TOP 100 SECRETS in Emergency Medicine

1. When formulating the differential diagnosis, ask “What is the most serious possible cause
of this patient’s presenting signs and symptoms?”
2. When uncertain of the diagnosis, communicate this truthfully to the patient and indicate it
in the final ED diagnosis.
3. Before discharging a patient from the ED, ask, “Why did the patient come, and have
I made the patient feel better?”
4. Familiarity with the indications and limitations of rescue airway devices is essential.
5. Preoxygenation is a critical component of rapid sequence intubation because it will
prevent significant hypoxia despite several minutes of apnea during the intubation
process.
6. When evaluating results of a research paper, the smaller the number needed to treat, the
more effective the intervention or treatment.
7. When in doubt, remember that a p value less than 0.05 is generally considered significant,
the difference found by chance alone being 1 in 20.
8. Consider HIV/AIDS in patients at risk who present with an illness or infection,
particularly those with opportunistic infections or extreme presentations of common
diseases.
9. In febrile patients, a white blood cell or band count is rarely useful in differentiating
between bacterial and viral illnesses.
10. A foreign body in the airway should be suspected in a child with sudden onset of
respiratory symptoms and lack of response to appropriate treatment.
11. The diagnosis of gastroenteritis cannot be made without the presence of both vomiting
and diarrhea.
12. Spinal epidural abscess should be suspected as the cause of back pain in immunocompromised
patients and IV drug users who present with localized spinal tenderness and
fever.
13. An afferent pupillary defect points to a defect of the retina or optic nerve.
14. Perilimbic flush suggests iritis or glaucoma, not conjunctivitis.
15. When a mandible fracture is suspected, a panoramic radiograph of the mandible is the
least expensive and most accurate film to assess the patient.
16. Documenting adherence to evidence-based guidelines is helpful in defending against a
malpractice claim.
17. In patients with a high suspicion for bacterial meningitis, administer antibiotics promptly
before the lumber puncture is performed and after blood cultures are obtained.
18. Consider Kawasaki’s disease in children presenting with 5 days of fever.
19. The initial objectives in treating an asthma or chronic obstructive pulmonary disease
(COPD) exacerbation are to relieve significant hypoxemia (oxygen), reverse airflow
obstruction (b-agonists 1 ipratropium), and to reduce of the likelihood of recurrence
(corticosteroids).
20. There is no increased risk for a serious bacterial illness in a child with a simple febrile
seizure.
21. Continuous positive airway pressure (CPAP) or bi-level positive airway pressure
(BiPAP) may well reduce the need for endotracheal intubation in both the ED and
prehospital arenas.
22. The most important tool in assessing patients in whom you suspect ischemic heart
disease is the history. The second most important tool is the history. The third most
important tool is, well, you get the picture.
23. Serum lactate is a useful marker to assess the extent of systemic hypoperfusion and
response to resuscitation.
24. It is not always necessary to identify a dysrhythmia prior to treating it. Assume all wide
complex tachycardia with hemodynamic instability is ventricular tachycardia (VT).
25. An external pacemaker can be used if a permanent pacemaker malfunctions.
26. The diagnosis of atrial fibrillation (AF) can be made clinically by palpating a peripheral
pulse and simultaneously auscultating the heart or visualizing the cardiac rhythm; AF is
the only dysrhythmia that results in a pulse deficit (fewer beats palpated than observed or
auscultated).
27. Every ED should have an interdisciplinary evidence-based guideline for the management of
acute stroke.
28. Do not acutely lower the mean arterial pressure (MAP) more than 20% to 25% in patients
with hypertensive encephalopathy.
29. It is not necessary to gradually empty the bladder when treating an episode of acute
urinary retention.
30. The indications for emergency dialysis are acute pulmonary edema, life-threatening
hyperkalemia, and life-threatening intoxication or overdose by agents normally
excreted by the kidneys.
31. When a patient with end-stage renal disease presents with shortness of breath,
volume overload is by far the most common cause, even when physical examination and
chest X-ray are not diagnostic.
32. In a young woman presenting with rash, fever, and diarrhea, consider toxic shock
syndrome and examine for a retained tampon.
33. Doxycycline is the drug of choice for most severe tick-borne infections, and it should be
used empirically and early in the febrile, severely ill patient with a possible tick exposure.
34. A febrile patient returning from the tropics has malaria until proved otherwise.
35. Consider syncope as a cause of fall in a geriatric patient.
36. Patients with myocardial infarction may get symptomatic relief from antacids, and
patients with esophageal disease may get symptomatic relief from nitroglycerin.
Antacids and nitroglycerin are therapeutic medications, not diagnostic tests.
37. Any complaint of abdominal pain in an elderly patient should be taken seriously even if
they have “normal” vital signs and no guarding or rebound tenderness on abdominal
examination.
38. A neutropenic fever is a single temperature greater than 38.3°C and an absolute
neutrophil count less than 1,000/mm2.
39. Intussusception occurs between 3 months and 3 years of age.
40. Bilateral retinal hemorrhages in an infant strongly suggest child abuse (shaken baby
syndrome).
41. Ketamine provides sedation, analgesia, and amnesia while protecting the cardiovascular
status and airway reflexes, making it an ideal agent for procedural sedation in children.
42. Because of the fast helical computed tomography (CT) scanners of today, many infants
and children can undergo this diagnostic procedure without sedation.
43. Mesenteric ischemia should be considered in any patient who has severe abdominal pain
out of proportion to the physical examination, often requiring large doses of narcotics.
44. Dermal exposure or ingestion of hydrofluoric acid can result in profound hypocalcemia,
hypomagnesemia, and hyperkalemia.
45. The most important action to take in the event of an attack of weapons of mass
destruction is simply self-protection by donning appropriate personal protective equipment.
46. Sodium bicarbonate (1–2 mEq/kg) should be considered for all poisoned patients with
ventricular dysrhythmias or a wide QRS.
47. Secure the airway early in the management of patients with significant soft-tissue neck
injuries.
48. Consider a computed tomography angiography (CTA) of the neck in patients with facial
or cervical spine fractures.
49. Hypotensive, tachycardic patients with penetrating chest trauma should be immediately
evaluated for tension pneumothorax and pericardial tamponade because emergent
treatment can be life-saving.
50. A suicide attempt should be considered in patients with illogical explanations for
serious accidents.
51. Analyzing a mass gathering will allow informed decisions about the needed levels of
staffing and equipment necessary to provide on-site care.
52. A CT scan for appendicitis is “negative” only if the entire appendix has been visualized
and is normal.
53. Abdominal aortic aneurysm (AAA) can mimic renal colic.
54. Helical CT is the radiologic modality of choice for diagnosing ureteral calculus.
55. Consider testicular torsion in any male with lower abdominal pain.
56. Early goal-directed therapy in patients with severe sepsis reduces short-term mortality
by 10% to 20% compared with an unstructured treatment regimen.
57. Culture and antibiotics are not indicated in non-immunocompromised patients with a
cutaneous abscess.
58. Necrotizing fasciitis should be considered in any patient with a soft-tissue infection who
has pain and tenderness out of proportion to the visible degree of cellulitis.
59. If using antibiotics to treat abscesses, assume Methicillin-resistant Staphylococcus
aureus (MRSA) as the causative agent.
60. Amphetamine and cocaine toxicity should be treated with IV benzodiazepine in incremental
doses titrated to adequate control of heart rate, blood pressure (BP), and temperature.
61. b-blockers are contraindicated in the treatment of stimulant toxicity because they may
potentiate alpha effects and cause coronary artery vasoconstriction and hypertension.
62. No diagnostic studies are indicated in an asymptomatic patient exposed to smoke in a
nonenclosed space.
63. In the presence of carbon monoxide (CO), pulse oximetry will yield a falsely elevated
reading.
64. A BP greater than 140/90 in a pregnant woman is suspicious for preeclampsia.
65. A pregnant woman with hypertension and seizures should be treated with IV magnesium
sulfate and consideration of emergent delivery of the fetus.
66. The most deceptive of serious hand injuries is the high pressure injection injury from
a hydraulic paint or oil gun because despite a seemingly innocuous appearance on
initial presentation, these injuries require aggressive, surgical management.
67. When allowing a patient to leave against medical advice, consideration of the patient’s
ability to pay is not part of the equation. Only the risks, benefits, and patient’s ability
to understand the risks and benefits are important.
68. Be aware of the long-term cancer risk of patients exposed to diagnostic radiation,
particularly those who are young or have had multiple studies.
69. With few exceptions, procedures performed in the ED can be done with fewer
complications and greater success using ultrasound guidance.
70. Any elderly patient with flank, back, abdominal pain, hypotension, syncope, or
pulseless electrical activity (PEA) should have an emergency ultrasound examination to
evaluate for an AAA.
71. IV bolus administration of epinephrine to a patient with an obtainable BP and pulse can
result in ischemic cardiac pain, hypertension, supraventricular tachycardia (SVT), and VT.
72. Examine every patient with urticaria for mucosal edema, stridor, wheezing, and
hypotension to rule out life threats associated with anaphylaxis.
73. A contaminated wound is one with a high degree of bacterial inoculum at the time of
injury and not synonymous with a dirty wound.
74. Determination of pretest probability for venous thromboembolism (VTE) is critical
in knowing when to initiate a diagnostic work-up and how to interpret your test
results.
75. A D-dimer assay is only useful to exclude thromboembolic disease in patients with a low
pretest probability.
76. The problem of “error” in medicine, and the adverse events that sometimes follow, are
problems of psychology and engineering, not of medicine.
77. Emergency medicine, by its nature, has more failure-producing conditions than any other
specialty in medicine.
78. CT of the head will identify 95% of patients with subarachnoid hemorrhage. Lumbar
puncture (LP) is recommended for patients with a strong clinical suspicion, despite
a negative CT of the head.
79. The patient with a posterior nasal packing in place must be monitored in the hospital for
recognition of hypoxia or apnea secondary to stimulation of the nasopulmonary reflex.
80. In almost all cases, trauma patients with unstable vital signs and a positive ED-focused
abdominal sonography for trauma (FAST) examination for free fluid should go directly to
laparotomy.
81. In patients with hyponatremia, to avoid central pontine myelinolysis, serum sodium
should never be raised by more than 0.5 mEq/hr or 12 mEq in 24 hours.
82. Consider a retropharyngeal space infection in a young child presenting with a history of
fever, refusal to drink, sore throat, and reluctance to move their neck.
83. The concomitant ingestion of ethanol (ETOH) with methanol or ethylene glycol protects
against toxic metabolites.
84. Myocarditis should be considered in a patient with a sustained, unexplained tachycardia.
85. Suspect ectopic pregnancy when there is no evidence of intrauterine pregnancy (IUP)
by transvaginal ultrasound and the quantitative human chorionic gonadotropin (HCG)
concentration is greater than 2000 IU/L.
86. In a lucid patient with blunt abdominal trauma, the clinical examination is the best
guide for selection of diagnostic tests.
87. Obtain a CT scan of the head on any patient on warfarin (Coumadin) with even a
minor head trauma.
88. A single negative abdominal ultrasound alone does not reliably exclude significant
intraperitoneal injury.
89. Children manifest shock later than adults with the same percentage of blood loss, yet
decompensate more quickly once this critical volume is lost.
90. In the case of vascular and/or skin compromise of a deformed limb, urgent realignment
and splinting of the involved extremity should precede radiography.
91. Always exclude associated fractures of the spine and lower extremities in patients with
calcaneal fractures.
92. Never restrain a patient in the prone position; restrain on their side to minimize risks of
aspiration and sudden death.
93. Consider domestic violence in women with depression, suicidal ideations, chronic pain,
psychosomatic complaints, or multiple ED visits.
94. As little as 2 weeks of chronic steroid use (prednisone . 20 mg/day) will cause
adrenal suppression, making a patient more prone to adrenal crisis.
95. Lightning strike is the one exception to the usual multicasualty incident (MCI) triage
rules: The first priority should go to those who are not breathing and not moving
because only those who present in cardiac arrest are at high risk of dying.
96. The NEXUS criteria are 99.6% sensitive and 12.9% specific for significant cervical spine
injuries in adults.
97. Follow potassium closely when treating patients with insulin.
98. Glucose should not be withheld due to the unfounded fear of precipitating Wernicke
Korsakoff’s syndrome.
99. Zoos usually keep antivenin on hand for the exotic venomous animals in their collections.
100. Transient ischemic attack (TIA) is a harbinger of early acute stroke (up to 10% in first
48 hours).
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