ER Board common mistakes
ER Board · Understand the traps and how to avoid them.
Discharging a patient with ongoing chest pain after a single non-diagnostic ECG and one troponin, without serial ECGs or a second troponin.
Ischemic patterns evolve. Posterior MI, Wellens, de Winter T waves, and hyperacute T waves can look near-normal on the first tracing, and an early troponin cannot exclude occlusion. Presentations in women, older adults, and people with diabetes are easily labelled 'atypical' and under-investigated.
What to do instead
Treat chest pain as a time series, not a snapshot: repeat the ECG at 15-30 minutes and with any symptom change, obtain serial high-sensitivity troponins, and deliberately search for posterior leads, reciprocal changes, and T-wave morphology before any discharge decision.
Ordering a D-dimer first in a patient with high clinical probability of pulmonary embolism and using a low or negative result to avoid imaging.
The D-dimer is a rule-out tool only in low or intermediate pretest probability. Reflexive ordering before risk stratification creates false reassurance, and age-adjusted or fixed cutoffs are misapplied to older patients.
What to do instead
Apply Wells or Geneva criteria before any test is ordered, use PERC only in low-risk patients, use the age-adjusted D-dimer in patients over 50, and proceed to CTPA when pretest probability is high regardless of the D-dimer value.
Completing the primary survey, addressing the obvious injury, and admitting the patient without a full secondary survey, log roll, or examination of the back and flanks.
Distracting injuries and the momentum of resuscitation cause posterior, flank, and occult extremity injuries to be missed. Occult pelvic, retroperitoneal, and long-bone bleeding are under-appreciated causes of ongoing instability.
What to do instead
Perform a structured head-to-toe secondary survey including log roll, perineal and rectal examination where indicated, and reassess after every intervention. Treat unexplained instability as occult haemorrhage until the pelvis, retroperitoneum, and long bones are excluded.
Attributing acute continuous vertigo with nausea and gait instability in a patient with vascular risk factors to vestibular neuritis after a normal non-contrast head CT.
CT is insensitive for posterior fossa ischaemia in the first hours, and the NIHSS underweights vertigo, gait, and truncal findings. The HINTS examination is not performed, so a central lesion is missed.
What to do instead
Perform HINTS (head impulse, nystagmus, test of skew) in every case of acute vestibular syndrome. A normal head impulse, direction-changing nystagmus, or skew deviation suggests a central cause: obtain MRI with diffusion weighting and involve stroke services.
Treating severe abdominal pain that is out of proportion to examination findings as gastroenteritis or ileus and discharging after basic labs and a plain film.
Acute mesenteric ischaemia initially presents with pain out of proportion and can have a deceptively benign abdomen. Early lactate and plain films are insensitive, and waiting for peritonitis or bowel-wall changes delays revascularisation.
What to do instead
When pain is out of proportion, obtain CT angiography of the abdomen and pelvis, check lactate without relying on it, involve surgery early, and start anticoagulation and revascularisation without waiting for confirmatory labs.
Discharging a patient once naloxone has reversed an opioid overdose and the patient is awake and talking.
Naloxone has a shorter half-life than many opioids, including methadone and long-acting formulations, so respiratory depression recurs. Co-ingestants such as acetaminophen, salicylates, or sedative-hypnotics are masked by the reversal.
What to do instead
Observe for recurrence for several hours, longer with long-acting opioids. Screen for co-ingestants with acetaminophen and salicylate levels and an ECG, and arrange observation or admission whenever the agent, dose, or intent is unclear.
Giving an insulin bolus and starting an insulin infusion in diabetic ketoacidosis before volume resuscitation and before reviewing the potassium.
Insulin shifts potassium intracellularly. In a patient with total-body potassium depletion, this can precipitate life-threatening hypokalaemia and arrhythmia, and starting insulin in a volume-depleted patient worsens haemodynamic instability.
What to do instead
Check potassium before insulin: resuscitate with fluids first, and if potassium is below 3.3 mmol/L replace it before starting insulin. Add dextrose when glucose falls, and monitor potassium hourly during the first hours of treatment.
Withholding empiric antibiotics from a febrile neutropenic patient while waiting for blood cultures, imaging, or a confirmatory white cell count.
Neutropenic fever carries high mortality when antibiotics are delayed, and cultures do not need to precede treatment. Clinicians wait for the ANC to return or for a source to be identified, neither of which should gate therapy.
What to do instead
Draw cultures, then give an empiric anti-pseudomonal beta-lactam within 60 minutes of presentation. Add vancomycin for line infection, skin or soft tissue involvement, or haemodynamic instability, and reassess at 48 hours rather than waiting for the ANC.
Working up abdominal pain, syncope, or vaginal bleeding in a person of reproductive age without first obtaining a pregnancy test.
Assumptions based on the patient's history, documented tubal ligation, or age lead to missed ectopic pregnancy, which can rupture and cause fatal haemorrhage before the diagnosis is considered.
What to do instead
Obtain a urine or serum hCG on every person of childbearing potential with abdominal pain, syncope, or bleeding before imaging, analgesia decisions, or disposition. If positive, obtain pelvic ultrasound and treat ectopic pregnancy as a surgical emergency until excluded.
Calculating paediatric drug doses, fluid volumes, or defibrillation energy from a guessed weight, an adult dose, or mental arithmetic performed under pressure.
Weight-based dosing errors are among the most common and most harmful paediatric medication errors. Verbal weight estimates and unverified per-kilogram calculations are error-prone in resuscitation.
What to do instead
Use a length-based tape or a measured weight in kilograms, double-check every weight-based dose against maximum adult caps, and verbalise the calculation aloud for verification by a second provider before administering high-risk drugs.