Clearing a Cervical Spine clinically (Mnemonic)

1st step is to look for high risk factors: PAD65

Paresthesias in Extremities, Age more than 65, Dangerous mechanism of injury (high speed, axial load, 1metre or 5 stairs, bicycle, recreational vehicle)

If any of these, get an imaging
If none of these, go to step 2

2nd Step is to look for Low risk factors: PARTS

Delayed onset of neck PAIN,
Ambulatory at any time
Simple Rear End Collision
No Midline Spinal Tenderness, or
Sitting in the ED

If any of these present, no Imaging, go to step 3

Lateral movement of neck 45 degrees

If movement possible, remove the collar

Difficult Airway

Difficult Airway

"The difficult airway is something one anticipates, the failed airway is something one experiences" - Ron Walls

Difficult airway can be due to:

1.  Difficult Bag Valve Mask (BVM); mnemonic = MOANS

2.  Difficult laryngoscopy and dificult intubation; mnemonics = LEMON

3.  Difficult cricothyrotomy; mnemonic = SHORT

4.  Difficult extraglottic devices; mnemonic = RODS

1. Difficult BVM = MOAN!

M = Mask seal not good, e.g. beard, facial deformity, etc

O = Obesity (difficult ventilate), 3rd trimester pregnancy, or obstruction e.g. neck swelling, angioedema, hematomas, cancer, etc

A = Age, elderly, loss of muscle tone to support the upper airway

N = No teeth (no teach causing caved in face)

S = Stiff lungs - upper airway obstruction - exacerbation of asthma, COPD, etc

2. Difficult laryngoscopy: use LEMON

L = Look externally, e.g. short neck, large tongue, large teeth, etc

E = Evaluate 3-3-2

        3 = adequacy of oral access

        3 = to assess capacity of mandibular space to accommodate tongue

        2 = distance of larynx to level of base of tongue

M = Mallampati scoring

O = Obstruction

        Any signs of upper airway obstruction?

        Three cardinal signs of upper airway obstruction:

        - muffled voice (hot potato voice),

        - difficult swallowing secretions,

        - stridor; when stridor happens, consider that circumference of airway reduced to
           roughly 10% of normal caliber!!!!

N = Neck mobility

3. Difficult cricothyrotomy

S = previous surgery

H = Hematoma/swelling around neck

O = Obesity

R = Radiation distortion

T = Tumor

4. Difficult Extraglottic devices

R = Restrictied mouth opening

O = obstruction upper airway

D = Disrupted or distorted upper airway

S = stiff lungs, spine of cervical

(Source: C K Sheng, 2009. Lecturer/Emergency Medicine Specialist, School of Medical Sciences, Universiti Sains Malaysia from http://emergencymedic.blogspot.ae/p/my-list-of-publications.html)

Ottawa Ankle & Foot Rule

Ottowa Ankle and Foot rules
Ankle radiographs are only required if there is pain in the malleolar area and any one of the following:
Bone tenderness over the distal 6cm of the posterior edge or tip of the lateral malleolus
Bone tenderness over the distal 6cm of the posterior edge or tip of the medial malleolus
Inability to weight bear immediately and in the Emergency Department

Foot radiographs are only required if there is pain in the midfoot area and any one of the following:
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular bone
Inability to weight bear immediately and in the Emergency Department

Ottowa rules do not apply to the following

Pregnant women
Head injury patients with diminished ability to follow test
Intoxicated patients with diminished ability to follow test
Children under 6

Resuscitation Guidelines ALS & APLS

The importance of knowing the guidelines cannot be further emphasized. These guidelines have been repeatedly tested in every part of the MCEM Exams. At least 2 to 3 OSCE stations in the part C are almost always reserved for these.
Not only that, knowing these guidelines will help all of us in saving or restoring several lives not only within the departmental settings, but wherever the need arises. Mastering these skills may bring up a smile and make a difference to several families.

Download here:

Resus Guidelines 2010  (Hyperlink Source: Resuscitation Council (UK))

Scoring System often Tested in MCEM Part B

Some scoring systems you should know

Wells criteria for PE
Wells criteria for DVT
TIMI Score for UA
CHAD2VASC Score for stroke in AF
Rockall pre endoscopy score
Mangled limb criteria for open fractures
TIA risk score (ABCD2)
San Fran syncope score

(Courtsey: Dr. Shweta Gidwani, London, UK)

Pulmonary Embolism Mnemonic for Well Score

Don’t                          (DVT symptoms)                         3 points 
Die                             (Diagnosis most likely PE)            3 points 
Tell                            (Tachycardia)                             1.5 points 
The Team                  (Three days [at least] of immobilization, or surgery in the past Thirty days) 1.5 points 
To                             (Thromboembolism in the past [DVT or PE]) 1.5 points
Calculate                    (Coughing up blood [hemoptysis]) 1 point
Criteria                       (Cancer)                                    1 point

This is what the scores mean:
> 6 High probability of PE
2-6 Moderate probability of PE
< 2 Low probability of PE

(Courtesy: Dr. Ram NG, Mumbai)

Cervical Spine Injury CCS Rule

MCEM Part B and C frequently tests you on this:

When do you do an imaging for cervical spine injury (High Risk Patients)

1  Age > 65
2  High Risk Mechanism of Injury:
    a  Fall from 3 ft or 5 stairs,
    b  High Speed collision > 100 kmph,
    c  Rollover accident, and
    d  Ejection injury
3  Paresthesia in upper limbs
4  Altered level of conciousness (Drug/alcohol abuse)

Low risk Patients

1  Simple rear end collision
2  Delayed onset of pain
3  Ambulatory at any time post event
4  Sitting in the ED
5  No spinal midline tenderness

If any of these present, ask patient to move his neck in 45 degrees to left or right, if that is possible then NO Imaging.

CT Scanning in Head Injury (NICE Guidelines)

CT scanning to be performed in head injury and reports available in 1 hour if any of these is present:

Mnemonic: Very Good Friends Should Drive AlcohoLiCs

V        more than 1 episode of Vomiting
G        GCS less than 13 on ED presentation
           GCS less than 15 at two hours from injury
F         Fractures (observed or expected: Open/Depressed/Base of Skull)
S         Post traumatic Seizures
D        Focal Neurological Deficits
ALC   Any Amnesia/LOC/Coagulopathy (abnormal coagulation/or on Aspirin/Clopigrel)

(Compiled by Dr Sajjad Pathan)

NEXUS Criteria for C-Spine Injury Mnemonic

NEXUS Criteria For Cervical Injury:

N    Neuro Deficit
E     EtOH/Intoxication
X    eXtreme distracting Injury
U    Unable to provide history (Altered LOC)
S    Spinal tenderness (midline)

Courtesy: Academic Life in EM Blog

Cardiology: Acute Coronary Syndromes

TIMI Score for UA/NSTEMI

TIMI Score for STEMI

Neurology: TIA, Stroke & Syncope

ABCD2 Score for TIA

San Francisco Syncope Rule to Predict Serious Outcomes

NIHSS Stroke Scale

CHADS2 Score for Atrial Fibrillation Stroke Risk

Pulmonay Embolism

Wells Criteria

PERC Rule

Revised Geneva Score

Trauma

Canadian C Spine Rule
NEXUS Criteria for C spine imaging
Ottawa ankle Rule
Ottawa Knee Rule