EMF Workbook

EM FUNDAMENTALS
Workbook
FIFTH EDITION
2021 – 2022
EM FUNDAMENTALS
Workbook
FIFTH EDITION
2021 – 2022
Copyright © 2021, 2020, 2019, 2018, 2017 by EM Fundamentals.

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Contributors EM Fundamentals
EDITOR-IN-CHIEF Michael A. Hernandez, MD David Peak, MD

Resident Physician, University of Assistant Professor, Massachusetts
Eric Shappell, MD, MHPE Chicago General Hospital / Harvard Medical
Assistant Professor, Massachusetts School
General Hospital / Harvard Medical Imikomobong Ibia, MD
School Resident Physician, BWH/MGH Gregory Peters, MD
Harvard Affiliated Emergency Medicine Resident Physician, BWH/MGH
Residency Harvard Affiliated Emergency Medicine
ASSOCIATE EDITOR Residency
Todd Jaffe, MD
James Ahn, MD, MHPE Resident Physician, BWH/MGH Taylor A. Petrusevski, MD
Associate Professor, University of Harvard Affiliated Emergency Medicine Resident Physician, University of
Chicago Residency Chicago
Inkyu Kim, MD Adam Pissaris, MD

Resident Physician, BWH/MGH Resident Physician, BWH/MGH
Harvard Affiliated Emergency Medicine Harvard Affiliated Emergency Medicine
SECTION EDITORS Residency Residency
Emily L. Aaronson, MD, MPH Paul Kukulski, MD Gregory Podolej, MD

Assistant Professor, Massachusetts Assistant Professor, University of Assistant Professor, University of Illinois
General Hospital / Harvard Medical Chicago College of Medicine at Peoria
School
Ashlin Larsen, MD Nicolas Ramsey, MD
Paul Aronson, MD, MHS Resident Physician, Oregon Health & Resident Physician, Rush University
Associate Professor, Yale School of Science University Medical Center
Medicine
Edward K. Lew, MD Giovanni Rodriguez, MD
Sofia Athanasopoulou, MD Attending Physician, Northwest Resident Physician, BWH/MGH
Resident Physician, Yale New Haven Permanente Harvard Affiliated Emergency Medicine
Hospital Residency
Kristin Lewis, MD, MA
Christine Babcock, MD, MSc Resident Physician, University of Madeline Schwid, MD
Associate Professor, University of Chicago Resident Physician, BWH/MGH
Chicago Harvard Affiliated Emergency Medicine
Zayir Malik, MD Residency
Connor W. Brown, MD, MPH Medical Education Fellow, University of
Resident Physician, BWH/MGH Chicago Laura Shook, MD
Harvard Affiliated Emergency Medicine Resident Physician, University of
Residency Isabel Malone, MD Washington
Medical Education Fellow, University of
Navneet Cheema, MD Chicago Jamie O. Staudt, MD
Assistant Professor, University of Resident Physician, University of
Chicago Katherine Dickerson Mayes, Chicago
Anne K. Chipman, MD, MS MD, PhD J. Kimo Takayesu, MD, MSc

Assistant Professor, University of Resident Physician, BWH/MGH
Assistant Professor, Massachusetts
Washington Harvard Affiliated Emergency Medicine
General Hospital / Harvard Medical
Residency
School
Danielle De Freitas, MD
Resident Physician, University of Rmaah Memon, MD Emily Wilkins, MD
Chicago Resident Physician, BWH/MGH
Resident Physician, University of
Harvard Affiliated Emergency Medicine
Chicago
Andrew J. Eyre, MD, Residency
MSHPEd A.J. Meyer, MD Kori S. Zachrison, MD, MSc

Instructor, Brigham and Women's Associate Professor, Massachusetts
Resident Physician, University of Illinois
Hospital / Harvard Medical School General Hospital / Harvard Medical
College of Medicine at Peoria
School
Devon Fiorino, MD Natalia M. Mosailova, DO
Resident Physician, University of Resident Physician, Oregon Health &
Alexander Zirulnik, MD
Chicago Resident Physician, BWH/MGH
Science University
Harvard Affiliated Emergency Medicine
Doug Franzen, MD, MEd Jared Novack, MD Residency
Associate Professor, University of Clinical Assistant Professor, NorthShore
Washington University HealthSystem
Michael Gottlieb, MD Kathryn Oskar, MD

Associate Professor, Rush University Resident Physician, BWH/MGH
Medical Center Harvard Affiliated Emergency Medicine
Residency
Laura A. Hancock, MD, PhD
Resident Physician, University of
Washington
EM Fundamentals Facilitator Guide
Table of Contents EM Fundamentals
TABLE OF CONTENTS
Small Group Activities................................................................................................ 1
Acute Coronary Syndromes............................................................................. 3
Airway Management.......................................................................................... 8
Cardiac Arrest...................................................................................................13
Sepsis.................................................................................................................18
Shock.................................................................................................................. 23
Stroke................................................................................................................. 28
Trauma................................................................................................................ 33
Abdominal Pain.................................................................................................38
Altered Mental Status......................................................................................42
Chest Pain..........................................................................................................47
Diabetic Ketoacidosis.. ....................................................................................52
Dyspnea.. ............................................................................................................ 57
The Febrile Infant............................................................................................. 62
First Trimester Bleeding..................................................................................66
GI Bleeding . . .......................................................................................................71
Headaches.........................................................................................................76
Syncope............................................................................................................. 79
Small Group Evaluation Form.................................................................................. 82
Simulation Checklists............................................................................................... 85
Endotracheal Intubation . . ................................................................................86
Cricothyrotomy................................................................................................. 89
Chest Tube Placement.. ...................................................................................92
Central Venous Access...................................................................................96
Radial Artery Line Placement . . .................................................................... 101
Lumbar Puncture........................................................................................... 105
Contact Us............................................................................................................... 110
EM Fundamentals Facilitator Guide
Small Group Activities EM Fundamentals 1
SMALL GROUP ACTIVITIES

2 EM Fundamentals Facilitator Guide
Small Group Activities - Acute Coronary Syndromes EM Fundamentals 3
ACUTE CORONARY SYNDROMES

Faculty Editor: Andrew J. Eyre, MD, MSHPEd
Resident Editor: Nicolas Ramsay, MD
Resources to Review Prior to Conference
Who Needs PCI?

EMCrit / Steve Smith’s ECG Blog
Non–ST-Elevation Acute Coronary Syndromes

ACEP Clinical Policy
Acute Coronary Syndromes

CDEM Curriculum
Activity 1: Quiz
Take 8 minutes to discuss the following questions as a team and come to a
consensus on your answers. Once time is up, be prepared to discuss your
answers with the group.
1. List the three diagnoses that comprise “acute coronary syndromes” and
how each of the three is diagnosed.
2. Describe the ECG criteria for diagnosing an ST-elevation myocardial in-

farction (STEMI) according to the 2018 consensus paper: Fourth Universal
Definition of Myocardial Infarction. 1 Discuss how these STEMI criteria relate
to the concepts of acute coronary occlusion (ACO) and occlusive myocardial
infarction (OMI).
3. Define Type 1 and Type 2 myocardial infarction.
4. Name the categories of medications used to treat acute coronary syn-

dromes and their indications/contraindications.
Activity 2: Cases
Case 1
A 56-year-old female patient with a history of diabetes, high blood pressure,
and smoking presents with an aching pressure in the center of her chest off
and on for the past 2 months. The sensation lasts a few seconds to a min-
ute at a time and is occasionally associated with mild nausea. She came in
today because it now happens nearly every day, which is more often than
before (approximately once per week). She has no complaints of shortness of
breath, pleurisy, diaphoresis, cough, back pain, or neurologic symptoms. Her
vital signs, exam, and ECG are all normal. The last time she had the symptoms
was 6 hours ago while assembling a bookshelf at her house.
List your plans for diagnostics, therapeutics, and disposition for this patient.
Case 2
A 68-year-old male patient with a history of diabetes, hypertension, hyper-
lipidemia, and coronary artery disease presents with shortness of breath and
weakness for the past hour. He had a cardiac catheterization 6 years ago that
showed moderate diffuse coronary artery disease and a stress test 8 weeks
ago that was normal. His vital signs are normal aside from a blood pressure of
156/76. He appears somewhat uncomfortable and has some beads of sweat
on his brow. His exam is otherwise unremarkable. His ECG is shown below.
Image source: Tyler Constantine, MD. Used with permission.
List your plans for diagnostics, therapeutics, and disposition for this patient.
NOTES
AIRWAY MANAGEMENT
Faculty Editor: Navneet Cheema, MD
Resident Editors: Kristin Lewis, MD, MA, Jamie O. Staudt, MD
RSI Checklist
EMCrit
Dominating the Vent

EMCrit
RSI Overview and Mnemonics

Life in the Fast Lane
Small Group Activities - Airway Management EM Fundamentals 9
Activity 1: Intubation Cases

Case 1
A 66-year-old female presents to the emergency department with a cough
and shortness of breath worsening over the past 4 days. She initially ap-
pears in moderate respiratory distress and is using some accessory muscles
to breathe. Her initial vitals are HR 90, BP 140/72, RR 41, SPO2 85%. She is
started on BiPAP 10/5, 60% FiO2. She receives a chest x-ray that shows a
large right-sided pneumonia for which she is treated with antibiotics. Her
repeat vital signs are HR 97, BP 138/75, RR 32, SpO2 88% on the BiPAP. On
reassessment she appears more fatigued and somnolent, so you make the
decision to intubate her.
Describe in the space below your approach to intubation in this patient, includ-
ing initial actions, the choice of intubation approach and why, equipment, and
medications (including doses).
Case 2
A 49-year-old man presents with tongue swelling for the past 30 minutes. He
felt completely fine prior. His only medical history is hypertension for which
he takes lisinopril. His exam reveals an asymmetric tongue with swelling pri-
marily on the right side. The posterior oropharynx is barely visible using a
tongue depressor.
While you are completing your exam, the patient notes that his tongue feels
even bigger, his voice is changing, and he is now short of breath. You re-ex-
amine the mouth and note a significant increase in swelling of the tongue,
now causing near complete obstruction of the mouth. You are concerned
with the speed and significance of the swelling and decide that intubation is
warranted for airway protection. His SpO2 is 100% on room air.
In the space below, describe your approach to intubation in this patient in-
cluding initial actions, equipment, and medications (including doses).
Activity 2: Ventilator Management Cases

Case 1
You have switched rotations and are now managing the 66-year-old female with
pneumonia from the previous case in the ICU. She has since progressed to being
diagnosed with ARDS (acute onset of symptoms, bilateral infiltrates on chest
x-ray, PaO2/FiO2 less than 200, respiratory failure not explained by heart failure
or volume overload).
Your fellow asks: “What ventilation mode and settings would you choose for
this patient? Tell me your desired initial settings and your rationale, then how
you would check if your initial settings are appropriate.”
Case 2
A 29-year-old man presented with a severe asthma exacerbation. Despite
continuous nebulized albuterol, IV steroids, magnesium, epinephrine, and Bi-
PAP, he began to tire and required intubation.
Your fellow again asks: “What ventilation mode and settings would you choose
for this patient? Tell me your desired initial settings and your rationale, then how
you would check if your initial settings are appropriate.”
Small Group Activities - Airway Management EM Fundamentals 11
Case 3
You are called to the bedside as the patient intubated for an asthma exac-
erbation in the previous case suddenly becomes hypoxemic with an SpO2 of
75%. What is your differential for this hypoxemia? What actions can you take
to correct it?
NOTES
Small Group Activities - Cardiac Arrest EM Fundamentals 13
CARDIAC ARREST
Faculty Editor: Edward K. Lew, MD
Resident Editors: Rmaah Memon, MD, Connor W. Brown, MD, MPH
H’s and T’s of Cardiac Arrest

EM in 5
The First 90 Seconds: Cardiac Arrest

EM:RAP
Post-Arrest Care
EMCrit
Activity 1: Getting the History

Case 1
You receive notice from your charge nurse that EMS is bringing in a middle-aged
patient in cardiac arrest. As your team begins to set up the room, your attending
tasks you with getting the history from EMS upon arrival of the patient.
In the space below, list the questions you plan to ask EMS and be prepared to
discuss your rationale for each question.
Activity 2: Room Set-up

Case 1
After an exemplary resuscitation of the patient in the previous activity, you
receive notice from your charge nurse that EMS is bringing another patient
in cardiac arrest. This time your attending tasks you with setting up the room
before the patient arrives.
In the space below, diagram your ideal set-up of the room that will be used to
attempt to resuscitate the incoming patient. Include the placement of all equip-
ment (airway equipment, crash cart, etc.) and all personnel (code leader, record-
er, etc.). Only diagram the resources available at your primary hospital location.
Activity 3: Case
Case 1
EMS arrives with a 55-year-old patient in cardiac arrest. The patient was found
unresponsive and pulseless in their apartment after a family member heard
a “thud” in the other room. They were last seen well 10 minutes prior to the
event. Family initiated CPR, which was continued by EMS. The initial rhythm for
EMS was PEA with regular and narrow QRS complexes and a rate of 142 bpm.
A supraglottic device was placed and the end-tidal CO2 level is 44 with a good
waveform. Family members reported the patient has a history of end-stage re-
nal disease and receives dialysis 3 days per week. Compressions are ongoing
as the patient is noted to still be pulseless on arrival to the ED bay.
Based on the above history, what diagnoses are at the top of your differential?
What empiric actions, if any, would you take in this case?

What diagnostic actions are your highest priority?
What are your thoughts on this patient’s prognosis given the history?
NOTES
SEPSIS
Faculty Editor: Emily L. Aaronson, MD, MPH
Resident Editor: Kathryn Oskar, MD
ProCESS Trial
Primary Literature
DART
ACEP Sepsis Tool
Early Warning Scores

Primary Literature
Small Group Activities - Sepsis EM Fundamentals 19
Activity 1: Cases
Case 1
A 67-year-old male presents with a cough and fever for the past 3 days. His
x-ray shows a left lower lobe consolidation. He has pitting edema to both
lower extremities but states “they’re always like that.” Your chart review re-
veals a history of COPD and a left ventricular ejection fraction of 36% from
an echo last month. His vital signs are HR 95, BP 110/75, RR 22, SpO2 94%
on room air, T 38.2°C.
What is your initial approach to fluid management in this patient?
Case 2
An 82-year-old female nursing home resident presents with altered mental
status. Her UA shows nitrites and >20 WBC/hpf. Vital signs are HR 115, BP
80/50, RR 20, SpO2 96% on room air, T 38°C after a total of 40cc/kg LR bolus
and an IVC US after resuscitation that is plump and without respirophasic
variation. Her heart contractility on bedside ultrasound is grossly normal.
What is your approach to hypotension in this patient? Discuss what agents

you would choose and in what order. Prepare to discuss your reasoning.
Case 3
The patient from the case above remains hypotensive despite the maximum
dose of multiple vasopressors. What other intervention(s) may help treat this
patient’s hypotension?
Activity 2: Journal Club

After splitting into 3 groups or having your individual study assigned, take
10 minutes to come up with a description for the group of the key elements
of the study. You can use whatever resources you want to help craft your
response (e.g., phones, laptops, etc.). After the 10 minutes of small group or
individual work, each study will be presented to the whole class (5 minutes
per study).
Small Group Activities - Sepsis EM Fundamentals 21
Rivers:
PROCESS:
Sepsis-3:
NOTES
Small Group Activities - Shock EM Fundamentals 23
SHOCK
Faculty Editor: Michael Gottlieb, MD
Resident Editor: Madeline Schwid, MD
Types of Shock
EM in 5
RUSH Protocol
Academic Life in Emergency Medicine
Activity 1: Cases
Case 1
A 64-year-old female presents with shortness of breath and lightheadedness
for the past 3 hours. She appears weak and diaphoretic. Her vital signs are
HR 116, BP 75/45, RR 22, SpO2 92% on room air, T 36.2°C.
What are your first steps in management of this patient?
Case 2
A 55-year-old man presents with worsening shortness of breath for the past 2
weeks that became acutely worse this morning. He has a history of hypertension,
hyperlipidemia, diabetes mellitus, and heart failure (EF 30%) that is attributed to
ischemic cardiomyopathy. His lungs have diffuse crackles. His vital signs are HR
87, BP 80/65, RR 24, SpO2 91% on room air, T 35.6°C. His RUSH exam shows dif-
fuse B lines, a plethoric IVC, and his heart has poor contractility.
What are your first steps in management of this patient? How do you deter-
mine if this patient is in shock?
Activity 2: Shock and Fluid Status Markers

After splitting into 3 teams, take 10 minutes to come up with a description of
the topic assigned to your team. You can use whatever resources you want to
help craft your response (e.g., phones, laptops, etc.). After 10 minutes, teams
will have 5 minutes each to present to the whole group.
Team 1: IVC ultrasound as a marker of fluid tolerance
Please comment on technique, quantitative criteria, and use in spontaneous-

ly breathing vs. mechanically ventilated patients
Team 2: Pulse pressure variation

Please comment on technique, quantitative criteria, and use in spontaneous-
ly breathing vs. mechanically ventilated patients
Team 3: RUSH (Rapid Ultrasound for Shock and Hypotension) Exam

Please comment on the ultrasound views and findings for the RUSH exam.
NOTES
STROKE
Faculty Editor: Kori S. Zachrison, MD, MSc
Resident Editor: Todd Jaffe, MD
Stroke
EM:RAP C3
Blood Pressure Management in Intracranial Hemorrhage

ACEP EQUAL
Anticoagulant Reversal
ACEP EQUAL
Small Group Activities - Stroke EM Fundamentals 29
Activity 1: Stroke Diagnosis Cases

Case 1
The triage nurse calls you over to evaluate a 56-year-old male presenting
to the emergency department with facial weakness for the past 3 hours.
The nurse is concerned that he may be having a stroke. The patient hoped it
would get better on its own; however, after having some difficulty drinking,
he decided to come in. He has no other complaints. His past medical histo-
ry includes hypertension and hyperlipidemia. His vital signs are HR 87, BP
181/112, RR 18, SpO2 97% on room air, T 36.6°C.
What is your differential diagnosis for this patient? How would you determine
if this patient is having a stroke?
Case 2
A 62-year-old woman presents with dizziness for the past hour. Her symp-
toms are described as a room-spinning sensation and unsteadiness on her
feet. She has nausea but has not vomited. The symptoms are worse with
movement but are not entirely relieved by rest. She has a history of well-con-
trolled hypertension and diabetes.
What is your differential diagnosis for this patient? How do you determine if
this patient is having a stroke?
Activity 2: Stroke Management Cases

For each of the following cases, please answer the following questions:
– What is your blood pressure goal for this patient?
– What medications (if any) would you use to alter the blood pressure?
– What other medications or interventions (if any) are indicated?
For medications, comment on the dose(s) you would give, whether you would
use intermittent dosing or continuous infusion, and re-dosing and titration
intervals for intermittent dosing and continuous infusions, respectively.
Case 1A
A 56-year-old male is brought in by EMS with left-sided weakness for the
past 45 minutes. He previously felt at his baseline with no other symptoms.
His head CT shows no hemorrhage or mass effect. Vital signs are HR 72, BP
215/112, RR 16, SpO2 97% on room air, T 36.6°C.
Case 1B
A 56-year-old male is brought in by EMS with left-sided weakness for the past
36 hours. He previously felt at his baseline with no other symptoms. His head
CT shows no hemorrhage or mass effect. Vital signs are HR 72, BP 215/112,
RR 16, SpO2 97% on room air, T 36.6°C.
Small Group Activities - Stroke EM Fundamentals 31
Case 1C
A 56-year-old male awakens from sleep with left-sided weakness. He went to
sleep 7 hours earlier, and both the patient and his family report that he had
no neurologic deficits prior to going to sleep. His head CT shows no hemor-
rhage or mass effect. His vital signs are HR 72, BP 182/85, RR 16, SpO2 97%
Case 2A
A 56-year-old previously healthy male is brought in by EMS with a severe
headache, vomiting, and right-sided weakness. He is minimally responsive
on arrival so he is intubated for airway protection. His head CT shows a large
subarachnoid hemorrhage. The CTA portion of the study reveals an aneu-
rysm. Vital signs are HR 72, BP 215/112, RR 22 (over-breathing the ventilator,
which is set at a rate of 12), SpO2 97% on FiO2 60%, T 36.6°C.
Case 2B
For the patient in Case 2A, in addition to blood pressure control and neurol-
ogy/neurosurgery consultation, what measures will you stake to treat this
patient’s intracranial hemorrhage?
NOTES
Small Group Activities - Trauma EM Fundamentals 33
TRAUMA
Faculty Editor: David Peak, MD
Resident Editors: Inkyu Kim, MD, Adam Pissaris, MD
Trauma Assessment
Life in the Fast Lane
Trauma Assessment Video

Vanderbilt Emergency Medicine
Activity 1: Primary Survey

The primary survey is a rapid, methodical way of evaluating for life-threat-
ening injuries. For each step in the algorithm listed below, discuss the key
steps of assessment, abnormal signs to look for, and how to address any
life-threatening abnormalities found.
1. Airway
2. Breathing and Ventilation
3. Circulation
4. Disability
5. Exposure
Activity 2: Hard Signs

Several categories of traumatic injuries have “hard signs” that necessitate
operative intervention. For each of the categories of traumatic injuries below,
list the “hard signs” that, if found, require operative management.
1. Penetrating Neck Trauma
2. Penetrating Chest Trauma
3. Penetrating Abdominal Trauma

Activity 3: Room Set-up

You receive notice from your charge nurse that EMS is bringing in a young pa-
tient with a gunshot wound to the chest. The patient reportedly has a pulse
but the EMS crew were unable to measure a blood pressure with the first
cycle of the cuff, so they are cycling it again. Your attending tasks you with
setting up the room prior to arrival of the patient.
In the space below, diagram your ideal set-up of the room that will be used
to resuscitate the incoming patient. Include the placement of all equipment
(airway equipment, procedural supplies, etc.) and all personnel including
roles, responsibilities, and expectations for communication. Only diagram
the resources that you have available at your hospital.
NOTES
ABDOMINAL PAIN
Faculty Editor: Zayir Malik, MD
Resident Editor: Gregory Peters, MD
Assessing Abdominal Pain

Emergency Medicine Practice
Abdominal Pain in the Elderly

EM:RAP C3
Small Group Activities - Abdominal Pain EM Fundamentals 39
Activity 1: Team Quiz

1. Patients over the age of 70 presenting to the emergency department with
abdominal pain are diagnosed with severe vascular pathology approximately
_____ % of the time.
2. The mortality of patients over the age of 80 presenting to the emergency

department with abdominal pain is approximately _____ %.
3. Based on history and physical exam alone, physician accuracy in diagnos-

ing the etiology of abdominal pain in a patient over 80 years in age is _____ %.
4. The most common organ responsible for pathology in patients over 50 pre-
senting to the emergency department with abdominal pain: _______________
5. Approximately _____ % of women of childbearing age that are ultimately

diagnosed with appendicitis were initially misdiagnosed.
6. _____ % of patients with surgically proven appendicitis have no right lower

quadrant pain or tenderness.
7. The presence of rigidity in the right lower quadrant increases the likeli-
hood of appendicitis by a factor of approximately _____ .
8. Approximately _____ % of women with pelvic inflammatory disease (PID)

have purulent drainage from the cervical os.
9. In a study of patients presenting to the emergency department with ab-

dominal pain, an elevated white blood cell count was _____ % sensitive for
severe abdominal pathology.
10. In a meta-analysis of >3,400 patients, CRP was approximately _____ %

sensitive and _____ % specific for diagnosing appendicitis.
11. Patients with appendicitis have blood, leukocytes, and/or bacteria in their
urine approximately _______% of the time.
12. The incidence of hematuria is approximately _____ % in patients ultimate-

ly diagnosed with a ruptured abdominal aortic aneurysm.
Activity 2: Ultrasound Lightning Exercise

Computed tomography is often used to assist in diagnosing conditions that
cause patients to present with abdominal pain. However, many diagnoses can
be made with ultrasonography. In the next 5 minutes, use the space below
to list as many diagnoses as possible that cause abdominal pain and can be
diagnosed with ultrasound.
Activity 3: Mapping
Take 7 minutes and the space below to create a mind map, flowchart, or oth-
er diagram to illustrate how you approach abdominal pain in the emergency
department. Once finished, you will discuss your creation with a partner (if
feasible) and the group.
Small Group Activities - Abdominal Pain EM Fundamentals 41
NOTES
ALTERED MENTAL STATUS

Faculty Editor: J. Kimo Takayesu, MD, MSc
Resident Editors: Taylor A. Petrusevski, MD, Emily Wilkins, MD
Approach to Altered Mental Status

EM in 5
Approach to Altered Mental Status

CDEM Curriculum
Altered Mental Status in the ED

Primary Literature
Small Group Activities - Altered Mental Status EM Fundamentals 43
Activity 1: Rapidly Reversible Life Threats

Many causes of altered mental status are life threatening. While all of these are
time-sensitive, only a few are rapidly reversible. In the space below, list 5 causes
of life-threatening altered mental status that are rapidly reversible and the treat-
ment for each condition. Be specific in your descriptions of treatments (e.g., in-
clude medication name/dose/route, ancillary equipment, alternative treatments,
and any specific treatment dose-response considerations, if relevant.
Session Activity 2: Cases

Case 1
EMS brings in an approximately 50-year-old male patient for which a bystand-
er called EMS after finding him sleeping on a park bench covered in blankets
and “afraid he wasn’t breathing.” On arrival to your department he is awake
and appears disheveled. He has slurred speech and incoordination but is able
to recite his name, the month, and that he is “in the hospital.” He states that
he has been drinking vodka all day, that he is hungry, and that he has no other
complaints.
What is your approach to this patient? Describe your diagnostic and thera-
peutic plan, as well as this patient’s anticipated course in the ED.
Small Group Activities - Altered Mental Status EM Fundamentals 45
Case 2
EMS brings in an approximately 50-year-old female patient for which a by-
stander called EMS after finding her on the ground in the bathroom of the bar
down the street from your ED. On arrival to your department, she is dressed
in appropriate street clothes but does not respond to verbal questions or
commands. Her only motor response is to appear annoyed and push your
hand away when you attempt a sternal rub. She smells strongly of alcohol
and appears to have urinated on herself. No further history is available.
What is your approach to this patient? Describe your diagnostic and thera-
peutic plan, as well as this patient’s anticipated course in the ED.
NOTES
Small Group Activities - Chest Pain EM Fundamentals 47
CHEST PAIN
Faculty Editor: Anne K. Chipman, MD, MS
Resident Editors: Laura Shook, MD, Michael A. Hernandez, MD
Approach to Chest Pain

CDEM Curriculum
Chest Pain Pocket Card

EM Basic
Activity 1: Mapping
Take 7 minutes and the space below to create a mind map, flowchart, or other
diagram to illustrate how you approach chest pain in the emergency depart-
ment. Once finished, you will discuss your creation with a partner and then
the group.
Activity 2: Cases
Case Series 1
For each of the following cases, determine: (1) whether the pulmonary em-
bolism rule-out criteria (PERC) can be appropriately applied to the patient
and, if so, (2) whether historical factors would cause them to “fail” PERC (i.e.,
require further testing beyond PERC to rule- out PE). Assume any missing
information is normal (i.e., if not mentioned in the stem, the patient does not
have abnormal vital signs, unilateral leg swelling, etc.).
1. A 26-year-old female presents with pleuritic chest pain and an oxygen sat-
uration of 96% on room air.
2. A 38-year-old male presents with chest pain. He was noted to be anxious at

triage with a heart rate of 106 bpm. Now that he is in the room and calm, his
heart rate is 88 bpm.
3. A 31-year-old female with a hormonal intrauterine device (Mirena) presents

with chest pain.
4. A 19-year-old patient who is 16 weeks pregnant and a smoker presents

with pleuritic chest pain.
Case Series 2
A 57-year-old female with a history of hypertension presents to the emer-
gency department with chest pain radiating to her back for the past 2 hours.
1. List historical and exam findings that would increase your suspicion that
this patient is having an aortic dissection.
2. You are concerned that this patient has an aortic dissection and decide
to treat empirically while you order confirmatory testing. Her vital signs are:
HR 96, BP 187/88, RR 14, SpO2 96% on RA, T 98.6°F. What treatment will you
order while the patient is worked up for dissection? What are your goals of
treatment?
3. You administer all the therapies mentioned above. Now, what test will you
order to confirm the diagnosis?
NOTES
DIABETIC KETOACIDOSIS
Section Editor: Paul Kukulski, MD
Resident Editors: Katherine Dickerson Mayes, MD, PhD, Alexander Zirulnik, MD
Hyperglycemic Emergencies
Severe DKA
EM:RAP
Small Group Activities - Diabetic Ketoacidosis EM Fundamentals 53
Activity 1: DKA Quiz

Take 10 minutes to answer the following questions individually or in teams.
The class will then reconvene to discuss answers as a group.
1. Describe the pathophysiology behind DKA
2. List common presenting symptoms and diagnostic criteria for diagnosing DKA
3. Describe common electrolyte derangements in DKA

Activity 2: Case
Take 10 minutes to answer the following questions. Answers will then be dis-
cussed as a group.
A 33-year-old female patient with a history of diabetes for which she takes
“shots” presents with malaise, nausea, and a vague diffuse abdominal ache
for the past 36 hours. Her fingerstick glucose in triage is 306. Her vital signs
are normal other than a heart rate of 118. She weighs 50kg.
1. “Make sure you send DKA labs,” your senior says as you stand to go see the
patient. In the absence of additional remarkable findings in your H&P, list the
initial diagnostic tests that you would order for this patient.
2. Your labs come back indicative of moderate DKA. The blood glucose lev-
el is unchanged, the corrected sodium is 136 mEq/L, the potassium level
is 3.0 mEq/L, and the beta hydroxy butyrate level is 6 mmol/L. Your nurse
asks about insulin therapy for this patient. Describe the appropriate timing,
dose(s), route(s), and monitoring of insulin therapy for this patient.
Small Group Activities - Diabetic Ketoacidosis EM Fundamentals 55
3. Your patient stabilizes after aggressive volume resuscitation and address-

ing metabolic derangements. You determine the likely trigger to be the pa-
tient not taking her insulin because she thought she didn’t need it because
she wasn’t eating much due to recent URI symptoms. After you sign out to
the medicine team, your senior asks how you would manage a 7-year-old pa-
tient with the same laboratory and exam findings. Describe any differences
in management of the pediatric version of this patient below.
NOTES
Small Group Activities - Dyspnea EM Fundamentals 57
DYSPNEA
Faculty Editor: Doug Franzen, MD, MEd
Resident Editor: Laura A. Hancock, MD, PhD
Shortness of Breath
CDEM Curriculum
Dyspnea in the ED
UpToDate
Activity 1: Approach
The facilitator will assign participants to one of three groups. Using the ta-
ble below, Group 1 will populate common patient demographics, Group 2 will
populate assessment strategies, and Group 3 will populate interventions and
dispositions for patients presenting with dyspnea.
Group 1: Group 2: Group 3:

Disease History Exam and Testing Interventions and Dispo-
sition
Acute
Coronary
Syndrome
Arrythmia
Asthma
CHF/
Pulmonary
Edema
Chronic
Obstructive
Pulmonary
Disease
Pneumonia
Pulmonary
Embolism
Cardiac
Tamponade
Activity 2: Cases
Case 1
A 26-year-old female presents to the emergency department with shortness
of breath worsening over the past 4 hours. Associated symptoms include a
sharp pain when taking a deep breath. She has no lower extremity pain or
swelling. She has no past medical history and has a levonorgestrel intrauter-
ine device (Mirena). Her vital signs are HR 87, BP 110/75, RR 18, SpO2 97%
What is your approach to this patient? Create a plan for diagnostics, thera-
peutics, and disposition.
Case 2
A 59-year-old man presents with worsening shortness of breath for the past
hour. He has a history of hypertension and heart failure (LVEF 42%) that is
attributed to ischemic cardiomyopathy. His medical record shows that he is
prescribed aspirin, clopidogrel, atorvastatin, furosemide, lisinopril, and clon-
idine. His lungs have diffuse crackles and he appears in distress, exclaiming
“I can’t breathe!” between gasps. His vital signs are HR 87, BP 198/125, RR
32, SpO2 86% on a non-rebreather mask, T 36°C.
What is your approach to this patient? Create a plan for diagnostics, thera-
peutics, and disposition.
NOTES
THE FEBRILE INFANT

Faculty Editor: Paul Aronson, MD, MHS
Resident Editors: Sofia Athanasopoulou, MD, Imikomobong Ibia, MD
The Febrile Infant

The Febrile Infant

Pediatric Emergency Medicine Practice
Febrile Infant Pathway

Children’s Hospital of Philadelphia
Small Group Activities - The Febrile Infant EM Fundamentals 63
Activity 1: Journal Club

After splitting into 3 groups or having your individual study assigned, take
10 minutes to come up with a description for the group of the key elements
of the study. You can use whatever resources you want to help craft your
response (e.g., phones, laptops, etc.). After the 10 minutes of small group or
individual work, each study will be presented to the whole class (5 minutes
per study).
2019 PECARN Prediction Rule for the Febrile Infant
2016 “Step-by-Step” Approach for Febrile Infants
2018 Modified Philadelphia Criteria for Febrile Infants

Activity 2: Cases
Case 1
A 16-day-old ex-38-week term female presents to the emergency depart-
ment with parents reporting a temperature of 100.8⁰F at home. Mom thinks
she has been a bit less hungry recently, but struggles to quantify her exact
intake as she is breastfeeding. Her urine output has remained at her approx-
imate baseline. Her older brother is in daycare and has a runny nose. There
are no other known sick contacts. In the ED her temperature is 99.8⁰F rectally
and her physical exam (including full skin exam) is unremarkable.
What is your approach to this patient? What additional questions do you

have? Create a plan for diagnostics, therapeutics, and disposition.
Case 2
A 36-day-old ex-38-week term male presents to the emergency department
with parents reporting a temperature of 101.2⁰F at home. Mom denies any
other medical history or complications with delivery. His activity, oral intake,
and urine output are all at his approximate baseline. His temperature now in
the ED is 100.4⁰F rectally and his physical exam (including full skin exam) is
unremarkable.
What is your approach to this patient? What additional questions do you

have? Create a plan for diagnostics, therapeutics, and disposition.
Small Group Activities - The Febrile Infant EM Fundamentals 65
NOTES
FIRST TRIMESTER BLEEDING

Faculty Editor: Christine Babcock, MD, MSc
Resident Editor: Giovanni Rodriguez, MD
First Trimester Bleeding

EM:RAP
First Trimester Bleeding

EM in 5
Small Group Activities - First Trimester Bleeding EM Fundamentals 67
Activity 1: Mapping
diagram to illustrate how you approach first trimester vaginal bleeding in the
emergency department. Once finished, you will discuss your creation with
the group.
Activity 2: Questions and Case

Take 12 minutes to respond to the following questions and cases. Once fin-
ished, you will discuss your answers with the group.
Questions:
1. What are the minimum ultrasound findings required to diagnose an intrauter-

ine pregnancy?
2. In the space below or in the notes section, draw the image you would ex-
pect to see when visualizing the above minimum findings of intrauterine
pregnancy on ultrasound.
3. What are the β-hCG discriminatory levels for detecting an intrauterine

pregnancy on transabdominal and transvaginal ultrasound?
4. Describe the indications for RhoGAM administration for pregnant patients

in the Emergency Department.
Small Group Activities - First Trimester Bleeding EM Fundamentals 69
Case 1
A 26-year-old G4P1021 female (positive urine pregnancy test today, last
menstrual period 6 weeks ago) presents to the emergency department with
lower abdominal cramping. Her vital signs are normal. Bedside transvaginal
ultrasound reveals an intrauterine gestational sac and trace free fluid in the
pelvis. No adnexal abnormalities are seen on ultrasound. Her quantitative
β-hCG level comes back at 115 mlU/mL.
– What is your approach to this patient?
– How do you interpret this β-hCG level (is it reassuring, non-reassuring,
or equivocal)?
– Create a plan for diagnostics, therapeutics, and disposition.
Case 2:
A 21-year-old woman presents with lower abdominal pain and vaginal spot-
ting. Her symptoms started several days ago but have worsened since that
time. She now says she feels like she is going to pass out whenever she
stands up. Her last normal menstrual period was 2 months ago. Her vital signs
are BP 86/58, HR 115, RR 15, and temp 99°F. Patient appears uncomfortable.
– What is your approach to this patient?
– Create a plan for diagnostics, therapeutics, and disposition.
NOTES
Small Group Activities - GI Bleeding EM Fundamentals 71
GI BLEEDING
Faculty Editor: Jared Novack, MD
Resident Editors: Devon Fiorino, MD, Danielle De Freitas, MD
Upper GI Bleeding
Lower GI Bleeding
NEJM Clinical Practice
Massive GI Bleeding
EM:RAP
Activity 1: Team Quiz

Take 10 minutes to answer the questions below. The class will then recon-
vene to discuss answers.
1. A patient presents with one episode of bright red hematemesis 10 min-

utes prior to arrival. After speaking with the patient and drawing labs, the
nurse estimates the total volume of blood loss as 250 mL. Assuming the
patient’s hemoglobin level was 14 g/dL prior to the episode of hematem-
esis, what do you anticipate the hemoglobin level to be on the labs drawn
just after the episode?
2. Of patients presenting with upper GI bleeding that received NG lavage,

what percentage of patients with a clear NG tube aspirate had a high-risk
lesion on endoscopy?
3. Describe the role of proton pump inhibitors (PPIs) in patients being treat-
ed for high-risk upper GI bleeding.
4. What changes in outcomes, if any, have been associated with the use of
somatostatin analogues in high-risk upper GI bleeding?
5. What changes in outcomes, if any, have been associated with the use of
antibiotics in patients with variceal bleeding?
6. Name the clinical scoring system that has the best evidence for identify-
ing high-risk patients that present with non-variceal upper GI bleeding.
7. Name three factors that can worsen bleeding during the resuscitation of
a bleeding patient.
Activity 2: Mapping
Take 7 minutes and use the space below to create a mind map, flowchart, or
other diagram to illustrate how you approach lower GI bleeding in the emer-
gency department. Once finished, you will discuss your creation with a part-
ner for 8 minutes (if feasible). The class will then reconvene for discussion.
NOTES
HEADACHES
Faculty Editor: Gregory Podolej, MD
Resident Editor: A.J. Meyer, MD
Acute Headache
Life Threatening Headaches

Small Group Activities - Headaches EM Fundamentals 77
Activity 1: Case (Part 1)

Case 1
A 36-year-old male presents to the emergency department with a persistent
headache for the past 4 hours. The headache pain was sudden and severe,
located on the left side of his head. He states it feels like a “severe pres-
sure.” He was washing the dishes when this headache began. The headache
caused him to stop and rest. He states he isn’t sure if this is the worst head-
ache of his life, but states he has never had a headache like this one. The pain
was mildly improved with acetaminophen and rest at home, but he decided
to come be evaluated because the pain persists. He endorses associated
nausea, photophobia, and phonophobia. He has no neck pain, no fevers, or
chills. He has no past medical history and no other associated symptoms. His
neurologic exam is normal.
How would you characterize this headache? Given the history above, does
this qualify as a “thunderclap headache”? Provide a definition for a thunder-
clap headache, a differential diagnosis for this patient’s headache, and a plan
for diagnostics and therapeutics for this patient.
Activity 2: Case (Part 2)

The facilitator will provide the details for this case during the small group
session.
NOTES
Small Group Activities - Syncope EM Fundamentals 79
SYNCOPE
Faculty Editor: Isabel Malone, MD
Resident Editors: Ashlin Larsen, MD, Natalia M. Mosailova, DO
Approach to Syncope
EM in 5
ECG in Syncope
EM:RAP
Activity 1: ECG in Syncope

Use the space below to list and describe as many ECG findings associated
with syncope as you can. After 10 minutes, the class will reconvene for dis-
cussion.
Activity 2: Mapping
diagram to illustrate how you approach syncope in the emergency depart-
ment. Once finished, you will discuss your creation with a partner and the
group.
Small Group Activities - Syncope EM Fundamentals 81
NOTES
SMALL GROUP EVALUATION FORM

Digital copies available at:
www.EMFundamentals.com
SmallGroup
Small GroupActivities
Evaluation- Small
Form Group Evaluation Form EM Fundamentals 83
SMALL GROUP SESSION EVALUATION
Topic: _________________________________
Date: _________________________________
Facilitator: _________________________________
1. Please rate the appropriateness of this topic for the EM Fundamentals cur-
riculum:
□ □ □ □ □
Very unhelpful Unhelpful Neutral Helpful Very helpful
2. Did you complete the “Prior to Conference” reading using the QR codes
provided and/or on the EM Fundamentals website?
□ □ □
No Partially completed Completed
3. Please rate the efficacy of the facilitator in the following areas:

No Somewhat Yes
Meaningful adds to conversation □ □ □
Manages time effectively □ □ □
Recommended as facilitator for future sessions □ □ □
4. Please rate the efficacy of the first activity in facilitating your learning on
this topic:
□ □ □ □ □
5. Please rate the efficacy of the second activity in facilitating your learning
on this topic:
□ □ □ □ □
6. How could we improve this small group session in the future?

Simulation Checklists EM Fundamentals 85
SIMULATION CHECKLISTS
Digital copies available at:
www.EMFundamentals.com
ENDOTRACHEAL INTUBATION
Mastery (Advancement) Standard

In this procedural assessment series, mastery is defined as a perfor-
mance without any threats to patient or provider safety and suggest-
ing a high likelihood of success in completing the procedure on a low
complexity patient without guidance, assistance, or advice.
Note
This simulation is designed to teach and assess the knowledge and skills required
to perform rapid sequence endotracheal intubation using direct or video laryn-
goscopy on a patient with respiratory failure. The emphasis in this simulation is on
equipment and mechanics; this simulation is not designed to teach or assess the
medical management of peri-intubation patients, pre-intubation airway assessment,
post-intubation patient management, or pharmacology.
Scenario
A 65-year-old 70kg patient (BMI 24) presents with shortness of breath and is diagnosed
with bilateral pneumonia. Despite medical management including a non-rebreather mask,
the patient remains hypoxemic with labored breathing. You and your attending physician
decide to intubate the patient using ketamine and rocuronium. You are asked to verbalize
your plan for intubation, gather the necessary supplies, and intubate the patient.
Action Rating
1 Verbalize planned approach to intubation □ Done correctly □ Done

incorrectly □ Not done
2 Verbalize donning gloves, mask with face shield □ Done correctly □ Done
3 Verbalize approach to pre-oxygenation □ Done correctly □ Done

Verbalize, gather, and check required equipment:
• Preoxygenation device
• Bag valve mask
• ET tube (6.5 to 8.0), stylet, syringe to inflate
• Check cuff
4 • Laryngoscope blade (mac 3-4 or similar) □ Done correctly □ Done
• Check light
• End-tidal CO2 detector
• Bougie
• Backup airway (e.g., supraglottic device)
• Cric equipment (minimum: bougie, scalpel)
Simulation Checklists - Endotracheal Intubation EM Fundamentals 87
5
Position patient (bed height; ear to sternal notch □ Done correctly □ Done
using, e.g., towel rolls) incorrectly □ Not done
Verbalize timing of medication administration,

6 when intubation attempt will begin relative to □ Done correctly □ Done
medications
7 Scissor open mouth, insert laryngoscope □ Done correctly □ Done

8
Advance laryngoscope to visualize epiglottis □ Done correctly □ Done
and verbalize visualization incorrectly □ Not done
9
Advance and lift laryngoscope to visualize lar- □ Done correctly □ Done
ynx; verbalize grade of laryngeal view incorrectly □ Not done
While maintaining visualization of larynx, insert
10 endotracheal tube through the vocal cords, □ Done correctly □ Done
remove stylet, and inflate cuff
11
Measure and verbalize tube depth from front □ Done correctly □ Done
teeth incorrectly □ Not done
Verbalize confirmation of tube placement via

12 waveform capnography and auscultation of epi- □ Done correctly □ Done
gastrium, bilateral lung fields
13
Verbalize securing of tube with tape or tube □ Done correctly □ Done
holder incorrectly □ Not done
Any additional actions threatening patient safety or otherwise suggesting

advancement criteria not met?
□ Yes, additional concerning actions noted □ No
If yes, please describe:
Resident: __________________ Date: ______________
Faculty: __________________ Pass/Fail: ______________

Notes / Performance Dimension Training

1. Plan should include equipment and approach for initial and back-up airway
management options. For example, an acceptable plan would be:
“My first attempt will be direct laryngoscopy with a mac 3. If this view is
inadequate or the attempt to pass the tube is unsuccessful, the next at-
tempt will be video laryngoscopy using a <manufacturer> size 3 blade. If
these attempts are unsuccessful, we will place a <supraglottic airway>. If
at any time the patient desaturates, we will abort the attempt and bag the
patient. If at any time we encounter a ‘cannot intubate, cannot oxygenate’
scenario, I will perform a cricothyroidotomy using a scalpel and bougie.”
4. Similar blades may include direct or video laryngoscopy equipment. For

example, for a 70kg adult with a normal body mass index, a macintosh 3,
miller 3, Glidescope 3, and C-MAC 3 would all be considered similar. Each of
these blades in size 4 would also be acceptable for the purposes of this sim-
ulation. The description or use of a size 2 blade in this case is inappropriate
and non-passable.
6. Timing should include the order and time between administration of each
medication. Doses need not be mentioned. Given the typical onset of ket-
amine within 30 seconds and the typical onset of intubation-dose rocuroni-
um of approximately 60 seconds, an appropriate plan would be:
“Now that the patient is preoxygenated, optimally positioned, and we have
all our equipment, we are now ready for intubation. The ketamine should
be administered first, followed immediately by the rocuronium. I will wait
approximately 45 seconds for the medication to take effect prior to my
intubation attempt.”
Simulation Checklists - Cricothyrotomy EM Fundamentals 89
CRICOTHYROTOMY

Note
This simulation is designed to teach and assess the knowledge and skills required to
perform a cricothyrotomy using the scalpel-bougie technique. This simulation is not
designed to teach or assess other techniques for this procedure (e.g., use of trach
kit with hook).
Action Rating
1
Verbalize donning mask; don □ Done correctly □ Done incorrectly
mock-sterile gloves □ Not done
Verbalize and gather the necessary
equipment for the procedure
• Scalpel
• Bougie
2 • Endotracheal (ET) tube (includ- □ Done correctly □ Done incorrectly
ing size) □ Not done
• Syringe
• Bag valve mask attached to
oxygen
3 Identify and verbalize landmarks □ Done correctly □ Done incorrectly

□ Not done
4 Verbalize cleansing of the skin □ Done correctly □ Done incorrectly
□ Not done
Make vertical incision through skin
5 and subcutaneous tissue over the □ Done correctly □ Done incorrectly
cricothyroid membrane □ Not done
6
Palpate the cricothyroid membrane □ Done correctly □ Done incorrectly
with non-dominant hand □ Not done
Make horizontal incision through
7 the cricothyroid membrane and into □ Done correctly □ Done incorrectly
the trachea □ Not done
Maintaining patency of the incision

8 with finger or scalpel, pass bougie □ Done correctly □ Done incorrectly
through incision into the trachea. □ Not done
9
Place cuffed ET tube over bougie □ Done correctly □ Done incorrectly
and into trachea □ Not done
10 Inflate cuff □ Done correctly □ Done incorrectly
□ Not done
Verbalize confirmation of placement
11 with waveform capnography, bilat- □ Done correctly □ Done incorrectly
eral breath sounds □ Not done
12 Verbalize securing the tube in place □ Done correctly □ Done incorrectly

□ Not done

Resident: ______________________ Date: ______________
Faculty: ______________________ Pass/Fail: ______________

Simulation Checklists - Cricothyrotomy EM Fundamentals 91

5. Landmarks should include the thyroid cartilage and cricothyroid mem-
brane.
12. Tube may be secured in place with sutures, tape, or commercial device.
Additional Notes
• “Peeking” by lifting the artificial skin or otherwise attempting to obtain
a view/obtain information that is not typically available in the clinical
setting is a non-passable action.
• A dropped piece of equipment does not automatically preempt a

passing score, as long as the action: (1) does not compromise patient
or provider safety, (2) does not suggest a likely problematic lack of
facility with the procedural equipment, and (3) if the equipment should
be sterile and is dropped in a way that compromises sterility, the learner
verbalizes that a new piece of equipment would be obtained and that
the contaminated equipment would not be used.
CHEST TUBE PLACEMENT

Note
This simulation is designed to teach and assess the knowledge and skills required
to perform a tube thoracostomy on a stable patient with a traumatic hemothorax.
This is not a simulation of a “crash” tube thoracostomy.
Action Rating
Verbalize informed consent includ-
1 ing listing the risks of the procedure □ Done correctly □ Done incorrectly
(see notes) □ Not done
2 Verbalize washing hands □ Verbalized

□ Not done
3 Verbalize patient positioning □ Done correctly □ Done incorrectly
□ Not done
4
Verbalize and identify landmarks, □ Done correctly □ Done incorrectly
mark site □ Not done
5
Perform time out (including name, □ Done correctly □ Done incorrectly
DOB, procedure, site) □ Not done
6 Open kit in sterile fashion □ Done correctly □ Done incorrectly

□ Not done
Verbalize donning mask with face
7 shield, sterile gown; don mock-ster- □ Done correctly □ Done incorrectly
ile gloves □ Not done
8 Mock sterile skin prep □ Done correctly □ Done incorrectly

□ Not done
9 Apply mock-sterile drape □ Done correctly □ Done incorrectly
□ Not done
Simulation Checklists - Chest Tube EM Fundamentals 93
10
Mock local anesthetic: skin wheel / □ Done correctly □ Done incorrectly
superficial □ Not done
11 Mock local anesthetic: deep tissue □ Done correctly □ Done incorrectly
□ Not done
12
Make appropriately-sized vertical □ Done correctly □ Done incorrectly
incision (~3.5cm) □ Not done
Advance Kelly clamp over rib using
13
two-handed technique to main- □ Done correctly □ Done incorrectly
tain control while puncturing then □ Not done
spreading pleura
Place finger into tract prior to
removing the Kelly clamp; confirm
14 intrapleural placement via palpation □ Done correctly □ Done incorrectly
and leave finger in tract as Kelly □ Not done
clamp is removed
Using the Kelly clamp as a guide,
15
pass the chest tube into the thorac- □ Done correctly □ Done incorrectly
ic cavity so that all holes are within □ Not done
pleural space
16
Verbalize attaching the tube to col- □ Done correctly □ Done incorrectly
lection chamber □ Not done
17 Suture the tube in place □ Done correctly □ Done incorrectly
□ Not done

Resident: _________________ Date: ______________
Faculty: _________________ Pass/Fail: ______________


1. Risks of the procedure should include infection, bleeding, and damage to
adjacent structures (including nerves and possible solid organs (e.g., spleen,
liver)).
2. Hand washing need only be verbalized. Both hand sanitizer and soap-and-
water are acceptable methods of hand washing.
3. Patient positioning should include placing or securing of the ipsilateral arm

above the head.
4. Landmarks should include anchors in both the transverse axis (i.e., 4th or
5th intercostal space, which may be estimated by use of the nipple line) and
coronal axis (i.e., mid-axillary line). Mention of trajectory over superior aspect
of rib must also be verbalized either here or elsewhere during the simulation
(e.g., steps 10-13).
5. Timing of the time out is flexible but must occur after the site is marked
and before the skin is broken. The time out should be verbalized, specifically
including:
a. Correct procedure
b. Correct patient (identified by name, date of birth, medical record number)
c. Correct site
8. Gloves are required. Jewelry and watches should be removed and sleeves
rolled up (if applicable). Bouffant caps and sterile gowns are not required for
the attempt, but should be used in practice and therefore must be verbal-
ized. For the sake of cost, regular exam gloves may be used in lieu of sterile
gloves. Regular gloves should still be treated as sterile, however (e.g., touch-
ing non-sterile equipment should be considered contamination and prompt
re-gloving). Contamination should only be considered a failing action if the
trainee does not correct for it by removing the contaminated supplies and
replacing those supplies in a sterile fashion.
9. Betadine swabs or chlorhexidine may be used. Swabs/prep sticks should

be disposed of away from the sterile field so as to avoid contamination.
11. Motions of needle manipulation should be made (including breaking the

skin); however, trainees should not inject air or fluid into the model (in order
to preserve the integrity of the simulator). Note that in practice, aspiration
before injection is not required for the initial skin wheel.
Simulation Checklists - Chest Tube EM Fundamentals 95
15. The chest tube should be directed posteriorly, medially and superiorly as
it enters the chest cavity.
Additional Notes
• If the sterile field is broken but no contaminated equipment has been
used on the patient, the trainee may verbalize gathering a new kit/
equipment and re-prepping/draping and still be considered eligible
for a passing performance. Use of any contaminated equipment and
failure to recognize contamination are non-passable actions.
• Safe needle handling is required at all times during the performance.

Needlesticks are non-passable. Recapping needles is only permissible
with the “scooping” technique where the cap is gripped at the base
after being “scooped up” with the needle. The hand should never hold
portions of the cap that are distal to the needle tip.
• “Peeking” by looking behind the artificial skin or otherwise attempting

to obtain a view or information that is not typically available in the
clinical setting is a non-passable action.

be sterile and is dropped in a way that compromises sterility, the trainee
CENTRAL VENOUS ACCESS

Action Rating
Verbalize informed consent includ-
1 ing listing the risks of the procedure □ Done correctly □ Done incorrectly
(see notes) □ Not done
2 Verbalize washing hands □ Verbalized

□ Not done
3 Verbalize and identify landmarks □ Done correctly □ Done incorrectly
□ Not done
4
Identify internal jugular vein on ul- □ Done correctly □ Done incorrectly
trasound and mark site □ Not done
5
Perform time out (including name, □ Done correctly □ Done incorrectly
DOB, procedure, site) □ Not done
6 Open kit in sterile fashion □ Done correctly □ Done incorrectly

□ Not done
Verbalize donning mask with face
7 shield, bouffant cap, sterile gown, □ Done correctly □ Done incorrectly
and sterile gloves. □ Not done
8
Verbalize positioning patient in Tren- □ Done correctly □ Done incorrectly
delenburg □ Not done
9
Mock cleanse skin with chlorhexi- □ Done correctly □ Done incorrectly
dine swab □ Not done
10 Verbalize sterile draping □ Done correctly □ Done incorrectly
□ Not done
11
Verbalize application of sterile ultra- □ Done correctly □ Done incorrectly
sound probe cover □ Not done
12
Apply occlusive caps to ports, flush □ Done correctly □ Done incorrectly
ports with saline □ Not done
Simulation Checklists - Central Venous Access EM Fundamentals 97
13
Re-identify internal jugular vein on □ Done correctly □ Done incorrectly
ultrasound □ Not done
14 Mock local anesthetic □ Done correctly □ Done incorrectly
□ Not done
Advance the needle under ultra-
15 sound guidance, aspirating while □ Done correctly □ Done incorrectly
advancing □ Not done
Confirm intravenous placement of
16 needle via ultrasound and aspiration □ Done correctly □ Done incorrectly
of blood □ Not done
17
Holding the needle securely, remove □ Done correctly □ Done incorrectly
the syringe □ Not done
Insert guide wire through the nee-
18
dle, confirm intravenous placement □ Done correctly □ Done incorrectly
via ultrasound, then remove needle □ Not done
without disturbing the guidewire
Thread the flexible catheter over the
wire and into the vein, remove the
19
wire without disturbing the catheter, □ Done correctly □ Done incorrectly
then connect the catheter to trans- □ Not done
duction tubing to confirm venous
placement (if available)
Insert guide wire through the cath-
eter, re-confirm intravenous place-
20 ment via ultrasound, then remove □ Done correctly □ Done incorrectly
catheter without disturbing the □ Not done
guidewire
21
Nick skin at wire entry site using □ Done correctly □ Done incorrectly
scalpel □ Not done
Maintaining control of wire at all
22 times, advance dilator over wire into □ Done correctly □ Done incorrectly
vein, then withdraw dilator □ Not done
Maintaining control of wire at all
23 times, advance triple-lumen cathe- □ Done correctly □ Done incorrectly
ter over guidewire □ Not done
24 Remove guidewire □ Done correctly □ Done incorrectly

□ Not done
25
Aspirate for blood return and flush □ Done correctly □ Done incorrectly
each port □ Not done
Verbalize placement of bio-patch,

26 suturing line in place, and placement □ Done correctly □ Done incorrectly
of sterile occlusive dressing □ Not done
27 Verbalize disposing of sharps □ Done correctly □ Done incorrectly

□ Not done

Resident: ________________ Date: ______________
Faculty: ________________ Pass/Fail: ______________

Small Group Activities - Central Venous Access EM Fundamentals 99

1. Risks of the procedure should include common complications (e.g., pain),
uncommon but severe complications (e.g., pneumothorax, arterial injury), in-
fection, and bleeding.
including:
c. Correct site (it should also be explicitly noted here that the site is marked)
learner does not correct for it by removing the contaminated supplies and
16. Puncture of the carotid artery is a non-passable action.
Additional Notes
used on the patient, the trainee may verbalize gathering a new kit/
failure to recognize contamination are non-passable.

• “Peeking” by looking down the open end of the model or otherwise

attempting to obtain a view/information that is not typically available
in the clinical setting is a non-passable action.

passing score, so long as the action: (1) does not compromise patient
Simulation Checklists - Radial Artery Line EM Fundamentals 101
RADIAL ARTERY LINE PLACEMENT

Action Rating
Verbalize informed con-
sent including listing the
1
risks of the procedure □ Done correctly □ Done incorrectly □ Not done
(see notes)
2 Verbalize washing hands □ Verbalized □ Not done
Verbalize and identify
3
landmarks □ Done correctly □ Done incorrectly □ Not done
Identify radial artery on
4
ultrasound and mark site □ Done correctly □ Done incorrectly □ Not done
5 Verbalize Allen’s test □ Done correctly □ Done incorrectly □ Not done
Perform time out (includ-
6 ing name, DOB, procedure, □ Done correctly □ Done incorrectly □ Not done
site)
7 Open kit in sterile fashion □ Done correctly □ Done incorrectly □ Not done
Mock cleanse skin with
8
chlorhexidine swab □ Done correctly □ Done incorrectly □ Not done
9 Don mock-sterile gloves □ Done correctly □ Done incorrectly □ Not done
Verbalize applying sterile
10
drape or sterile towels □ Done correctly □ Done incorrectly □ Not done
Verbalize applying sterile
11
ultrasound probe cover □ Done correctly □ Done incorrectly □ Not done
Re-identify radial artery

12
location on ultrasound □ Done correctly □ Done incorrectly □ Not done
Advance needle into radial
13
artery □ Done correctly □ Done incorrectly □ Not done
Advance wire, then ad-

14
vance catheter over wire □ Done correctly □ Done incorrectly □ Not done
Remove needle and wire
15 without disrupting the □ Done correctly □ Done incorrectly □ Not done
catheter
Hold pressure proximal
16 to catheter to prevent □ Done correctly □ Done incorrectly □ Not done
leakage
Attach arterial catheter to
17
transducer tubing □ Done correctly □ Done incorrectly □ Not done
Verbalize confirming
18 placement with arterial □ Done correctly □ Done incorrectly □ Not done
waveform on monitor
Verbalize securing line
19
with sterile dressing □ Done correctly □ Done incorrectly □ Not done

Resident: ________________ Date: ______________

Simulation Checklists - Radial Artery Line EM Fundamentals 103

1. Risks of the procedure should include common complications (e.g., pain at
the site), uncommon but severe complications (e.g., vascular injury), as well
as infection and bleeding.
including:
learner does not correct for it by removing the contaminated supplies and
Additional Notes
used on the patient, the learner may verbalize gathering a new kit/

• “Peeking” by looking down the open end of the model or otherwise

attempting to obtain a view/information that is not typically available in
the clinical setting is a non-passable action.

passing score, so long as the action: (1) does not compromise patient
be sterile and is dropped in a way that compromises sterility, the
learner verbalizes that a new piece of equipment would be obtained
and that the contaminated equipment would not be used.
Small Group Activities - Lumbar Puncture EM Fundamentals 105
LUMBAR PUNCTURE

Action Rating
Verbalize informed con-
sent including listing the
1
risks of the procedure □ Done correctly □ Done incorrectly □ Not done
(see notes)
2 Verbalize washing hands □ Verbalized □ Not done
3 Verbalize patient positioning □ Done correctly □ Done incorrectly □ Not done
Verbalize and identify
4
landmarks □ Done correctly □ Done incorrectly □ Not done
5 Mark site (pressure marking) □ Done correctly □ Done incorrectly □ Not done
Perform time out (includ-
6 ing name, DOB, procedure, □ Done correctly □ Done incorrectly □ Not done
site)
7 Open kit in sterile fashion □ Done correctly □ Done incorrectly □ Not done
Verbalize donning mask;
8
don mock-sterile gloves □ Done correctly □ Done incorrectly □ Not done
Organize supplies in ster-
9
ile fashion (tubes, column) □ Done correctly □ Done incorrectly □ Not done
Mock cleanse skin with
10
betadine (circular, outward) □ Done correctly □ Done incorrectly □ Not done
11 Apply sterile drape □ Done correctly □ Done incorrectly □ Not done
Mock local anesthetic:
12
skin wheel □ Done correctly □ Done incorrectly □ Not done
Mock local anesthetic:
13
deep tissue □ Done correctly □ Done incorrectly □ Not done
Verbalize spinal needle
14
position (L3-4, L4-5) □ Done correctly □ Done incorrectly □ Not done

15
angle (at umbilicus) □ Done correctly □ Done incorrectly □ Not done
16
orientation (bevel lateral) □ Done correctly □ Done incorrectly □ Not done
17 Measure opening pressure □ Done correctly □ Done incorrectly □ Not done
Collect CSF in tubes (col-
18
lect and verbalize volume) □ Done correctly □ Done incorrectly □ Not done
Replace stylet prior to
19
needle removal □ Done correctly □ Done incorrectly □ Not done
Pressure applied with
20
sterile dressing □ Done correctly □ Done incorrectly □ Not done

Resident: ________________ Date: ______________

Small Group Activities - Lumbar Puncture EM Fundamentals 107

1. Risks of the procedure should include common complications (e.g., head-
ache), uncommon but severe complications (e.g., CSF leak requiring blood
patch), as well as infection, bleeding, and damage to adjacent structures (in-
cluding nerves).
3. Patient positioning should include description of either the lateral decubi-

tus or sitting position. Descriptions (e.g., “patient lying on their side with their
knees to their chest”) are acceptable in lieu of specific terms (e.g., “lateral
decubitus”). Note that the learner will be required to demonstrate measure-
ment of the opening pressure regardless of which position is chosen / repre-
sented by the manikin (i.e., seated or lateral decubitus).
4. Landmarks should include mention of the iliac crests as a guide to the ap-
propriate spinal level. The anterior superior iliac spine (ASIS) is not a relevant
landmark for lumbar puncture and mention of this landmark as a guide is an
unacceptable (non-passable) action.
5. Site should be marked with equipment such as a syringe or cap (this need
not be sterile unless already prepped). Fingernails and needles are not ap-
propriate tools for marking the site for the procedure and use of either of
these methods constitutes a non-passable action.
including:
rolled up (if applicable). Bouffant caps are not required for the attempt, but
should be used in practice and therefore must be verbalized. Sterile gowns
are not required. For the sake of cost, regular exam gloves may be used in
lieu of sterile gloves. Regular gloves should still be treated as sterile, howev-
er (e.g., touching non-sterile equipment should be considered contamination
and prompt re-gloving). Contamination should only be considered a failing
action if the learner does not correct for it by removing the contaminated
supplies and replacing those supplies in a sterile fashion.
9. Supplies should be prepared such that the learner is ready to collect spinal
fluid as soon as the subarachnoid space is accessed. Delay in collection of
fluid due to poor preparation is considered an unacceptable (non-passable)
action.
10. Swabs should be used sequentially in an outward circular motion. Swabs

should be disposed of away from the sterile field so as to avoid contamina-
tion.

to preserve the integrity of the simulator). Note that in practice, aspiration
before injection is not required for the initial skin wheel.

to preserve the integrity of the simulator). The spinal needle with stylet re-
moved should not be used to inject the deep tissues – lidocaine possesses
antimicrobial properties that may inhibit culture growth. Note that in practice,
aspiration before injection IS required prior to injection of deep local anes-
thetic.
14. Needle should be inserted at the previously marked site, identified by

the landmarks of the iliac crests. The bevel should be perpendicular to the
vertebral column. The stylet need not be replaced when manipulating spinal
needle beyond the initial dermal layers; however, the stylet must be replaced
prior to removal of the needle from the subarachnoid space (Action #17).
15. Note that the learner will be required to demonstrate measurement of

the opening pressure regardless of which position is chosen / represented
by the manikin (i.e., seated or lateral decubitus). This step is only meant to
evaluate technique in the assembly and attachment of the manometry equip-
ment. There is no “correct” opening pressure and learners should not receive
“incorrect” scores.
16. During CSF collection, briefly dripping spinal fluid while making purpose-
ful movements is permissible. Non-deliberate actions (e.g., fumbling with
equipment without clear purpose) while dripping spinal fluid is an unaccept-
able (non-passable) action.
Additional Notes
used on the patient, the learner may verbalize gathering a new kit/

• “Peeking” by looking down the open end of the canal or otherwise

attempting to obtain a view/information that is not typically available in
the clinical setting is a non-passable action.

CONTACT US
We hope that you find the activities, information, and organization of this book
and all EM Fundamentals resources to be helpful in your work as a medical
educator. If you or anyone at your program have any questions, comments,
concerns, or suggestions for improvement of this book or any of the EM Fun-
damentals curricular materials, please feel free to reach out to us at any time!
You can reach us at EMFundamentals@gmail.com or by using the “Contact

Us” form at the bottom of every page on the EM Fundamentals website.
We are also available to discuss a number of different ways in which EM Fun-

damentals resources can be integrated into your training program. Drawing
from years of experience deploying this curriculum at EM training programs
across the country (and even a few overseas), we have learned that no two
programs are alike and careful consideration is warranted when implement-
ing curricular change. Please reach out to us if you would like to discuss how
curricular innovation with EM Fundamentals can best be implemented at your
program.
Contact Us EM Fundamentals 111
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EM FUNDAMENTALS

Copyright © 2021, 2020, 2019, 2018, 2017 by EM Fundamentals.

EB Medicine and the Council of Residency Directors in Emergency

EB Medicine provides practical, evidence-based education that in-

CORD was established to lead the advancement of emergency

EDITOR-IN-CHIEF Michael A. Hernandez, MD David Peak, MD

Inkyu Kim, MD Adam Pissaris, MD

Emily L. Aaronson, MD, MPH Paul Kukulski, MD Gregory Podolej, MD

Anne K. Chipman, MD, MS MD, PhD J. Kimo Takayesu, MD, MSc

MSHPEd A.J. Meyer, MD Kori S. Zachrison, MD, MSc

Michael Gottlieb, MD Kathryn Oskar, MD

SMALL GROUP ACTIVITIES

ACUTE CORONARY SYNDROMES

Resources to Review Prior to Conference

Who Needs PCI?

Non–ST-Elevation Acute Coronary Syndromes

Acute Coronary Syndromes

2. Describe the ECG criteria for diagnosing an ST-elevation myocardial in-

3. Define Type 1 and Type 2 myocardial infarction.

4. Name the categories of medications used to treat acute coronary syn-

Image source: Tyler Constantine, MD. Used with permission.

Resources to Review Prior to Conference

Dominating the Vent

RSI Overview and Mnemonics

Activity 1: Intubation Cases

Activity 2: Ventilator Management Cases

Resources to Review Prior to Conference

H’s and T’s of Cardiac Arrest

The First 90 Seconds: Cardiac Arrest

Activity 1: Getting the History

Activity 2: Room Set-up

What empiric actions, if any, would you take in this case?

What diagnostic actions are your highest priority?

Resources to Review Prior to Conference

Early Warning Scores

What is your initial approach to fluid management in this patient?

What is your approach to hypotension in this patient? Discuss what agents

Activity 2: Journal Club

Resources to Review Prior to Conference

What are your first steps in management of this patient?

Activity 2: Shock and Fluid Status Markers

Team 1: IVC ultrasound as a marker of fluid tolerance

Please comment on technique, quantitative criteria, and use in spontaneous-

Team 2: Pulse pressure variation

Team 3: RUSH (Rapid Ultrasound for Shock and Hypotension) Exam

Resources to Review Prior to Conference

Blood Pressure Management in Intracranial Hemorrhage

Activity 1: Stroke Diagnosis Cases

Activity 2: Stroke Management Cases

Resources to Review Prior to Conference

Trauma Assessment Video

Activity 1: Primary Survey

2. Breathing and Ventilation

Activity 2: Hard Signs

1. Penetrating Neck Trauma

2. Penetrating Chest Trauma

3. Penetrating Abdominal Trauma

Activity 3: Room Set-up

Resources to Review Prior to Conference

Assessing Abdominal Pain

Abdominal Pain in the Elderly

Activity 1: Team Quiz

2. The mortality of patients over the age of 80 presenting to the emergency

3. Based on history and physical exam alone, physician accuracy in diagnos-