EMERGENCY MEDICINE

Clinical Rotation Prep Guide

High-Yield | Evidence-Based | Student-Focused

GUIDE CONTENTS
• Section 1: Before You Start — Mindset, Logistics & Professionalism
• Section 2: High-Yield Presentations & Chief Complaints
• Section 3: Critical Diagnoses You Cannot Miss
• Section 4: Essential Labs & Diagnostics
• Section 5: Pharmacology Essentials
• Section 6: Procedures & Skills
• Section 7: Approach to Common Scenarios
• Section 8: High-Yield Tips & Pimp Questions
SECTION 1: Before You Start

The EM Mindset
Emergency Medicine is about ruling out life threats first, then working toward a diagnosis. Your job is
not always to diagnose — it is to stabilize, risk-stratify, and disposition.

CORE EM PRINCIPLE: Rule Out CRITICAL Before COMMON

• Chest pain → Rule out ACS, PE, aortic dissection BEFORE thinking musculoskeletal
• Headache → Rule out SAH, meningitis, herniation BEFORE thinking tension/migraine
• Syncope → Rule out cardiac, PE, hemorrhage BEFORE thinking vasovagal
• Abdominal pain → Rule out AAA, ectopic, ischemia BEFORE thinking gastritis

Logistics & Professionalism

• Arrive early, stay late, volunteer for procedures — attitude is graded
• Know the flow: triage → nurse assessment → provider evaluation → workup → disposition
• Disposition = Admit, Discharge, or Transfer. Always be thinking about this from the start
• Pre-round: check boards, look up 1-2 patients, know their vitals and chief complaint
• Always present with: CC, HPI, PMH, meds, allergies, vitals, exam, assessment & plan
• Document your own H&P and note even if the attending will co-sign

Safety Culture
• Speak up if you notice something wrong — students catch errors
• Use SBAR for handoffs: Situation, Background, Assessment, Recommendation
• Time-outs before procedures, even in the ED
• Isolation precautions: know when to use droplet vs contact vs airborne
SECTION 2: High-Yield Presentations
These are the most common chief complaints in any ED. Master the differential and initial workup for
each.

Chest Pain
Diagnosis Key Features Initial Workup Don't Miss
ACS/MI Crushing, radiation to EKG (w/in 10 min!), STEMI → cath lab
arm/jaw, diaphoresis, troponin x2, CXR immediately
N/V
Pulmonary Embolism Pleuritic, tachycardia, Wells score → D-dimer Can mimic ACS
risk factors (Virchow’s) or CT-PA
Aortic Dissection Tearing, ripping, worst CXR (wide No anticoag/lytics!
of life, BP differential mediastinum), CT
angiography
Pneumothorax Unilateral breath CXR; if tension → Tension = emergency
sounds absent, tracheal needle decompression
deviation
Pericarditis Sharp, positional, EKG, Echo, ESR/CRP Diffuse saddle ST, PR
friction rub, diffuse ST depression
elevation
GERD/MSK Reproducible, Diagnosis of exclusion Only after ruling out
positional, no radiation above

Shortness of Breath / Dyspnea

Diagnosis Key Features Initial Workup
Asthma exacerbation Wheezing, prolonged expiration, Peak flow, SpO2, CXR, ABG if
triggers severe
COPD exacerbation Smoker, pursed-lip breathing, CXR, ABG, BNP, EKG
barrel chest
CHF/Pulmonary edema Orthopnea, PND, JVD, crackles, CXR (vascular congestion),
edema BNP, Echo
Pneumonia Fever, cough, focal CXR, CBC, BMP, sputum
consolidation cultures
Anaphylaxis Urticaria, stridor, hypotension, Clinical diagnosis → EPI FIRST
exposure
PE Pleuritic CP, tachycardia, Wells, D-dimer, CT-PA
hypoxia
Altered Mental Status (AMS)
The AEIOU-TIPS Mnemonic for AMS
• A — Alcohol / Acid-base
• E — Epilepsy / Electrolytes
• I — Insulin (hypoglycemia) → CHECK GLUCOSE ON EVERY AMS PATIENT
• O — Opiates / Overdose
• U — Uremia
• T — Trauma / Temperature
• I — Infection (sepsis, meningitis, encephalitis)
• P — Psychiatric / Poisoning
• S — Stroke / Structural lesion

Workup: STAT glucose, BMP, CBC, LFTs, ammonia, EKG, CXR, UA, urine/blood tox screen, head CT
if focal neuro deficits or trauma

Abdominal Pain
Location Top Diagnoses Key Test
RUQ Cholecystitis, cholelithiasis, RUQ ultrasound, LFTs
hepatitis
RLQ Appendicitis, ovarian pathology, Alvarado score, CT
inguinal hernia abdomen/pelvis
LLQ Diverticulitis, ovarian cyst, IBD CT abdomen/pelvis
flare
Epigastric PUD, GERD, pancreatitis, ACS Lipase, EKG, H. pylori
Periumbilical → RLQ Appendicitis (classic migration) CT or ultrasound
Diffuse SBO, mesenteric ischemia, CT with contrast, surgical
AAA, peritonitis consult
Flank Nephrolithiasis, pyelonephritis UA, CT KUB (non-contrast)

NEVER MISS IN ABDOMINAL PAIN

• Ruptured AAA: pulsatile mass, hypotension, back pain — immediate OR
• Ectopic pregnancy: BHCG on ALL women of childbearing age with abdominal pain
• Mesenteric ischemia: pain out of proportion to exam, elderly with afib
• Bowel perforation: free air on CXR/CT, rigid abdomen

Headache
• Thunderclap headache = SAH until proven otherwise → CT head non-contrast → LP if CT
negative
• Worst headache of life = SAH
 • Fever + headache + stiff neck = Meningitis → empiric antibiotics BEFORE LP if concerned
• Focal neuro deficits + headache → stroke workup: CT/MRI, CT angiography
• Headache + visual changes + papilledema → Intracranial hypertension
• Tension/migraine: diagnosis of exclusion after ruling out dangerous causes

Syncope
Benign Features Dangerous Features
✅ Likely Benign ❌ High Risk — Admit/Monitor
• Vasovagal (prodrome, triggers) • Cardiac (exertional, no prodrome)
• Orthostatic hypotension • EKG abnormality (prolonged QT, WPW)
• Situational (cough, micturition) • Elderly, structural heart disease
• Associated chest pain or palpitations
• Family history sudden cardiac death

Workup: EKG (always), orthostatic vitals, BMP, CBC, troponin if cardiac concern, echo, telemetry
monitoring
SECTION 3: Critical Diagnoses You Cannot Miss

☠ THE DEADLY 6 IN CHEST TRAUMA

• 1. Tension Pneumothorax — Needle decompression 2nd ICS midclavicular line
• 2. Open Pneumothorax — Occlusive dressing (3-sided), chest tube
• 3. Massive Hemothorax — Chest tube, blood transfusion, OR
• 4. Flail Chest — Positive pressure ventilation
• 5. Cardiac Tamponade — Beck’s Triad (JVD, hypotension, muffled heart sounds) →
pericardiocentesis
• 6. Aortic Disruption — CT angiography, surgical emergency

Sepsis & Septic Shock

• SIRS criteria: temp >38 or <36, HR >90, RR >20 or pCO2 <32, WBC >12k or <4k or >10%
bands
• Sepsis = SIRS + suspected infection + organ dysfunction (SOFA score ≥2)
• Septic shock = sepsis + vasopressors needed + lactate >2 despite fluids

SEPSIS BUNDLE (Hour-1 Bundle)

• 1. Measure lactate — repeat if >2 mmol/L
• 2. Blood cultures x2 BEFORE antibiotics
• 3. Broad-spectrum antibiotics within 1 hour
• 4. 30 mL/kg IV crystalloid for hypotension or lactate ≥4
• 5. Vasopressors if hypotension persists (Norepinephrine = first-line)

Stroke (CVA/TIA)
• BEFAST: Balance, Eyes, Face drooping, Arm weakness, Speech, Time to call 911
• CT head non-contrast FIRST — rule out hemorrhagic stroke before tPA
• tPA window: 3-4.5 hours from symptom onset in eligible patients
• BP management: do NOT lower BP aggressively in ischemic stroke unless >220/120 (or
>185/110 if tPA candidate)
• NIHSS score: 0-42, guides severity and treatment decisions
• TIA: ABCD2 score for stroke risk; admit if ABCD2 ≥4 or unknown etiology

Hypertensive Emergency vs Urgency

Urgency Emergency
Hypertensive URGENCY Hypertensive EMERGENCY
 BP >180/120 BP >180/120 + end-organ damage
No end-organ damage Encephalopathy, MI, dissection, eclampsia,
renal failure
Oral meds okay IV meds required
Lower BP over 24-48 hours Lower MAP by 25% in first hour

DKA vs HHS
Feature DKA HHS
pH <7.3 >7.3
Glucose >250 mg/dL >600 mg/dL
Ketones Positive (large) Absent/trace
Bicarb <18 mEq/L >15 mEq/L
Onset Hours (T1DM) Days-weeks (T2DM)
Mortality ~1% ~15%
Key Treatment IV fluids, insulin drip, K+ Aggressive IV fluids, insulin after
repletion fluids

KEY: In DKA, don’t start insulin until K+ >3.5. Always check K+ first — insulin drives K+ into
cells!
SECTION 4: Essential Labs & Diagnostics

Critical Values to Know Immediately

Lab Critical Low Critical High Action
Glucose <40 mg/dL >500 mg/dL Dextrose IV; DKA/HHS
workup
Potassium <2.5 mEq/L >6.5 mEq/L EKG immediately; IV or
PO repletion; stabilize
membrane
Sodium <120 mEq/L >160 mEq/L Correct slowly; osmotic
demyelination risk with
rapid correction
pH (ABG) <7.2 >7.6 Identify underlying
cause; ventilator
adjustment
Hemoglobin <7 g/dL — Transfusion threshold
varies by clinical
context
Troponin Any elevation — Serial troponins q3-6h;
EKG correlation
Lactate >4 mmol/L — Tissue hypoperfusion
— sepsis workup,
aggressive
resuscitation
INR >3.0 — Bleeding risk; reversal
agents if active
bleeding

ABG Interpretation — Step-by-Step

• Step 1: Check pH (Normal: 7.35-7.45). Low = acidosis, High = alkalosis
• Step 2: Check pCO2 (Normal: 35-45). If pH low + CO2 high → Respiratory acidosis
• Step 3: Check HCO3 (Normal: 22-26). If pH low + HCO3 low → Metabolic acidosis
• Step 4: Determine compensation. Is the other system trying to compensate?
• Step 5: Calculate anion gap if metabolic acidosis: Na − (Cl + HCO3). Normal = 8-12

MUDPILES — Elevated Anion Gap Metabolic Acidosis

• M — Methanol
• U — Uremia
• D — DKA
• P — Propylene glycol / Paraldehyde
• I — Isoniazid / Iron
 • L — Lactic acidosis (sepsis, ischemia, metformin)
• E — Ethylene glycol
• S — Salicylates

EKG Interpretation — High-Yield Findings

Finding Diagnosis Action
ST elevation in 2+ contiguous STEMI Cath lab activation <90 min
leads door-to-balloon
ST depression + T-wave NSTEMI / UA Anticoagulation, cardiology
inversions consult
Peaked T-waves, wide QRS, Hyperkalemia Calcium gluconate IV
sine wave immediately
Prolonged QTc (>450 ms M, Torsades de pointes risk Check meds, electrolytes; Mg
>470 ms F) sulfate
Delta wave + short PR + wide WPW Avoid AV nodal agents;
QRS electrical cardioversion if
unstable
S1Q3T3 + sinus tach + right PE CT-PA
heart strain
Saddle-shaped ST elevation Pericarditis Echo; NSAIDs + colchicine
(diffuse)
Electrical alternans Cardiac tamponade Emergent pericardiocentesis

Imaging Decisions
• CXR: Always first for chest/respiratory complaints. Know to read: consolidation, pneumothorax,
effusion, cardiomegaly, mediastinal width
• CT Head Non-Contrast: Stroke, AMS, trauma, severe headache, seizure
• CT Abdomen/Pelvis With Contrast: Abdominal pain workup (appendicitis, diverticulitis, masses)
• CT Angiography Chest: PE, aortic dissection
• Ultrasound (FAST Exam): Trauma — free fluid in pericardium, peritoneum
• Bedside Echo: Tamponade, effusion, LV function, volume status (IVC collapsibility)
• CT KUB Non-Contrast: Nephrolithiasis (most sensitive)
SECTION 5: Pharmacology Essentials

Cardiac Medications
Drug Use Key Points / Cautions
Aspirin 325 mg ACS Give immediately; inhibits
platelet aggregation (COX-1)
Nitroglycerin ACS, CHF, hypertensive CONTRAINDICATED with PDE5
emergency inhibitors (sildenafil); causes
hypotension; hold if SBP <90
Heparin (UFH) ACS, PE, DVT aPTT monitoring; antidote =
protamine sulfate
Metoprolol Rate control (AFib), ACS Avoid in decompensated CHF,
bradycardia, high-degree AV
block, severe bronchospasm
Amiodarone Afib rate/rhythm, VT/VF Multiple toxicities: pulmonary,
thyroid, hepatic, corneal
deposits, skin photosensitivity
Adenosine SVT termination Very short half-life (~10 sec);
warn patient of chest tightness;
AVOID in WPW with Afib
Alteplase (tPA) STEMI, stroke, massive PE Absolute CI: prior ICH, active
bleeding, recent surgery/trauma
Norepinephrine Septic shock (first-line Alpha > beta; increases SVR;
vasopressor) monitor for ischemia

Respiratory Medications
Drug Use Key Points
Albuterol Asthma/COPD exacerbation SABA; first-line bronchodilator;
tachycardia, hypokalemia at high
doses
Ipratropium Asthma/COPD exacerbation Anticholinergic; synergistic with
albuterol; dry mouth, urinary
retention
Methylprednisolone Asthma, COPD, allergic rxn Systemic corticosteroid; give
early in exacerbations; glucose
elevation
Epinephrine 0.3 mg IM Anaphylaxis, severe asthma ALWAYS first-line in
anaphylaxis; IM thigh (not
deltoid, not IV in anaphylaxis)
Magnesium Sulfate Severe asthma, torsades, Smooth muscle relaxant;
eclampsia monitor for respiratory
depression and hyporeflexia
Heliox Severe upper airway obstruction Helium-oxygen mix; reduces
airway resistance; buys time for
definitive airway

Neurologic / Seizure Medications

Drug Use Key Points
Lorazepam (Ativan) Status epilepticus — first-line Give IV (0.1 mg/kg); IM if no IV
access; respiratory depression
risk
Levetiracetam (Keppra) Status epilepticus — second-line Loading dose 60 mg/kg IV;
fewer drug interactions than
phenytoin
Phenytoin / Fosphenytoin Status epilepticus — second-line Fosphenytoin preferred IV;
monitor for cardiac arrhythmias
Propofol Refractory status epilepticus, Hypotension, propofol infusion
RSI syndrome with prolonged use
Haloperidol Acute agitation Typical antipsychotic; QT
prolongation; avoid in
Parkinson’s
Dexamethasone Meningitis (before or with abx), Give with or before first antibiotic
brain mets dose in bacterial meningitis

RSI (Rapid Sequence Intubation) Drugs

RSI Sequence: STOP → PREOXYGENATE → SEDATE → PARALYZE →
INTUBATE
• Premedication (optional): Lidocaine (1.5 mg/kg) for head injury/elevated ICP; Atropine for
pediatrics
• Induction agents: Ketamine (1-2 mg/kg) — preserves airway reflexes, bronchodilator, good for
asthma/hypotension
• Etomidate (0.3 mg/kg) — hemodynamically stable; single-dose adrenal
suppression
• Propofol (1.5-3 mg/kg) — great for ICP; causes significant hypotension
• Paralytic (succinylcholine 1.5 mg/kg): Fastest onset/offset; AVOID in hyperkalemia, burns
>24h, crush injury, denervation
• Paralytic (rocuronium 1.2 mg/kg): Longer duration; use if succinylcholine contraindicated
• Reversal of rocuronium: Sugammadex (16 mg/kg) — rapid reversal in failed airway

Pain Management
• Acetaminophen (IV/PO): Safe, effective, avoid in hepatic failure (max 4g/day, 2g in liver
disease)
• Ketorolac (IV): NSAID; excellent for renal colic, MSK pain; avoid with renal failure, GI bleed,
elderly
• Morphine: 0.1 mg/kg IV; respiratory depression, N/V, histamine release (avoid in asthma)
• Hydromorphone: More potent than morphine; less histamine release
• Fentanyl: Rapid onset, short duration; preferred in hemodynamic instability and renal failure
• Ketamine (sub-dissociative): 0.3 mg/kg IV; excellent analgesia; minimal respiratory depression
• Lidocaine (IV): Useful for renal colic, headache; 1.5 mg/kg over 10 min
SECTION 6: Procedures & Skills

Procedures Students May Do or Assist With

Procedure Indication Key Points
IV access / Phlebotomy All patients 18g or larger for blood products;
antecubital, forearm preferred
Foley catheter Urinary retention, ICU Always clean technique; balloon
monitoring 10 mL after confirming
placement
Wound closure Lacerations Know: nylon vs absorbable;
simple interrupted vs mattress
sutures
Splinting Fractures, sprains Plaster vs fiberglass; always
leave space for swelling
Abscess I&D Cutaneous abscess Anesthesia first; elliptical
incision; break loculations;
packing; f/u in 48h
NGT insertion GI bleed, decompression, tox Confirm placement with CXR;
ingestion flush after meds
ECG acquisition All chest pain, arrhythmia, AMS Know standard lead placement;
limb leads vs precordial
FAST Exam Trauma, hypotension 4 views: pericardial, RUQ, LUQ,
pelvis/suprapubic
Lumbar Puncture Meningitis, SAH workup L3-L4 or L4-L5; lateral decubitus
or sitting; opening pressure first

Airway Management Ladder

• 1. Position + BVM ventilation — jaw thrust, head-tilt chin-lift
• 2. Oropharyngeal airway (OPA) / Nasopharyngeal airway (NPA)
• 3. Supraglottic airway (LMA, King airway) — not for RSI
• 4. RSI with direct laryngoscopy (DL) or video laryngoscopy (VL)
• 5. Surgical airway: cricothyrotomy — can’t intubate, can’t oxygenate scenario

Confirm ETT placement: Waveform capnography (gold standard), bilateral breath sounds, CXR
SECTION 7: Approach to Common Scenarios

The Unstable Patient — ABCDE Approach

• A — Airway: Is it patent? Protect with jaw thrust, OPA/NPA, or intubation if needed
• B — Breathing: Rate, SpO2, breath sounds. BVM if inadequate
• C — Circulation: HR, BP, skin perfusion. Two large-bore IVs. Fluids vs pressors vs blood
• D — Disability: GCS, pupils, glucose. Any focal neuro deficits?
• E — Exposure: Fully expose patient. Look for rashes, wounds, trauma, extremity ischemia

Shock — Types & Treatment

Type Mechanism Cause Examples Treatment
Distributive Vasodilation, low SVR Sepsis (most Fluids + vasopressors;
common!), anaphylaxis, treat underlying cause;
neurogenic epi for anaphylaxis
Hypovolemic Low preload/volume Hemorrhage, GI bleed, Hemorrhage control,
loss dehydration, burns blood products, IV fluids
Cardiogenic Pump failure MI, CHF, myocarditis, Treat arrhythmia;
arrhythmia inotropes (dobutamine);
avoid excess fluids
Obstructive Mechanical obstruction PE, tamponade, tension Treat the obstruction:
PTX lytics,
pericardiocentesis,
needle decompression

Toxicology — Classic Toxidromes

Toxidrome Signs Classic Cause Treatment
Anticholinergic Hot, dry, flushed, tachy, Atropine, Physostigmine (if
urinary retention, antihistamines, TCAs severe); benzos for
delirium agitation
Cholinergic (SLUDGE) Salivation, Lacrimation, Organophosphates, Atropine (large doses),
Urination, Defecation, nerve agents pralidoxime
GI distress, Emesis +
miosis, bradycardia,
seizures
Opioid Miosis, RR depression, Heroin, oxycodone, Naloxone (0.4-2 mg
sedation, ‘coma’ fentanyl IV/IM/IN); repeat as
needed
Sympathomimetic Hypertension, Cocaine, Benzos first-line; NO
tachycardia, amphetamines, MDMA beta-blockers
hyperthermia, agitation, (unopposed alpha)
mydriasis
Serotonin syndrome Agitation, hyperthermia, SSRIs, triptans, Cyproheptadine;
clonus (ankles!), linezolid, tramadol benzos; cooling; avoid
diaphoresis antipsychotics

UNIVERSAL ANTIDOTES TO KNOW

• Opioid overdose → Naloxone
• Benzodiazepine overdose → Flumazenil (use cautiously — can precipitate seizures)
• Acetaminophen overdose → N-Acetylcysteine (NAC) — use Rumack-Matthew nomogram
• Warfarin/coumadin → Vitamin K + 4-factor PCC (Kcentra) for emergent reversal
• Heparin → Protamine sulfate
• Digoxin toxicity → Digibind (Fab antibodies)
• Beta-blocker/CCB overdose → High-dose insulin therapy, glucagon, lipid emulsion
• TCA overdose → Sodium bicarbonate (for cardiac toxicity)
SECTION 8: High-Yield Tips & Pimp Questions

The Most Important Vital Sign Rules

• Tachycardia is the FIRST vital sign to change in shock
• Hypotension is a LATE sign — patients can lose 30% blood volume before BP drops
• Fever >41°C (>105.8°F) = heat stroke, serotonin syndrome, malignant hyperthermia —
emergencies
• SpO2 90% ≈ PaO2 60 mmHg — on the steep part of the O2-Hgb dissociation curve

Commonly Tested Pimp Questions

Question Answer
First thing to do for ANY patient in the ED ABCDE assessment + vital signs + IV access +
monitoring
First drug in anaphylaxis Epinephrine 0.3 mg IM (anterolateral thigh)
Why not IV epi first in anaphylaxis? IV epi → severe hypertension/arrhythmia; IM is
safer and equally effective
First drug in status epilepticus Benzodiazepine (lorazepam IV or IM, or diazepam
rectal, or midazolam IM/IN)
Door-to-balloon time for STEMI <90 minutes from first medical contact
Door-to-needle time for stroke <60 minutes; tPA within 3-4.5 hours of symptom
onset
Why not give beta-blockers in cocaine chest pain? Unopposed alpha stimulation → paradoxical
hypertension and coronary vasospasm
Classic EKG in hyperkalemia Peaked T waves → wide QRS → sine wave
pattern → VFib
Treatment of hyperkalemia (stabilize membrane) Calcium gluconate IV — stabilizes the cardiac
membrane (does NOT lower K+)
Most common cause of cardiac arrest (shockable Ventricular fibrillation (VFib) — shock first, then
rhythm) CPR for 2 min
Most sensitive test for SAH if CT negative Lumbar puncture — look for xanthochromia
Beck’s Triad JVD + hypotension + muffled heart sounds =
cardiac tamponade
Cushing’s reflex (triad) Hypertension + bradycardia + irregular
respirations = impending herniation
What does a normal D-dimer tell you? PE is unlikely (high sensitivity, low specificity) —
only useful if low pre-test probability
When to give empiric antibiotics for meningitis? Before LP if LP will be delayed; do NOT delay
antibiotics for imaging
Final Reminders
TOP 10 STUDENT SUCCESS TIPS FOR EM ROTATION
• 1. Know your ABCs — stabilize before diagnosing
• 2. Check a GLUCOSE on every AMS patient (don’t miss hypoglycemia)
• 3. Rule out life-threatening diagnoses FIRST
• 4. Get a β-HCG on every woman of reproductive age with abdominal pain or AMS
• 5. Know the basic EKG findings by heart — especially STEMI and hyperkalemia
• 6. Be organized when presenting: CC → HPI → PMH → Vitals → Exam → Assessment →
Plan
• 7. Disposition thinking starts at triage — admit, discharge, or transfer?
• 8. Always ask about time of last meal, last tetanus, allergies, medications, pregnancy status
• 9. Volunteer for procedures, ask questions, look things up in front of attendings
• 10. Know your limits and ask for help — that is a strength, not a weakness, in the ED

Good luck on your rotation! You’ve got this.