: “ATROPINES”
Anterior MI
Thyroid, Adrenal disorders
Rhythm disorder
Overdose- BBB, CCB, digoxin, a2 cholinergics
Pressure- increased ICP
Inferior MI
Nippy- hypothermia, tick bites (lyme)
Electrolytes- K Ca Mg
Shock- neurogenic
2
27
90
5 criteria for TRALI: 1) acute onset during or within 6 hrs of transfusion 2) Hypoxemia 3) CXR w bilateral infiltrates 4) No evidence of volume overload 5) No preexisting lung injury
Free study guide on transfusion reactions ->
0
28
89
Every single ED patient must have an EKG after a syncopal event - also should be done in first time seizure patients as often syncope can be reported as a seizure like presentation. Remember to get a pregnancy test in women of child bearing age.
1
14
87
Rapid high dose IV fentanyl (as low as 100mcg) carries the risk of glottic spasm & chest wall rigidity - these are not always reversible w/narcan. Be prepared (& push slow)
6
25
85
When managing bleeding esophageal varices, IV ceftriaxone is indicated for all patients with cirrhosis & acute GI bleeding. For limiting bleeding, Vasopressin is never the right answer anymore - octreotide is the splanchnic vasoconstrictor of choice now!
5
20
84
A "DNR" in simplest form = do not perform CPR. It does NOT mean-
-withhold standard of care in ED
-not giving pain meds
-not giving antibiotics
-treating them grossly different from any other pt w/ a pulse
#medtwitter
#FridayFeeling
5
19
87
Them: but resuscitation of DKA with NS is our protocol and we've always done it that way
Us:
1
8
84
Tired of confusing your Hepatitis B serologies? Remember that the virus makes antigen (Ag) & the immune system makes antibody (Ab). So anything with Ag means the virus is active (HBsAg) and/or highly infective (HBeAg)
1
22
84
First line therapy for seizures in acute hepatic encephalopathy includes *phenytoin* due to the liver’s inability to clear other sedatives well. This is one of the few times that second line seizure treatment is short acting benzodiazepines.
0
19
82
How to tell hyperK peaked T waves from hyperacute T waves? Go back to basics ie look at the base of the wave! Hyperacute will usually have a broader base & more symmetric sloping (see image) + J point is more likely to be elevated. In ischemia the QRS can fit inside the T wave.
4
25
81
Unlike COPD, ABG in asthma is not predictive of the need to intubate or predictive of clinical outcome.
1
15
78
In infancy, RV > LV. This means that NORMAL infant EKGs will look like RV hypertrophy (Dominant R wave and RSR' in precordials, T inversion V1-3 which typically goes upright around age 8)
Free podcast here:
1
19
79
Walking your patient is part of the Neuro exam. It might be a chore to take them off the monitor, but it doesn’t excuse not walking your patients
#neurotwitter
#Medstudents
2
7
82
Why is there such a risk of intubation in status asthmaticus? The transition from negative to positive pressure ventilation → increased intrathoracic pressure→decreased preload→asystole
*Strongly consider starting epi drip prior
*Ketamine is your sedative friend
2
34
80
If a patient is suspected of having variceal bleeding, they automatically qualify as unstable, even if they “look fine” when they arrive to the ED. Don't be fooled because once the hematemesis starts in this patient you are WAY behind.
#FridayFeelings
3
6
79
Still ordering serum uric acid levels during a suspected gout flare? Why?
Those levels don’t correspond to gout flares & they shouldn't change management - normal serum uric acid levels do not rule out gout!
Free podcast Ep 141
1
22
80
Start NAC in any patient with signs of hepatotoxicity from known acetaminophen ingestion OR a acetaminophen Tylenol level. NAC can prevent hepatic injury if the first dose is given within 8h of acute ingestion (there's still have benefit as far out as 48h post-ingestion)
1
14
80
SA node perfusion: 60% RCA 40% LCx
AV node perfusion: 90% RCA 10% LCx
If your STEMI EKG shows heart block + hypotension this is concerning for RV failure – a preload dependent state where you should prioritize IVF & inotropes (on the way to PCI of course). Pace if necessary.
0
23
76
In a female patient with rectal pain don't forget to keep ruptured ectopic on your differential. Blood is in the rectouterine pouch (=pouch of Douglas =cul-de-sac) may produce tenesmus by irritating the rectum
Wednesdays are for
#WomensHealth
at EMBB!
#WCW
0
23
78
Repeat after us: No leukocytosis does NOT mean "no infection". Ordering CBC's to "rule out infection" needs to stop.
@RosenelliEM
#FOAMed
#MedTwitter
3
28
77
First sign of lidocaine toxicity (>5mg/kg) is lightheadedness. This progresses to perioral numbness, tinnitus, shivering & twitching. Intralipid time!
Side note - did you know vets use intralipid for accidental THC ingestion in pets?
2
14
78
Pressors are less effective when the patient is hypothermic - you want to first rewarm and then move to pressor therapy!
Remember that when you start to rewarm, cold, acidotic blood returns to circulation from the extremities & pts can end up with a drop in MAP by up to 30 points
1
16
78
Poopy pearls:
💩Abx most commonly a/w c diff = fluoroquinolones, clinda, cephalosporins (during ongoing therapy or within 1 month of administration)
💩Severe C diff = WBC>15000 or Crt >1.5, hypotension/shock, ileus/megacolon
💩Megacolon = colonic dilation >6cm
1
18
76
Open fracture with water contamination? Remember to adjust your abx.
💧Fresh water = zosyn
🌊Salt water = zosyn & doxycycline
#FOAMed
1
13
77
EM doc? You've got to know tpa contraindications like the back of your hand! Here's our simplified list
0
15
75
Diagnosis of WPW syndrome requires EKG findings (short PR, wide QRS with delta wave) PLUS symptomatic tachyarrhythmia (most commonly paroxysmal SVT)
0
8
75
If you don't have access, Magnesium can be given IM for eclampsia (5g in each buttock) - don't delay!
#OBintheED
6
11
74
5 criteria for TRALI: 1) acute onset during or within 6 hrs of transfusion 2) Hypoxemia 3) CXR w bilateral infiltrates 4) No evidence of volume overload 5) No preexisting lung injury
Read more for free:
0
35
73
Half of patients with intracranial hemorrhage die in the first 48 hours. You need to know how to recognize these (podcast & study guide ) and how to manage them ()!
0
21
73
Metformin OD PEARLS
"MALA" =metformin associated lactic acidosis is MC in pts w renal or hepatic dysfunction (in addition to pts w large dose OD) - tx w Thiamine IV, sodium bicarb IV, consider dialysis
Trend glucose (hypoglycemia is rare) & lactate
Tx GI sxs supportively
#FOAMtox
0
14
74
A normal lactate does NOT rule out mesenteric ischemia because it only rises later on in the process
1
14
72
STEMI time goals are a must know!
Door to needle at PCI capable hospital: <90min
Door to needle at non-PCI hospital: <120
Door to thrombolytic time if not able to get either of the above: <30min
PCI preferred in patients in cardiogenic shock or presenting >3hr from symptom onset
0
36
74
Repeat after us: In the setting of high BP, an uncomplicated headache is NOT evidence of end-organ damage or hypertensive emergency!
#FOAMed
#MedTwitter
4
11
73
Electrical alterans is not common, <30% of Tamponade pts. Don’t rely on it. Look for low voltage (QRS <5-10 mm) and tachycardia on EKG instead.
3
18
71
Hypothermia = diuresis, but how?
Hypothermia triggers peripheral vasoconstriction ➡️ body thinks volume overload ➡️ drop in ADH production ➡️ diuresis! It can lead to hypotension/hypovolemic shock.
We did 2 free episodes on hypothermia: 40 & 126 (a collab w
@ACEPNow
PEER review)
1
17
68
Cause of seizures that you might forget but that your boards wont: isoniazid toxicity. Give pyridoxine (5g if the ingestion amount is unknown) along with your usual benzos!
1
12
70
When that atraumatic, chronic, low back pain ends up getting imaged...
Sometimes you have to listen to your EM spidey sense!
11
6
71
Massive upper GI bleed? Ulcers are responsible for 40-50% of cases, variceal bleeding 5-30% of cases, esophagitis 10% of cases, vascular malformations 5% of cases. In practice, treat for all of these when undifferentiated
0
15
70
Board exams expect you to know Ranson criteria for increased mortality in pancreatitis at presentation:
Glucose > 200
Age > 55
WBC > 18k ("leukocytosis")
LDH > 350
AST > 250 ("liver")
("GALLL")
2
10
69
Anterior TMJ dislocation is the MC type and is usually non-traumatic (think yawning). These can usually be reduced in the ED manually from various maneuvers. Check this out for more
0
15
70
High anion gap in DKA is seen bc without insulin, fatty acids break down to ketones in the liver. Renal excretion of ketoacids is a therapeutic result of rehydration that helps to decrease anion gap
1
12
68