Emergency Medicine No ﬁnancial Topics disclosures

Emergency Medicine Topics

David Duong, MD MSUCSF-SFGH Emergency Medicine

Residency

UCSF Family Medicine Board Review Course

Tuesday, March 17, 15

No financial disclosures


Case #1

• 20-yo M with no PMHx presenting with non-radiating, pleuritic right sided chest pain starting about 5 hours ago while playing video games. transient sensation of palpitations. no dyspnea. no leg swelling, denies trauma.

• occasional TOB, remainder of history unremarkable


Case #1

• Exam is unremarkable except that the patient is tachycardic and with decreased breath sounds on right.

• Pt is speaking comfortably, chest wall non-tender

• CXR is obtained

20-yo M with CP



Case 1, Q #1

• Which of the following conditions is most likely to be a precipitating factor for pneumothorax?

a) COPD

b) cigarette smoking

c) marfan syndrome

d) exertion

e) Pneumocystis pneumonia


Case 1, Q #1

• Which of the following conditions is most likely to be a precipitating factor for pneumothorax?

a) COPD

b) cigarette smoking

c) marfan syndrome

d) exertion

e) Pneumocystis pneumonia


Pneumothorax

• Primary Spontaneous - occurring in patients without underlying lung dz

• account for 2/3 of all PTX

• more common in tall, thin men, 20-40 years of age and SMOKERS

• 20:1 increased risk in smokers


Other choices

• Marfans is a risk factor in primary spontaneous PTX, but is not as strong a risk factor

• Exertion is not a risk factor

• COPD and PCP pneumonia are important risk factors for secondary PTX, but are not as common as primary PTX


Pneumothorax

• Secondary Spontaneous - occurring in patients with existing underlying lung disease (COPD, PCP)

• PCP is the most common cause of pneumothorax in HIV patients


Traumatic Pneumothorax

• More common in penetrating trauma (stab wound, gun shot wound) than blunt trauma (rib fractures)

• Includes iatrogenic PTX

• Transthoracic needle procedures (thoracentesis, needle biopsies)

• Subclavian central lines


Case 1, Q #2

• The nurse reports that this patient has become very dyspneic and his blood pressure is now 80/50. His neck veins are distended. What is the next best course of action?

a) 100% oxygen via non-rebreather

b) immediate placement of a chest tube

c) intubation

d) needle thoracostomy

e) normal saline 1000 cc IV bolus


Case 1, Q #2

• The nurse reports that this patient has become very dyspneic and his blood pressure is now 80/50. His neck veins are distended. What is the next best course of action?

a) 100% oxygen via non-rebreather

b) immediate placement of a chest tube

c) intubation

d) needle thoracostomy

e) normal saline 1000 cc IV bolus


Tension Pneumothorax

• Positive pressure from PTX reduces venous return to the right heart, thus decreasing cardiac output

• PE: distended neck veins, tracheal deviation (away from side of PTX), hypotension

• Immediate decompression required: 14 gauge needle - 2nd intercostal space, mid-clavicular line

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Pneumothorax and Treatment

• High-Flow oxygen:

• promotes resorption of nitrogen-rich air in PTX

• appropriate as sole therapy in small (<15%), stable, and atraumatic PTX

• Observation:

• for small, primary spontaneous PTX

• repeat CXR in 6 hours - if no change on CXR and clinically, follow-up is ensured, and reassuring social situation -> may be discharged with another repeat CXR recommended in 12-48 hours.


Pneumothorax and Treatment

• Needle thoracostomy:

• indicated in tension pneumothorax

• insert 14 gauge IV in 2nd intercostal space, mid-clavicular line

• Tube Thoracostomy:

• for larger (>15%) spontaneous PTX and all traumatic PTX

• chest tube is placed at 4th or 5th intercostal space, mid-or anterior-axillary line


Case # 2

• A 23-yo man presents holding both hands over his right eye. He was playing basketball when another player hit him in the eye. He is able to cooperate with the examination and reports decreased vision. The BEST treatment option is:

A) Carbonic Anhydrase Inhibitor

B) Gentle pressure to reduce the eye

C) Lateral canthotomy

D) Ophthalmology outpatient follow-up next day

E) Decongestant nasal sprays, oral antibiotics, and pain medications

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Case # 2

• A 23-yo man presents holding both hands over his right eye. He was playing basketball when another player hit him in the eye. He is able to cooperate with the examination and reports decreased vision. The BEST treatment option is:

A) Carbonic Anhydrase Inhibitor

B) Gentle pressure to reduce the eye

C) Lateral canthotomy

D) Ophthalmology outpatient follow-up next day

E) Decongestant nasal sprays, oral antibiotics, and pain medications


Retrobulbar hemorrhage

• caused by blood accumulation within the orbit with transmission of pressure to the optic nerve and globe. This in turn leads to central retinal artery occlusion and optic nerve ischemia

• signs - acute proptosis, vision loss, decrease in ocular movement, increased IOP

• irreversible vision loss occurs within 60 minutes

• the best DEFINITIVE treatment option is a lateral canthotomy

y y y blood accumumumumulalalalatititition within the oror


Lateral Canthotomy


Other selections

• CA inhibitor, mannitol, and topical beta-blocker may be used to decreased IOP, but is not definitive treatment

• Gentle pressure to reduce the eye would cause more damage. This may be treatment for a globe luxation without suspicion of globe rupture.

• Ophthalmology consultation is necessary but since vision loss can quickly ensue, next day followup is inappropriate.


Other selections

• The most common orbital fracture is the inferior wall blow-out fracture. There is communication with the ethmoid and maxillary sinuses in this fracture.

• Emergent ophthalmology consultation is needed if there is diplopia, enophthalmos, or large fractures (>1/3 of the orbital floor).

• Treatment is avoidance of nose blowing, nasal decongestants, +/- oral antibiotics, pain management and ophthalmology referral.


Case #3

• A 40-yo M presents with cough, low-grade fever, and myalgias for the past 3 to 4 days. Today he has severe, sharp pleuritic chest pain radiating to the left shoulder, worse when he is supine. He smokes 1 ppd. BP 160/95, HR 110, RR 18, T 37.2. The ECG shows:


question 4

• Appropriate next steps include:

A) Aspirin 325 mg, morphine 2 mg IV, and admit to CCU

B) Aspirin 325 mg, nitroglycerin SL x3, heparin bolus, activate cardiac cath team

C) Ketorolac 30 mg IV, followed by ibuprofen 800 mg PO TID for 1 week as outpatient care

D) Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20 mg IV, and admit to a monitored bed

E) Metoprolol 5 mg IV, nitroglycerin IV infusion titrated to pain, and cardiology consultation


question 4

• Appropriate next steps include:

A) Aspirin 325 mg, morphine 2 mg IV, and admit to CCU

B) Aspirin 325 mg, nitroglycerin SL x3, heparin bolus, activate cardiac cath team

C) Ketorolac 30 mg IV, followed by ibuprofen 800 mg PO TID for 1 week as outpatient care

D) Lidocaine 75 mg bolus then 2 mg/min infusion, labetalol 20 mg IV, and admit to a monitored bed

E) Metoprolol 5 mg IV, nitroglycerin IV infusion titrated to pain, and cardiology consultation


acute pericarditis

• typical ECG findings (Stage 1 - hours to days): diffuse ST-segment elevation with a “concave up” pattern (except aVR and V1), PR interval depression (except aVR and V1)


acute pericarditis

• Stage 2: ST and PR segments normalize, but T waves flatten

• Stage 3: deep symmetric T wave inversion

• Stage 4: normalization, though T wave inversions may be permanent

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acute pericarditis

• treatment includes NSAIDs, hydration, and reassurance

• Patients with idiopathic pericarditis who achieve reasonable pain control in the ED may be sent home with instructions for outpatient follow-up care.


acute pericarditis

• vs. acute MI and BER


other choices

• In acute MI, ST segments correspond to ischemic portions of the heart and typically have ST-segment depression in reciprocal leads.

• Although aspirin can be an effective treatment in pericarditis, there is no indication for nitrates, anticoagulation, beta-blockers, or admission to a monitored setting. The tachycardia and hypertension are most likely secondary to pain.


Case #4

• A 55-yo M with an unknown PMHx brought in by ambulance with altered mentation. Dextrose stick was 100 mg/dL. He had a thready femoral pulse in the field. The RN is having a hard time getting a BP and is trying again. You cannot find a femoral pulse and you see this on the monitor:

•


question 5

• What is the next appropriate step in the management of this patient?

a) intubation

b) epinephrine 1 mg IV

c) magnesium 1-2 g IV

d) cardioversion at 100 J monophasic

e) defibrillation at 360 J monophasic


question 5

• What is the next appropriate step in the management of this patient?

a) intubation

b) epinephrine 1 mg IV

c) magnesium 1-2 g IV

d) cardioversion at 100 J monophasic

e) defibrillation at 360 J monophasic


Question 5

• Wide complex tachycardia + no pulse = unstable ventricular tachycardia

• Defibrillation is the most apropriate next step, above managing the airway or giving pressors.

• Synchronized cardioversion is not appropriate for an unstable patient

• Magnesium for torsades de pointes


question #6

• After the initial defibrillation, what is the next MOST appropriate step?

a) start CPR, 2 minutes

b) check for a pulse

c) check the monitor, and administer another shock if needed

d) administer epinephrine 1 mg IV


question #6

• After the initial defibrillation, what is the next MOST appropriate step?

a) start CPR, 2 minutes

b) check for a pulse

c) check the monitor, and administer another shock if needed

d) administer epinephrine 1 mg IV


question #6

• 2005 and 2010 AHA/ACLS guidelines emphasize uninterrupted chest compressions after defibrillation

• Only after CPR should a pulse and monitor check be performed

• Giving epinephrine should not delay resumption of CPR


Ventricular FibrillationPulseless V-Tach

CAB’s

defibrillation, immediate CPR, then check rhythm

intubation, establish IV

epinephrine 1 mg IV/IO every 3-5 minutes

may substitute 1st or 2nd dose of epi with vasopressin 40 U IV/IO

after 3 shocks/CPR, consider amiodarone 300 mg IV

consider other drugs: lidocaine, magnesium

Think of H’s & T’s

Remember the order: shock - CPR - check - shock - CPR - check - drugs

defibrillation, immediate CPR, then check rhythm



Asystole &PEA

CAB’s

initiate CPR early


epinephrine 1 mg IV/IO every 3-5 minutes

may substitute 1st or 2nd dose of epi with vasopressin 40 U IV/IO

atropine REMOVED from asystole/PEA algorithm!

no shocks, no pacing


no shocks, no pacing


initiate CPR early



H’s and T’s

Hypovolemia

Hypoxia

Hydrogen Ions (acidosis)

Hyperkalemia/hypokalemia

Hypoglycemia

Hypothermia

Toxins/Tablets

Tamponade - cardiac

Tension Pneumothorax

Thrombosis (coronary or pulmonary)

Trauma


Case #5

• A 19-yo F with depression and multiple suicide attempts presents to hospital 1 hour following an ingestion of 30 tablets of extra strength tylenol in a suicide attempt. She denies any EtOH or illicit drug use.

• Physical exam is unremarkable


Case #5

The physician decides to administer activated charcoal.

19-yo F s/p OD of acetaminophen.

VS and exam unremarkable


Question #8

• Which of the following oral overdoses will NOT benefit from activated charcoal administration?

a) acetaminophen

b) iron

c) lorazepam

d) levothyroxine


Question #8

• Which of the following oral overdoses will NOT benefit from activated charcoal administration?

a) acetaminophen

b) iron

c) lorazepam

d) levothyroxine


Activated Charcoal

• Highly adsorbant, inert material made from distilled wood pulp with a very large surface area that non-specifically binds to many substances

• Decreases absorption by 75% if given within 1 hour

• Do not give if patient cannot protect their airway


Activated Charcoal


Question #9• Activated charcoal is absolutely

contraindicated in the treatment of toxic ingestions of:

a) caustics (acids/alkalis)

b) any substance if milk was co-ingested or administered

c) lithium

d) heavy metals

e) digitalisTuesday, March 17, 15

Question #9• Activated charcoal is absolutely

contraindicated in the treatment of toxic ingestions of:

a) caustics (acids/alkalis)

b) any substance if milk was co-ingested or administered

c) lithium

d) heavy metals

e) digitalisTuesday, March 17, 15

Question #9

• The only absolute contraindication to the use of AC is ingestion of acids/alkalis. AC does not absorb these well and ineffective in preventing tissue damage.

• AC interferes with subsequent endoscopy and may cause vomiting as well as further caustic injury to the esophagus and upper airway.

• Although it doesn’t work in Li and heavy metals, it is not contraindicated.


Question #10If this patient adamantly refused to comply with drinking the activated charcoal, which of the following is true regarding your ability to administer charcoal?

a) You cannot force the patient to take charcoal

b) You must wait to get parental permission prior to treating her

c) A court injunction is needed to force her to drink the charcoal

d) After repeated attempts to get the patient to take charcoal, a nasogastric tube may be placed to facilitate treatment

e) Refusal to take charcoal orally is an indication for IV charcoal


Question #10If this patient adamantly refused to comply with drinking the activated charcoal, which of the following is true regarding your ability to administer charcoal?

a) You cannot force the patient to take charcoal

b) You must wait to get parental permission prior to treating her

c) A court injunction is needed to force her to drink the charcoal

d) After repeated attempts to get the patient to take charcoal, a nasogastric tube may be placed to facilitate treatment

e) Refusal to take charcoal orally is an indication for IV charcoal


Question #10

• Suicidal patients do not have the right to refuse potentially life-saving care. Physicians may do what they need to do in an effort to save the patient. In emergencies, parental permission for treatment is unnecessary.

• Charcoal is not used IV.


Case #5

ECG was unremarkable

urine pregnancy test negative

chemistry and LFT’s unremarkable

acetaminophen level 175 micrograms/mL

19-yo F s/p OD of acetaminophen.

VS and exam unremarkable


Question #11• Which of the following statements about

acetaminophen ingestion is TRUE?

a) serial LFTs are indicated in all acetaminophen ingestions

b) renal sequelae are expected

c) IV N-acetylcysteine (NAC) is safer than oral NAC

d) an acetaminophen level drawn 4 hours post-ingestion dictates need for antidotal therapy


Question #11• Which of the following statements about

acetaminophen ingestion is TRUE?

a) serial LFTs are indicated in all acetaminophen ingestions

b) renal sequelae are expected

c) IV N-acetylcysteine (NAC) is safer than oral NAC

d) an acetaminophen level drawn 4 hours post-ingestion dictates need for antidotal therapy


Acetaminophen toxicity

• An acetaminophen level drawn at hours 4-20 can be plotted on the Rumack-Matthew nomogram to guide therapy based on hepatic (not renal) toxicity.

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other choices

• Liver function tests are not indicated for trivial acetaminophen ingestions, but may be useful in severe ingestions.

• One potential side effect of IV NAC is an anaphylactoid reaction.


Case #6

A 32-yo man presents 30 minutes after getting a tooth knocked out in a fight. On examination, a small clot in the socket is noted. The next step in management is:

A) Call the patient’s dentist

B) Clean the tooth with a brush

C) Gently irrigate the socket

D) Immediately replace the tooth

E) Tell the patient the tooth cannot be reimplanted


Case #6

A 32-yo man presents 30 minutes after getting a tooth knocked out in a fight. On examination, a small clot in the socket is noted. The next step in management is:

A) Call the patient’s dentist

B) Clean the tooth with a brush

C) Gently irrigate the socket

D) Immediately replace the tooth

E) Tell the patient the tooth cannot be reimplanted


Question 12

The patient has an avulsion injury and the tooth should be reimplantated.

Although little preparation is needed to ready the socket for reimplantation, clots should be removed with gentle irrigation with NS, though there should be as little manipulation of the socket as possible.


other selections

• Reimplantation is possible within 2 to 3 hours

• The avulsed tooth should be rinsed with sterile NS or tap water to remove debris before implantation

• The avulsed tooth should not be scrubbed as this may injure the periodontal ligament, which might still be attached to the tooth.

• early improper tooth reimplantation holds a higher success rate for tooth salvage than delayed reimplantation resulting in waiting for an oral surgeon


Tooth avulsion


Tooth avulsions

1. Where is the tooth?

2. How old is the patient?

3. How long has the tooth been out? (periodontal ligament cells die within 60 minutes outside the oral cavity)

4. Is there other significant maxillofacial trauma?


Case #7

A 24-yo woman presents with diffuse tongue swelling and hoarse voice that began shortly before arrival. Now she is drooling, dyspneic, and can barely talk.

She has hypertension and is on lisinopril and hydrochlorothiazide. She has not eaten new foods, used any new toiletries, clothing, or medications.


Question 13

• Which of the following medications would be most efficacious to treat this condition?

A) Cetirizine

B) Diphenhydramine

C) Epinephrine

D) Methylprednisolone

E) Solumedrol


Question 13

• Which of the following medications would be most efficacious to treat this condition?

A) Cetirizine

B) Diphenhydramine

C) Epinephrine

D) Methylprednisolone

E) Solumedrol


Angioedema

• Severe allergic reactions range from urticaria to angioedema to anaphylaxis.

• In this patient with airway compromise from angioedema, intramuscular epinephrine is indicated.

• Epinephrine-induced catecholamine release causes vasoconstriction to reduce periglottic edema and improve patency.

• It also increases systemic vascular resistance to maintain blood pressure in anaphylactic shock.


Angioedema

• Angioedema is an allergic reaction involving the dermis and presents as nonpruritic edema of the submucosa (tongue, lips, face)

• Have a high degree of suspicion for airway compromise, consider laryngoscopic evaluation

• Treatment is same for urticaria, but consider IM epinephrine (0.3-0.5 cc of 1:1000) for impending airway compromise and early airway protection with intubation with intraoral, pharyngeal, and lingual involvement

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Urticaria

• Urticaria is an allergic reaction involving the epidermis and presents with pruritic, erythematous, raised wheals of the skin.

• Treatment is mainly supportive

• removing the offending agent, cold compresses

• H1 blockade/antihistamines

• H2 blockers added for severe or refractory sx

• corticosteroids for severe or refractory sx (use short course)


Anaphylaxis

• A severe systemic hypersensitivity reaction characterized by multisystem involvement, manifested by hypotension or airway compromise

• Look for bronchospasm, voice changes and stridor from laryngeal edema, drooling

• Treatment is same as urticaria/angioedema, but also consider:

• intubation for unstable patients, pressors

• usual ACLS resuscitation


• A 22-yo M presents with a “spider bite,” after he was cleaning his garage. He developed crampy muscle aches that spread up his arm initially. Now he has abdominal cramping, nausea, and dizziness. He has a rigid abdomen on your exam. Which of the following is the likely culprit?

a) tarantula d) wolf spider

b) hobo spider e) black widow spider

c) brown recluse spider

Case #8


• A 22-yo M presents with a “spider bite,” after he was cleaning his garage. He developed crampy muscle aches that spread up his arm initially. Now he has abdominal cramping, nausea, and dizziness. He has a rigid abdomen on your exam. Which of the following is the likely culprit?

a) tarantula d) wolf spider

b) hobo spider e) black widow spider

c) brown recluse spider

Case #8


Spider bites

• Black widow spiders

• Classically present with an initial pinprick sensation followed by a mild local inflammatory response (<1 hr)

• Then crampy mylagias at the bite site and spread up the extremity

• Myalgias eventually involve the entire body; patient may present with a rigid abdomen which is difficult to differentiate clinically from peritonitis


Black widow

• Treatment is supportive

• Opioids and BZs for pain and muscle spasms

• Ca-gluconate found NOT to be effective

• Antivenom may be an option in severe cases


Brown Recluse

• Classically causes dermal necrosis and black eschars, which are self-limited

• Rarely causes DIC and hemolysis

• Treatment is supportive


Case #9

• A 20-yo M with no PMHx comes to your office after being bitten on his left forearm by his neighbor’s cat only 2 hours ago. There is no bleeding, no swelling, and the patient is neurovascularly intact.


question #15

• Which of the following statements regarding bite wounds is correct?

a) Cat bites are most commonly polymicrobial

b) Cat bites do not require prophylactic antibiotics unless there is a foreign body in the wound

c) Mammal bites are not tetanus-prone wounds

d) Only 5-6% of dog bites ultimately become infected


question #15

• Which of the following statements regarding bite wounds is correct?

a) Cat bites are most commonly polymicrobial

b) Cat bites do not require prophylactic antibiotics unless there is a foreign body in the wound

c) Mammal bites are not tetanus-prone wounds

d) Only 5-6% of dog bites ultimately become infected


question 15

• Most dog bite infections are polymicrobial and may involve Pasturella, but not usually multocida. Only 5-6% of dog bites become infected (about the same for nonbite lacerations).

• EXCEPT for wounds involving the hand and high-risk patients

• Cat bites become infected 60-80% of the time and thought to be related to virulent strains of P. multocida.


Mammalian BitesPrinciples

• Assess for life-threatening bites (vascular, bites on the neck)

• Examine for joint & tendon involvement

• Emphasis on wound cleaning

• XRs if foreign body is suspected

• Don’t close hand/foot bites, puncture-type bites, bites >6 hrs, & contaminated wounds


Dog Bites

• Uncomplicated dog bites do not routinely need prophylactic antibiotics

• EXCEPTION: patient is immuno-compromised (EtOH liver dz, asplenia, chronic corticosteroid use)

• risk of sepsis from C. canimorsus (with gangrene, purpura, petechiae)


Dog Bites

• amoxicillin/clavulanate for 5-7 days

• alternatives: fluroquinolone (moxifloxacin), doxycycline

• tetanus toxoid


Cat Bites

• All cat bites should receive prophylactic antibiotics

• amox/clavulanate for 5-7 days

• PCN, amoxicillin, cefuroxime, doxycycline will cover P. multocida


Human Bites

• Treat all human bites as contaminated puncture wounds

• Usually polymicrobial (Staph and Strep species, Eikenella corrodens, anaerobes)

• treatment of choice is amox/clavulanate


Case #10

• What is the total body surface area (TBSA) of a man who presents with blistered burns of the anterior halves of both his thighs and legs after spilling scalding water?

a) 9%

b) 18%

c) 27%

d) 36%


Case #10

• What is the total body surface area (TBSA) of a man who presents with blistered burns of the anterior halves of both his thighs and legs after spilling scalding water?

a) 9%

b) 18%

c) 27%

d) 36%


Rule of Nines

• Head - 9%

• Chest - 18%

• Back - 18%

• Each Leg - 18%

• Each Arm - 9%

• Perineum, Palm - 1%


burns classification

• Superficial

• 1st degree

• only involves the epidermis

• local pain and erythma

• no blistering

• heals without scarring

• Partial Thickness

• 2nd degree

• involves dermis and epidermis


Partial Thickness Burn

• Superficial Partial

• blisters, blanches, scarring risk low

• Deep Partial

• blisters, no blanching, scarring risk high


Third degree burn

• involves all layers of skin (may involve muscle and bone)

• painless

• variable color, dry

• do not heal


Indications for Burn Unit Admission

• Burns of face, hand, feet, genitalia, perineum, major joints

• Electrical burns

• Chemical burns with potential for cosmetic/functional impairment

• Significant inhalation injury

• Co-morbid disease

• Partial thickness burns >10% TBSA

• Full thickness burns in any age group


Parkland Formula


Pearls in Burn Cases

• Consider carbon monoxide poisoning

• Look for singed nasal hairs, carbonaceous sputum, and facial burns as markers for potential airway edema and obstruction

• Look for circumferential burns

• Prophylactic Abx are not indicated in burns


Case 11

13-yo with no PMHx accompanied with Dad,

presenting with left thigh pain for 1 week

starting 1 day after football practice. He used

“icy-hot” with no relief. It hurts mainly to run.

exam - obese. nl abdominal and GU exam. left

groin is tender with decreased and painful

internal ROM of the hip. + antalgic gait. thigh

& knee exam WNL.

an

n

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rts

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Case 11


Case 11


Case 11

• Which of the following is the most common adolescent hip disorder?

a) Osgood-Schlatter

b) Hip fracture

c) Septic arthritis

d) Growing pains

e) Slipped Capital Femoral Epiphysis


Case 11

• Which of the following is the most common adolescent hip disorder?

a) Osgood-Schlatter

b) Hip fracture

c) Septic arthritis

d) Growing pains

e) Slipped Capital Femoral Epiphysis


SCFE

• Most common adolescent hip disorder

• Risk factors: obesity, male, black/

hispanic

• Obtain AP and frog-leg OR cross-table lateral XRs - look for Kline’s lines.

• Non-weight bearing and surgical intervention as soon as recognized to prevent avascular necrosis

Tuesday, March 17, 15 Tuesday, March 17, 15

Klein’s lines


• Pneumothorax

• Orbital Trauma

• Pericarditis

• Unstable VTach/VFib

• AC & Acetaminophen Toxicity

Summary


• Tooth Avulsion

• Angioedema/Anaphylaxis

• Spider & Mammalian Bites

• Burns

• SCFE


Thanks for your attention!

Good Luck on the Boards!


Documents

Emergency Medicine No ﬁnancial Topics disclosures