A 30-year-old man presents to the emergency department with severe chest pain that began suddenly after repeated, self-induced episodes of vomiting. He appears uncomfortable and diaphoretic. His vitals show a blood pressure of 100/65 mmHg, heart rate of 115 bpm, respiratory rate of 24 breaths per minute, and oxygen saturation of 94% on room air. On examination, you note crepitus on palpation of the chest wall and a “crunching” sound on cardiac auscultation. A chest X-ray reveals a widened mediastinum and subcutaneous emphysema. What is the next best step in management?

A) Endoscopy with esophageal dilation

B) Contrast esophagography with water-soluble contrast

C) Administration of proton pump inhibitor and discharge

D) Nasogastric tube placement and observation

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Correct Answer: B) Contrast esophagography with water-soluble contrast

Explanation:

This patient’s presentation is highly suggestive of Boerhaave’s syndrome, which is a spontaneous esophageal perforation typically following forceful vomiting. The Mackler triad—vomiting, chest pain, and subcutaneous emphysema—is a classic but variably present feature.

• Chest X-ray findings can include pneumomediastinum, subcutaneous emphysema, and a pleural effusion (often left-sided).
• The next best step in management is contrast esophagography with a water-soluble contrast agent (e.g., Gastrografin), which helps confirm the diagnosis by demonstrating extravasation of contrast from the esophagus.

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Why Not the Other Answers?

• (A) Endoscopy with esophageal dilation – Endoscopy is not the first-line test as it may exacerbate the tear. It is typically reserved for cases where contrast studies are inconclusive.
• (C) Proton pump inhibitor and discharge – This option is appropriate for Mallory-Weiss tears (a partial mucosal tear), but Boerhaave’s syndrome is a full-thickness rupture and requires urgent intervention.
• (D) Nasogastric tube placement and observation – Conservative management may be attempted in small, contained perforations in stable patients, but given this patient’s systemic symptoms and imaging, urgent diagnosis and surgical consultation are warranted.

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Next Steps:

• Urgent surgical consultation is required, as most cases need operative repair.
• Broad-spectrum IV antibiotics and fluid resuscitation should be initiated promptly to prevent sepsis.
• NPO status and IV proton pump inhibitors can help minimize further esophageal injury.

Early recognition and management are critical, as delayed diagnosis significantly increases mortality in Boerhaave’s syndrome.

A 64-year-old male with a history of ischemic cardiomyopathy and an implanted cardioverter-defibrillator (ICD) presents to the emergency department after experiencing multiple ICD shocks over the past two hours. His medications include carvedilol, lisinopril, and furosemide. On arrival, he is awake but visibly anxious, with the following vitals:

• HR: 120 bpm, irregular
• BP: 110/70 mmHg
• SpO₂: 96% on room air
• ECG shows polymorphic ventricular tachycardia (VT) with recurrent defibrillation by the ICD.

What is the next best step in the management of this patient?

A) Administer intravenous amiodarone and sedate the patient for synchronized cardioversion
B) Start intravenous lidocaine and perform overdrive pacing
C) Administer a beta-blocker intravenously and titrate to HR
D) Provide deep sedation with propofol and consider catheter ablation
E) Correct reversible causes while initiating antiarrhythmic therapy and sympathetic blockade

Correct Answer: E) Correct reversible causes while initiating antiarrhythmic therapy and sympathetic blockade

Explanation:

Electrical storm (ES) is defined as three or more episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) requiring ICD intervention within 24 hours. It is a medical emergency that necessitates prompt stabilization and definitive therapy.

1. Initial Priorities:
   • Assess hemodynamic stability and airway, breathing, circulation (ABCs).
   • Provide analgesia and sedation if the patient is experiencing painful ICD shocks.
2. Correct Reversible Causes:
   Common triggers include electrolyte disturbances (e.g., hypokalemia, hypomagnesemia), ischemia, or drug toxicity. These should be addressed first, as they may alleviate the electrical storm.
3. Antiarrhythmic Therapy:
   • Amiodarone is often the first-line agent due to its efficacy in controlling polymorphic VT or VF.
   • Lidocaine may also be used, particularly in ischemic VT.
4. Sympathetic Blockade:
   • Beta-blockers (e.g., esmolol) help reduce sympathetic tone, which is a key driver of electrical instability. However, they should be used cautiously in patients with hypotension.
5. Additional Measures:
   • Deep sedation or anesthesia (e.g., with propofol) can reduce sympathetic drive in refractory cases.
   • Catheter ablation may be considered for recurrent arrhythmias not controlled with medical therapy.

Incorrect Responses:

A) Administer intravenous amiodarone and sedate the patient for synchronized cardioversion:

• While amiodarone is appropriate, synchronized cardioversion is not indicated for polymorphic VT unless the patient is unstable or pulseless.

B) Start intravenous lidocaine and perform overdrive pacing:

• Overdrive pacing is rarely the first intervention and is typically reserved for monomorphic VT or when ICD therapies fail.

C) Administer a beta-blocker intravenously and titrate to HR:

• Beta-blockers are important for sympathetic blockade but should not be the sole treatment in ES. They are adjunctive to antiarrhythmic therapy.

D) Provide deep sedation with propofol and consider catheter ablation:

• Sedation may help with ICD shock-related distress but does not address the underlying arrhythmia. Catheter ablation is not a first-line therapy in acute management.

Key Learning Points:

• Electrical storm requires a multifaceted approach, including correction of reversible causes, antiarrhythmic therapy, and sympathetic blockade.
• Stabilizing the patient’s hemodynamics and addressing the underlying trigger are essential for successful management.
• Involve cardiology and electrophysiology early for advanced therapies, such as catheter ablation.

References:

A 64-year-old male with a history of ischemic cardiomyopathy and an implanted cardioverter-defibrillator (ICD) presents to the emergency department after experiencing multiple ICD shocks over the past two hours. His medications include carvedilol, lisinopril, and furosemide. On arrival, he is awake but visibly anxious, with the following vitals:

• HR: 120 bpm, irregular
• BP: 110/70 mmHg
• SpO₂: 96% on room air
• ECG shows polymorphic ventricular tachycardia (VT) with recurrent defibrillation by the ICD.

What is the next best step in the management of this patient?

A) Administer intravenous amiodarone and sedate the patient for synchronized cardioversion
B) Start intravenous lidocaine and perform overdrive pacing
C) Administer a beta-blocker intravenously and titrate to HR
D) Provide deep sedation with propofol and consider catheter ablation
E) Correct reversible causes while initiating antiarrhythmic therapy and sympathetic blockade

Correct Answer: E) Correct reversible causes while initiating antiarrhythmic therapy and sympathetic blockade

Explanation:

Electrical storm (ES) is defined as three or more episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) requiring ICD intervention within 24 hours. It is a medical emergency that necessitates prompt stabilization and definitive therapy.

1. Initial Priorities:
   • Assess hemodynamic stability and airway, breathing, circulation (ABCs).
   • Provide analgesia and sedation if the patient is experiencing painful ICD shocks.
2. Correct Reversible Causes:
   Common triggers include electrolyte disturbances (e.g., hypokalemia, hypomagnesemia), ischemia, or drug toxicity. These should be addressed first, as they may alleviate the electrical storm.
3. Antiarrhythmic Therapy:
   • Amiodarone is often the first-line agent due to its efficacy in controlling polymorphic VT or VF.
   • Lidocaine may also be used, particularly in ischemic VT.
4. Sympathetic Blockade:
   • Beta-blockers (e.g., esmolol) help reduce sympathetic tone, which is a key driver of electrical instability. However, they should be used cautiously in patients with hypotension.
5. Additional Measures:
   • Deep sedation or anesthesia (e.g., with propofol) can reduce sympathetic drive in refractory cases.
   • Catheter ablation may be considered for recurrent arrhythmias not controlled with medical therapy.

Incorrect Responses:

A) Administer intravenous amiodarone and sedate the patient for synchronized cardioversion:

• While amiodarone is appropriate, synchronized cardioversion is not indicated for polymorphic VT unless the patient is unstable or pulseless.

B) Start intravenous lidocaine and perform overdrive pacing:

• Overdrive pacing is rarely the first intervention and is typically reserved for monomorphic VT or when ICD therapies fail.

C) Administer a beta-blocker intravenously and titrate to HR:

• Beta-blockers are important for sympathetic blockade but should not be the sole treatment in ES. They are adjunctive to antiarrhythmic therapy.

D) Provide deep sedation with propofol and consider catheter ablation:

• Sedation may help with ICD shock-related distress but does not address the underlying arrhythmia. Catheter ablation is not a first-line therapy in acute management.

Key Learning Points:

• Electrical storm requires a multifaceted approach, including correction of reversible causes, antiarrhythmic therapy, and sympathetic blockade.
• Stabilizing the patient’s hemodynamics and addressing the underlying trigger are essential for successful management.
• Involve cardiology and electrophysiology early for advanced therapies, such as catheter ablation.

References:

Electrical Storm

A 58-year-old man with a history of diabetes mellitus and obesity presents to the emergency department reporting groin pain, fever, and malaise. HR 112, BP 105/68, RR 18, SpO2 98%, Temp 101.3F.  

Physical examination reveals erythema, foul-smelling drainage. You appreciate crepitus in the perineal region.

Laboratory studies show a white blood cell count of 21,000/μL, blood glucose of 350 mg/dL, and serum lactate of 4.3 mmol/L.

Which of the following is the most appropriate next step in the management of this patient?

A) Start intravenous antibiotics and perform wide surgical debridement.
B) Obtain a CT scan of the pelvis to evaluate the extent of tissue involvement.
C) Administer intravenous antibiotics and observe for clinical improvement.
D) Perform bedside incision and drainage in the emergency department.
E) Consult urology for elective surgical management.

Answer: A) Start intravenous antibiotics and perform wide surgical debridement.

Explanation:

The patient is presenting with history and physical exam findings concerning for Fournier’s Gangrene

Correct Answer: 

A) Fournier’s gangrene is a rapidly progressive, necrotizing fasciitis of the perineum, scrotum, and/or genital area. It is a surgical emergency that requires prompt intervention. The mainstay of treatment includes broad-spectrum intravenous antibiotics (1st line: Vancomycin and Zosyn) to cover aerobic and anaerobic bacteria. If concern for shock, or known Group A strep infection, add Clindamycin to suppress toxin and cytokine production.

Urgent surgical debridement should be performed to remove necrotic tissue and control the spread of infection. Delay in surgical intervention significantly increases mortality.

Incorrect Answers:

B) Obtain a CT scan of the pelvis: While imaging such as CT may provide detailed information about the extent of tissue involvement, it should not delay definitive surgical treatment. Clinical findings are typically sufficient to diagnose Fournier’s gangrene.

C) Administer intravenous antibiotics and observe for clinical improvement: Antibiotics alone are insufficient for the treatment of Fournier’s gangrene. Without surgical debridement, the infection will likely progress.

D) Perform bedside incision and drainage in the emergency department: Fournier’s gangrene requires wide surgical debridement under appropriate sterile conditions in the operating room, rather than limited bedside procedures.

E) Consult urology for elective surgical management: Fournier’s gangrene is a medical and surgical emergency that demands immediate intervention. Elective management is inappropriate in this life-threatening condition.

Teaching Points:

• Risk Factors: Diabetes mellitus, obesity, immunosuppression, and trauma to the perineal region
• Clinical Presentation: Severe pain, swelling, erythema, crepitus, systemic signs of sepsis, and foul-smelling discharge
• Management:
  • Broad-spectrum antibiotics (e.g., Vancomycin + piperacillin-tazobactam + clindamycin)
    • If Penicillin allergy: Cefepime + Metronidazole
  • Emergent surgical debridement in OR to remove necrotic tissue
  • Supportive care, including fluid resuscitation and glycemic control
• Complications: High mortality rate if not treated promptly

References

CorePendium, Fournier Gangrene

A 62-year-old man with a history of hypertension, coronary artery disease, and recent hip replacement surgery presents to the emergency department with acute onset of pleuritic chest pain, dyspnea, and dizziness. On examination, his blood pressure is 85/60 mm Hg, heart rate is 120 bpm, and respiratory rate is 24/min. He is mildly confused, and his oxygen saturation is 88% on room air. A CT pulmonary angiogram reveals a massive pulmonary embolism (PE) in the right main pulmonary artery. The patient is in shock, with signs of right heart strain.

Which of the following is the most appropriate next step in management?

A) Administer intravenous unfractionated heparin and monitor in the intensive care unit
B) Initiate fibrinolytic therapy and transfer to the intensive care unit
C) Start oral apixaban and admit for observation
D) Perform immediate surgical embolectomy and transfer to the intensive care unit
E) Place an inferior vena cava (IVC) filter and admit for observation

Explanation:

This patient is presenting with a massive pulmonary embolism (PE), which is defined by PE causing hemodynamic instability (e.g., shock or hypotension). The diagnosis is confirmed by a CT pulmonary angiogram, which shows a large embolus in the right main pulmonary artery, however, patients will not be stable enough to confirm on CT. Patients will commonly demonstrate signs of right heart strain (e.g., tachycardia, hypotension, and altered mental status). POCUS can be used to quickly assess for R heart strain and IVC distention at the bedside. R heart strain indicates the severity of the embolism and the impaired ability of the right ventricle to pump blood effectively against the obstructed pulmonary circulation.

Management of massive PE with hemodynamic instability involves:

• Fibrinolytic therapy (Option B): In patients with massive PE, fibrinolytic therapy (tPA) is the first-line treatment when there is evidence of hemodynamic instability (e.g., hypotension, shock). The goal is to rapidly dissolve the thrombus, reduce pulmonary artery pressure, and restore hemodynamic stability. Drugs like tPA (tissue plasminogen activator) or alteplase are used for this purpose. These patients need to be closely monitored in an intensive care unit (ICU) due to the risk of bleeding complications and ongoing cardiovascular instability.

Why the other options are not correct:

• Unfractionated heparin and ICU monitoring (Option A): While anticoagulation therapy is essential in PE management, heparin alone is not adequate for massive PE with shock. For hemodynamically unstable patients, fibrinolysis is preferred as the first-line therapy to rapidly restore circulation. Heparin would be considered in patients with low- or intermediate-risk PE but not in massive PE with shock.
• Oral apixaban and observation (Option C): Oral anticoagulants like apixaban are used for stable patients with non-massive PE who do not require urgent interventions. This patient is unstable, so starting oral anticoagulation alone is not sufficient, and immediate fibrinolysis or surgical intervention is required.
• Surgical embolectomy (Option D): Surgical embolectomy can be considered if fibrinolysis fails or if the patient is not a candidate for fibrinolytic therapy (e.g., contraindications to fibrinolysis like active bleeding). However, it is not the first-line treatment for massive PE with shock, and it carries more risks than fibrinolysis, including longer procedure time and surgical complications.
• IVC filter placement and observation (Option E): An inferior vena cava (IVC) filter is used in patients who have contraindications to anticoagulation or in those with recurrent embolism despite appropriate anticoagulation. It is not a treatment for acute massive PE or shock and does not address the immediate need to remove the thrombus or restore pulmonary circulation. IVC filters are primarily used for secondary prevention of PE, not in the acute management of unstable patients.

Summary:

In patients with a massive pulmonary embolism and hemodynamic instability (shock), fibrinolytic therapy is the most appropriate initial treatment (Option B), with subsequent ICU monitoring to manage complications and ensure hemodynamic stabilization.