ABEM ACCM common mistakes
ABEM ACCM · Understand the traps and how to avoid them.
Stops the chest pain evaluation after one nondiagnostic ECG and one troponin, especially when the pain has resolved.
Early ischemia can produce normal initial tests, and the candidate anchors on the first data set rather than reassessing a dynamic process.
What to do instead
Repeat the ECG at 15 to 30 minutes and with recurrent symptoms, use serial high-sensitivity troponin per protocol, add posterior and right-sided leads when indicated, and document serial reassessment.
Continues repeated nebulizer treatments in a wheezing patient while ignoring fatigue, a silent chest, or decreasing responsiveness.
The act of ordering bronchodilators creates a false sense of control, and subtle signs of impending respiratory failure are easy to miss.
What to do instead
Reassess work of breathing, mentation, speech, and capnography or blood gas after each treatment; escalate to noninvasive ventilation or intubation and involve critical care early.
Discharges an older or female patient with abdominal pain as gastroenteritis after a single benign examination, without imaging or surgical input.
Atypical presentations of aortic aneurysm, mesenteric ischemia, or perforation are common, and the candidate anchors on the most familiar benign diagnosis.
What to do instead
Risk-stratify using age, vascular risk factors, and serial examinations; obtain CT angiography or ultrasound when indicated and consult surgery early for high-risk features.
Rules out posterior circulation stroke because a noncontrast head CT is normal and the symptoms are labeled as dizziness.
Early noncontrast CT is insensitive for posterior stroke, and vertigo or headache overlaps heavily with benign causes.
What to do instead
Perform a structured neurologic examination including HINTS when trained, obtain MRI diffusion-weighted imaging and vascular imaging, and reassess for thrombolysis or thrombectomy candidacy rather than relying on CT alone.
Omits full exposure and log-roll in major trauma and does not repeat the primary survey after blood products or fluids.
Attention is captured by the obvious injury, so posterior wounds, spinal step-offs, and occult shock are missed, and resuscitation changes the physiologic picture.
What to do instead
Fully expose and log-roll the patient, perform secondary and tertiary surveys, and repeat vital signs and the primary survey after each major intervention with the trauma team.
Uses a negative urine drug screen to exclude a significant poisoning or ignores the possibility of delayed toxicity from co-ingestants.
Urine drug screens have limited sensitivity and specificity and do not cover many dangerous agents; co-ingestions are common.
What to do instead
Order targeted levels such as acetaminophen and salicylate, obtain an ECG, observe for delayed toxicity, call poison control, and treat the clinical toxidrome rather than the screen.
Treats an altered, hyperthermic patient with oral fluids and antipyretics while delaying active cooling.
Heat exhaustion is confused with heat stroke, and concerns about shivering or logistics delay definitive cooling.
What to do instead
Measure core temperature, and if heat stroke is present, begin immediate cold-water immersion or evaporative cooling, provide IV fluids, obtain labs, and arrange intensive care.
Documents a normal neurovascular examination without actually testing pulses, sensation, motor function, and compartments, then discharges a limb injury without splinting.
Minor-mechanism bias and time pressure lead to an abbreviated examination that misses compartment syndrome or occult neurovascular injury.
What to do instead
Document pulses, sensation, motor function, and compartment findings before and after reduction or splinting; immobilize the limb, treat open fractures with antibiotics and tetanus prophylaxis, and reassess.
Waits for fever or positive cultures before giving antibiotics to an older or immunocompromised patient with suspected sepsis.
Sepsis often presents atypically in these groups, and the candidate seeks laboratory confirmation before acting.
What to do instead
Apply sepsis screening criteria, obtain lactate and cultures without delaying treatment, give broad-spectrum antibiotics within one hour for septic shock, and reassess after resuscitation.
Attributes altered mental status to intoxication or psychiatric illness without checking glucose, renal function, electrolytes, or acid-base status.
Psychiatric bias and an incomplete chart review allow metabolic causes such as hypoglycemia, uremia, or diabetic ketoacidosis to mimic intoxication.
What to do instead
Obtain point-of-care glucose, venous blood gas, basic metabolic panel, ECG, and targeted toxicology; treat reversible metabolic causes first and reassess mental status after treatment.