Friday Board Review

Board Review by Dr. Edward Guo (Edited by Dr. Parikh)

Vidhi ParikhLeave a comment

A 40 year old female with a history of hyperlipidemia presents for abdominal pain. She has been having intermittent pain in her right upper quadrant after meals without vomiting or change in her bowel habits. Vital signs are within normal limits. She has mild tenderness to palpation to the right upper quadrant on exam with a negative Murphy’s sign. Point of care pregnancy test is negative. Her workup including CBC, BMP, LFTs, and lipase are unremarkable. A right upper quadrant ultrasound demonstrates numerous gallstones without evidence of cholecystitis. Which of the following is recommended for first line treatment of this patient’s suspected condition?

A: Acetaminophen

B: Gabapentin

C: Ketorolac

D: Morphine

Answer: Ketorolac

This patient is presenting with biliary colic which occurs by a gallstone causing periodic obstruction of the cystic duct. Management includes symptom control and outpatient surgical referral for cholecystectomy. NSAIDs are first line therapy. When administered parenterally, NSAIDs have similar analgesic effect compared to opioids for biliary colic. In addition, NSAIDs reduce the rate of short term complications such as acute cholecystitis. 

Acetaminophen is an antipyretic that has analgesic properties but is not first line for biliary colic. Gabepentin is typically used for neuropathic pain such as diabetic neuropathy or shingles. Opioids such as morphine are reserved for when NSAIDs are not effective in reducing pain but are not first line due to safety and side effects such as hypoventilation. It is known that opioids cause sphincter of Oddi spasm, but the clinical significance of this is unclear. 

References:

Besinger B, Stehman CR. Pancreatitis and Cholecystitis. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Colli  A, Conte  D, Valle  SD, Sciola  V, Fraquelli  M: Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic. Aliment Pharmacol Ther 35: 1370, 2012. [PubMed: 22540869]

Wednesday Image Review

What’s the Diagnosis? By Dr. Julie Calabrese

Edward GuoLeave a comment

75 y/o M PMHx of ESRD on HD, pulmonary HTN, HLD presents to the ED with 1 week of progressive fatigue and SOB. Pt on 2L NC home O2 but requiring 4L NC in the ED to maintain saturation > 95%. On exam, pt with increased WOB and RR > 20. Lungs are CTA. Cardiac exam shows RRR with mild JVD, abdominal distention and +1 pitting edema B/L. POCUS was performed and is shown below. What is the diagnosis? 

Answer: Right Heart Strain from Pulmonary Hypertension 

  • Signs in POCUS that are indicative of R heart strain:
    • D-sign: septal flattening seen in the parasternal short orientation that is indicative of increased RV pressures 
    • McConnel’s Sign: seen in the apical 4 chamber view. R ventricular free wall akinesis with sparing of the apex (apical hyperkinesis) 
    • Increased RV:LV ratio, typically should be ⅓:⅔ 
    • Decreased TAPSE: measurement of the vertical motion of the tricuspid valve in the apical 4 chamber view (normal > 16 mm)
  • Causes of R- Heart Strain:
    • Pulmonary Embolism
    • Pulmonary hypertension 
    • Biventricular failure
    • R sided heart failure 
    • Valvular dysfunction (Acute TR) 
  • Pulmonary Hypertension:
    • Type 1: primary arterial pulmonary HTN 
    • Type 2: PH due to L heart failure
    • Type 3: PH due to lung disease 
    • Type 4: PH due to chronic thromboembolic disease 
    • Type 5: idiopathic PH 
  • Acute Treatment for PH includes
    • Optimize RV preload- patients typically euvolemic or hypervolemic and do not respond well to rapid shifts in fluid status (usually avoid fluids). If hypovolemia/sepsis consider small 250 ml boluses with frequent reassessments 
    • Improve cardiac output: consider early ionotropes 
    • Reduce RV afterload: avoid hypoxia, acidosis, hypercapnia 
    • Treat arrhythmias: most common is SVT followed by afib/flutter 

Resources: 

https://courses.coreultrasound.com/courses/take/fundamentals/lessons/18316427-right-heart-strain-5minsono

The Crashing Pulmonary Hypertension Patient
Tuesday Advanced Cases

Critical Cases – Hypothermia Induced Arrhythmia!

Richard ByrneLeave a comment

Dr. Edward Guo

Hypothermia Arrhythmia by Dr. Edward Guo

HPI: A 29 year old male with a past medical history of polysubstance use presents to the ED in December via EMS for a suspected overdose. History is limited due to patient cooperation. EMS states that he was found outside in a puddle, minimally responsive. He was given 2mg IM naloxone by EMS and became acutely agitated and combative afterward, requiring 5mg IM midazolam and 5mg IM haloperidol upon arrival. Fingerstick glucose 226. ECG is obtained and shown below.

Exam: BP 182/84, HR 111, T 86.1F, RR 18, SpO2 100%

Disheveled appearing male in wet clothes, intermittently thrashing. Cold to touch. Pupils 5mm bilaterally. No signs of trauma. GCS E3 V2 M5. Moves all extremities equally. Heart rate is tachycardic and irregular

ECG interpretation: atrial fibrillation with Osborne waves

Differential diagnosis: polysubstance use, environmental cold exposure, severe sepsis, hypothyroidism

Case continued: Active rewarming is initiated by removing wet clothes, administering warmed IV fluids, and placing a bair hugger. Labs are notable for a creatinine kinase of 3966. The patient’s temperature, heart rate, and mental status significantly improve within 5 hours, and his repeat EKG shows normal sinus rhythm without Osborn waves. He is ultimately admitted to medicine.

Pearls:

– The cardiovascular response to cold is peripheral vasoconstriction and initial increase in heart rate and blood pressure. As core temperature drops below 32C, there is myocardial irritability and risk of cardiovascular collapse.

o Atrial fibrillation and flutter are common arrhythmias associated with hypothermia.

o Rescue collapse is a term to describe cardiac arrest that occurs during extrication or transport of a profoundly hypothermic patient due to profound myocardial irritability.

– Osborn waves are positive deflections at the end of the QRS complex that are non-specific but may occur in temperatures below 32C.

o Size of the wave correlates with the degree of hypothermia but has no prognostic value.

– As temperature continues to drop, EKG changes are variable but classically include bradycardia with prolonged PR, QRS, and QTc. Heart block or ventricular dysrhythmias may be encountered as well. Asystole is the common final dysrhythmia.

– Rewarming is the treatment of choice.

o Atrial dysrhythmias such as atrial fibrillation will often resolve with warming.

o Cardioversion for unstable arrhythmias should be attempted but may be refractory in severe hypothermia.

References:

Brown DA. Hypothermia. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Hoek T. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010. 122:5829-5861

Friday Board Review

Board Review by Dr. Guo (Edited by Dr. Parikh

Vidhi ParikhLeave a comment

A 72 year old male with a past medical history of Parkinson’s disease and type 2 diabetes presents for progressive cough and shortness of breath for 3 days. Vitals include Temp 100.8F, HR 110, BP 126/80, RR 22, SpO2 89% on room air. Lung sounds are notable for crackles in the lower right lung. A chest x-ray shows focal consolidations of the right middle and right lower lobes with a moderate sized right pleural effusion. Aspiration of the pleural effusion demonstrates grossly purulent fluid with a pleural pH of 7.1. Which of the following antibiotic regimens is NOT appropriate for initial treatment of this patient’s condition?

A: Ampicillin & gentamicin

B: Cefepime & metronidazole

C: Ceftriaxone & ampicillin-sulbactam

D: Vancomycin & piperacillin-tazobactam

Answer: Ampicillin & gentamicin

This patient is presenting with pneumonia complicated by an empyema based on the pleural fluid findings. The initial treatment of an empyema consists of drainage with broad spectrum antibiotics that will cover Staphylococcus and anaerobes. Ampicillin has poor sensitivity against Staphylococcus and weak coverage of gram-negative organisms. Gentamicin is a potent aminoglycoside with good sensitivity against MSSA and gram-negatives but has poor anaerobic coverage. In addition, aminoglycosides have poor penetration into the pleural space. 

Cefepime, ceftriaxone, ampicillin-sulbactam, piperacillin-tazobactam have good sensitivity against MSSA. Vancomycin has additional coverage against MRSA. Metronidazole, ampicillin-sulbactam, and piperacillin-bactam have good coverage of anaerobic organisms.

Diagnostic Criteria for EmpyemaLight Criteria for Exudative Pleural Effusion (requires 1 of the following)
Aspiration of grossly purulent fluid plus one of the following:Pleural protein/serum protein > 0.5
    Positive gram stain or culturePleural LDH/serum LDH > 0.6
    Pleural fluid glucose < 40Pleural LDH > 2/3 upper limit of normal serum LDH
    Pleural pH < 7.2
    Pleural LDH > 1000

References:

Mace SE, Anderson E. Lung Empyema and Abscess. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Vaudaux P, Waldvogel FA. Gentamicin inactivation in purulent exudates: role of cell lysis. J Infect Dis. 1980;142(4):586-593. doi:10.1093/infdis/142.4.586

Wednesday Image Review

What’s the Diagnosis? By Dr. Carlos Cevallos

Edward GuoLeave a comment

A 39 y.o. woman who is G9P1 and currently 6 weeks pregnant presents to the ED with a chief complaint of vaginal bleeding that began in the morning with associated lower abdominal pain and lightheadedness. Physical exam demonstrates lower abdominal tenderness without peritonitis and a small amount of blood in the posterior vaginal fossa with a closed cervical os. You obtain a serum HCG which is 8,960 and perform a transvaginal ultrasound which demonstrates the following. What’s the diagnosis?

Answer: Ectopic Pregnancy

  • When performing a pelvic US in the ED, the focused question is: “Is there an intrauterine pregnancy (IUP) or not?”
  • To diagnose an IUP, one must visualize a gestational sac AND either a yolk sac or fetal pole within the uterus.
  • In this patient, no gestational sac nor yolk sac are visualized within the uterus.
  • The left adnexa demonstrates a tubal ring concerning for an ectopic pregnancy. OBGYN was consulted who took the patient Level 1 to the OR where the ectopic pregnancy was confirmed and removed along with a left salpingectomy.

Resources:

Heaton, Heather. “Chapter 98: Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy.” Tintinalli’s Emergency Medicine A Comprehensive Study GUide, 9th ed., McGraw-Hill, 2020, pp. 615–623.

Pontius E. Ectopic Pregnancy & Heterotopic Pregnancy. In: Johnson W, Nordt S, Mattu A and Swadron S, eds. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/reci4t2X66l3qk1SX/Ectopic-Pregnancy-and-Heterotopic-Pregnancy#h.za15ev4ckcfv. Updated February 2, 2024. Accessed April 17, 2024.

Tuesday Advanced Cases

Critical Cases – Diaphragmatic Hernia!!!

Richard ByrneLeave a comment

by: Richard Byrne M.D.

HPI:

  • 22 yo male hx of prior GSW to L chest with retained bullet presents with chief complaint of 2 days of left sided chest and left upper quadrant abdominal pain, along with intermittent nonbilious emesis
  • No fevers, no dyspnea, normal bowel movements

Physical Exam

  • VS: T 97.3 HR 80 BP 153/70 O2 98% on RA
  • Well appearing, in no distress
  • Lungs clear bilaterally, heart sounds normal
  • Abdomen soft, +tenderness in LUQ without guarding and rebound tenderness
  • No lower extremity edema

ECG:

Chest film:

Interpretation: Apparent left sided pleural effusion, not apparent on lateral view

CT chest:

Highlighted area indicates diaphragmatic hernia with portion of the stomach in the left chest

Clinical Course

  • NGT placed to decompress stomach
  • Admitted to CT surgery
  • Had EGD to assess viability of gastric mucosa which was normal
  • Underwent open surgical repair of diphragmatic hernia with reduction of stomach into abdominal cavity

Pearls

  • Diaphragmatic hernia is a rare condition usually a sequelae of trauma
  • Conventional imaging such as CT will likely not detect an acute injury to the diphragm
  • Patients often present late after acute trauma when visceral contents herniate into the chest cavity
  • Exam may demonstrate acute respiratory distress and bowel sounds on pulmonary auscultation
  • Patients may be in frank shock from gastric/intestinal ischemia
  • Treatment is surgical, usually cardiothoracic
Monday Back to Basics

Uveitis and Iritis with Dr. Carlos Cevallos

Erica WestlakeLeave a comment

References:

Walker, R.A. Adhikari, S. Eye Emergencies. In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (9th ed.). 

https://www.google.com/imgres?q=perilimbal%20flush%20uveitis&imgurl=https%3A%2F%2Fs3.ap-southeast-2.amazonaws.com%2Fwikem.cf.bucket%2Fimages%2Fthumb%2FAnterior-uveitis.jpg%2F300px-Anterior-uveitis.jpg&imgrefurl=https%3A%2F%2Fwikem.org%2Fwiki%2FUveitis&docid=i16sTpseqXcUeM&tbnid=LV7HE_b44e_8WM&vet=12ahUKEwiSn4-v1LqFAxUdD1kFHd29DxAQM3oECGoQAA..i&w=300&h=198&hcb=2&ved=2ahUKEwiSn4-v1LqFAxUdD1kFHd29DxAQM3oECGoQAAhttps://www.google.com/url?sa=i&url=https%3A%2F%2Faneskey.com%2Firitis-acute-anterior-uveitis%2F&psig=AOvVaw1g_mAok7XanZ3d_OYcUcbF&ust=1712942893847000&source=images&cd=vfe&opi=89978449&ved=0CBIQjRxqFwoTCPiil9fXuoUDFQAAAAAdAAAAABAE

Today’s Essential Teaching Image: Traumatic Iritis