Emergency Medicine Cases with Dr. Barlock
Emergency Medical Minute
Contributors: Travis Barlock MD, Jeffrey Olson MS4 Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points. Case 1 25 M, presents to the ED with chest pain. Stabbing, started a few hours ago, substernal. Thinks it is GERD. After 2-3 minutes, pain worsens and radiates to the back. VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA. Additional VS: Temp of 37.2, height of 6’5”, BMI of 18. PMH: None, doesn’t see a doctor. Meds: None FH: Weird heart thing (Mitral Valve Prolapse), weird lung...
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Episode 973: Meningitis Retention Syndrome
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Meningitis retention syndrome is a relatively novel and rare clinical condition Aseptic meningitis + acute urinary retention One study reports an incidence of about 8% in patients with acute aseptic meningitis Clinical presentation Typical meningeal symptoms including fever, stiff neck, and headache Urinary retention occurs about one week after initial symptoms Potential pathophysiology Immune-mediated dysfunction of the central nervous system Detrusor muscle underactivity from inflammation of the spinal cord Management Supportive...
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Episode 972: Hepatic Encephalopathy
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: Hepatic encephalopathy (HE) is defined as a disruption in brain function that results from impaired liver function or portosystemic shunting. Manifests as various neurologic and psychiatric symptoms such as confusion, inattention, and cognitive dysfunction Although ammonia levels have historically been recognized as important criteria for HE, the diagnosis is ultimately made clinically. An elevated ammonia level lacks sensitivity and specificity for HE Trends in ammonia levels do not correlate with disease improvement or resolution A 2020...
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Episode 971: Calcium Pretreatment for Diltiazem in AFib with RVR
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is atrial fibrillation with rapid ventricular response (AFib with RVR) and how does it differ from atrial fibrillation (AFib)? AFib is an abnormal heart rhythm in which the heart has disorganized atrial electrical activity. This causes the atria to quiver with only select signals being conducted through the Atrioventricular (AV) Node to reach the ventricles and result in ventricular contraction. Often described as “irregularly irregular”, a patient's EKG will present with no discernible P-waves, and irregular R-R intervals. AFib with...
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Episode 970: Fever Management
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Recorded March 2025 What is the best treatment for a fever? Tylenol? Ibuprofen? Combined? Alternating the two? The journal Pediatrics aimed to answer this question with a meta-analysis of 31 randomized controlled trials including 5,009 febrile children. Results showed that both combined and alternating acetaminophen/ibuprofen regimens were significantly more effective at reducing fever at 4 and 6 hours compared with acetaminophen alone, with numbers needed to treat (NNT) of 3 and 4, respectively. High-dose ibuprofen alone also offered modest...
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Episode 969: Shoulder Reduction
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: There are many techniques for reducing a shoulder dislocation A recent study discussed a new variation of closed reduction technique: wrist-clamping shoulder-lifting The patient is in a sitting position The provider holds the wrist of the injured arm with both hands and slowly rotates the arm to 90 degrees of abduction and 60 degrees of external rotation After this traction, the arm is slowly moved to 45 degrees of abduction and 60 degrees of external rotation The provider then secures the patient’s wrist between the provider’s knees and...
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Episode 968: Heavy Metals
Emergency Medical Minute
Contributor: Megan Hurley MD Educational Pearls: Acute toxicity of heavy metals: Gastrointestinal upset is the most common presentation Chronic toxicity of heavy metals: Symptoms depend on the metal ingested Increased risk of cancer Altered mentation Developmental delays (in children) Kidney failure Four heavy metals that are tested for in a general panel and their sources: Lead Old paint (homes built before 1977) or some older toys Pipes of older homes or those with corrosive agents May obtain testing kits from home improvement stores to test water supply Mercury Previously in...
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Episode 967: Dilutional Hyponatremia
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Dilutional Hyponatremia: Occurs when there is an excess of free water relative to sodium in the body. Causes a falsely low sodium concentration without a true change in total body sodium. Commonly seen in DKA: Hyperglycemia raises plasma osmolality. Water shifts from the intracellular to extracellular space. This dilutes serum sodium, creating apparent hyponatremia. Corrected sodium calculation: Use tools like MDCALC, or apply this formula: Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100. Clinical...
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EMSAC 2024
Emergency Medical Minute
Contributors: Col. (Dr.) Stacy Shackelford Dr. Sean Keenan Paramedic Alan Moreland Dr. Chris Tems Kara Napolitano From military-inspired trauma protocols to behavioral health alternatives and cardiac resuscitation, EMS is evolving fast. Our Medical Minutes from EMSAC highlight the growing need for prehospital providers to think critically, act quickly, and adapt to new approaches in trauma, crisis response, and patient advocacy. Educational Pearls: What was covered & recorded at EMSAC 2024 by EMM? Col. (Dr.) Stacy Shackelford, U.S. Air Force trauma surgeon and Director of the Joint Trauma...
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Episode 966: Acetaminophen Toxicity
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS4 Educational Pearls: What is the toxic dose of acetaminophen? 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver. This is equivalent to fifteen 500mg pills. What are the symptoms of acetaminophen toxicity? First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic. 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion) Fulminant liver failure at 72-96 hours Liver function tests (LFTs) peak at 72-96...
info_outlineContributors: Travis Barlock MD, Jeffrey Olson MS4
Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points.
Case 1
25 M, presents to the ED with chest pain.
Stabbing, started a few hours ago, substernal. Thinks it is GERD.
After 2-3 minutes, pain worsens and radiates to the back.
VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA.
Additional VS: Temp of 37.2, height of 6’5”, BMI of 18.
PMH: None, doesn’t see a doctor. Meds: None
FH: Weird heart thing (Mitral Valve Prolapse), weird lung thing (spontaneous pneumothorax), tall family members with long fingers and toes
Physical Exam:
Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric
MSK: Knees, elbows, and wrists are hypermobile.
Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion
CTA/MRA doesn’t come back until after the case.
ECG: Sinus Tach
Labs:
NT-proBNP 500 pg/mL
D-Dimer: 7000 ng/L
CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL
Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180
LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4,
Ca: 7.8
LDH: 2200
PT: 20.5, INR: 2.2, Fibrinogen: 170
5th gen High-Sensitivity Troponin: <3
Lactate: 7 mmol/L
VBG: pH 7.22, paCO2 28, bicarb 15
Notes: Can have patient crash somewhere in middle and show 2nd xray
Case 2:
A 67-year-old female is brought to the ED by her daughter due to progressive weakness, confusion, and fatigue that have worsened over the past week.
Unable to get out of bed and has become increasingly lethargic. Also having some nausea, constipation. The daughter denies any preceding illness, recent trauma, or travel. Does not know her meds but will head home to get them after talking with you.
VS: BP 88/55 mmHg, HR 110, RR 20, O2 Sat 98% on room air.
Additional VS: Temp 36.8°C.
PMH: Hypertension, osteoarthritis, and depression.
Physical exam:
General: Thin, somnolent but arousable.
HENT: Dry mucous membranes
Neuro: Confused, A&Ox1 (self), hyporeflexia
Labs (Includes many that would not return in the ED in case you want to take this case forward to the floor)
CBC: WBC 9,500, Hb 16.5, Hct: 50%, Platelets 220,000
Chem7: Na 129, K 2.1, Cl 95, HCO3 34, Creatinine 1.6, BUN 40, Glucose 115
LFTs: normal
Magnesium: 1.1
Calcium: 10.8 mg/dL (corrects to 12.8)
iCal: 3.2
Phosphate: 2.3 mg/dL
Albumin: 2
BUN:Cr ratio: 25
VBG: pH: 7.49, PaCO2 45, HCO3: 34
Lactate: 2.8
Serum Osmolality: 276 mOsm/kg (Osmolal gap of 2)
Urine Osmolality: 550 mOsm/kg
Urine Sodium (UNa): 10 mEq/L (low). Urine Potassium (UK): 25 mEq/L (elevated). Urine Chloride (UCl): 12 mEq/L (low). Urine Magnesium (UMg): 20 (Elevated). Urine Calcium (UCa): 50 in 24 hrs (Low)
100 cc of urine with foley
FeNa <1%
Plasma renin activity: 15 mg/mL/hr (elevated), Aldosterone: 25 ng/dL (Elevated), ADH: Elevated, Diuretic screen: Positive for thiazides
PTH: 8 (low), HsTrop: 32, Cortisol and ACTH: Normal.
EKG: Hypokalemia features
CXR: Normal
Renal US: shows stones
Improves with fluids
Note: Can have daughter return with med list at some point including HCTZ, ibuprofen, and sertraline
Case 3:
Patient Presentation
EMS Report: A 27-year-old male involved in a high-speed motorcycle collision is brought to the emergency department by EMS. The patient was found unconscious at the scene with evidence of severe thoracic and extremity trauma. He was intubated en route for airway protection due to altered mental status (GCS 7).
VS: HR 130, BP 90/60, RR: bagging at 12 bpm, satting 88% on 100% FiO2
Primary Survey
Airway: Endotracheal tube in place.
Breathing: Decreased breath sounds on the left side with visible chest asymmetry and paradoxical chest wall movement.
Circulation: Mottled extremities noted, with significant deformity of the right thigh. Pulses are diminished in the right leg
Disability: GCS remains 7 (E1 V2 M4). Pupils equal and reactive.
Exposure: Full-body examination reveals an open fracture of the right femur, multiple abrasions, and bruising over the chest wall.
Vent alarms
Peak Inspiratory Pressure (PIP) 40 cm H₂O (elevated)
Plateau Pressure (Pplat) 35 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 55 mmHg
High-Pressure Alarm Triggering frequently
Glucose 120
CBC: Hgb 8.9, Hct 27, WBC 14.2, platelets 220,000
VBG: pH 7.28, pCO2 33, bicarb 18, lactate 4.5
CXR with tension pneumothorax
Patient improves after chest tube, pigtail catheter, or needle decompression.
Ready to be transferred upstairs and O2 starts tanking again
Vent alarms- second episode
Peak Inspiratory Pressure (PIP) 35 cm H₂O (elevated)
Plateau Pressure (Pplat) 30 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 20 mmHg
HR: 140, satting 84%, temp 38.5,
ABG: pH 7.32, pCO₂ 30 mmHg, pO₂ 60 mmHg on 100% FiO₂, HCO₃⁻ 18 mmol/L (hypoxemia and metabolic acidosis).
D-dimer: Elevated
Thrombocytopenia: Platelets 90,000/µL.
US shows blown right ventricle
ECG shows new RBBB
CT PE: Ground glass opacities, consolidation, centrilobular nodules, septal thickening, and fat-attenuating lesions.
Note: Management is largely supportive care so once the diagnosis is made, end the case.
References
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Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 2003 May 1;67(9):1959-66. PMID: 12751658.
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Coelho SG, Almeida AG. Marfan syndrome revisited: From genetics to the clinic. Rev Port Cardiol (Engl Ed). 2020 Apr;39(4):215-226. English, Portuguese. doi: 10.1016/j.repc.2019.09.008. Epub 2020 May 18. PMID: 32439107.
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Palmer BF. Metabolic complications associated with use of diuretics. Semin Nephrol. 2011 Nov;31(6):542-52. doi: 10.1016/j.semnephrol.2011.09.009. PMID: 22099511.
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Reed MJ. Diagnosis and management of acute aortic dissection in the emergency department. Br J Hosp Med (Lond). 2024 Apr 30;85(4):1-9. doi: 10.12968/hmed.2023.0366. PMID: 38708978.
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Roberts DJ, Leigh-Smith S, Faris PD, Blackmore C, Ball CG, Robertson HL, Dixon E, James MT, Kirkpatrick AW, Kortbeek JB, Stelfox HT. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015 Jun;261(6):1068-78. doi: 10.1097/SLA.0000000000001073. PMID: 25563887.
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Rothberg DL, Makarewich CA. Fat Embolism and Fat Embolism Syndrome. J Am Acad Orthop Surg. 2019 Apr 15;27(8):e346-e355. doi: 10.5435/JAAOS-D-17-00571. PMID: 30958807.
Produced by Jeffrey Olson, MS4
Special thanks to Evan Fisch MD
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