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.

A 55-year-old man with end-stage renal disease (ESRD) on hemodialysis presents to the emergency department with complaints of shortness of breath, chest pain, and confusion. His vital signs are as follows: BP 170/100 mm Hg, HR 105 bpm, RR 26 breaths/min, SpO2 88% on room air. His physical exam reveals jugular venous distension, diffuse crackles on lung auscultation, and pitting edema in his lower extremities. A chest X-ray shows bilateral pulmonary edema. His most recent dialysis session was 4 days ago.

Which of the following is the most appropriate initial management for this patient?

A) Administer intravenous nitroglycerin
B) Initiate noninvasive positive pressure ventilation (NIPPV)
C) Administer intravenous furosemide
D) Perform emergent hemodialysis
E) Administer intravenous morphine

Answer: D) Perform emergent hemodialysis

Explanation: This patient is presenting with symptoms of acute volume overload and pulmonary edema, a life-threatening complication in patients with ESRD on dialysis who miss or delay dialysis sessions. His history of missed dialysis, elevated blood pressure, jugular venous distension, pulmonary crackles, and pitting edema all point toward hypervolemia. Additionally, his symptoms of confusion and shortness of breath raise concern for uremic encephalopathy and pulmonary edema.

Emergent hemodialysis is the most definitive treatment in this case, as it addresses both fluid overload and potential uremia by rapidly removing excess fluid and toxins. Other options may provide temporary relief and may be initiated in the ED while awaiting initiation of hemodialysis, but do not address the underlying cause.

• Option A (IV nitroglycerin) may reduce preload and afterload, providing some symptomatic relief, but it does not directly treat the excess fluid or uremia
• Option B (NIPPV) can help improve oxygenation in acute pulmonary edema but is an adjunct and not a definitive therapy for fluid overload in ESRD
• Option C (IV furosemide) is ineffective in patients with ESRD as their kidneys cannot produce urine, making diuresis impossible
• Option E (IV morphine) may reduce dyspnea but is rarely used due to potential side effects like respiratory depression and worsening hypercapnia

References:

• Tintinalli’s Emergency Medicine Manual, 9th Edition

A 65-year-old male presents to the emergency department with complaints of severe shortness of breath and chest pain. He has a history of myocardial infarction and congestive heart failure. On physical exam, he is diaphoretic, hypotensive with a blood pressure of 80/50 mmHg, heart rate of 120 bpm, and jugular venous distension. His lungs reveal crackles bilaterally. An ECG shows ST-segment elevation in the anterior leads, and troponin levels are significantly elevated. Bedside echocardiography reveals an ejection fraction of 25% with global hypokinesis.

Which of the following is the most appropriate immediate treatment?

A) Intravenous fluids bolus
B) Nitroglycerin infusion
C) Norepinephrine infusion
D) Non-invasive positive pressure ventilation

Answer: C) Norepinephrine infusion

Explanation:

This patient is in cardiogenic shock, likely secondary to acute myocardial infarction (AMI) based on his history, clinical presentation, and ECG findings. 

Norepinephrine is widely recommended as a front-line agent for cardiogenic shock. Norepinephrine will improve the blood pressure, but there is a risk that excessive afterload could drop the cardiac output. The cath team should be notified ASAP if MI is the suspected cause of cardiogenic shock. Early consultation of the heart failure team can help guide further management if available at your institution.

Key Points:

• Cardiogenic shock occurs when there is inadequate tissue perfusion due to the failure of the heart as a pump. It is typically characterized by hypotension, signs of poor perfusion (cold extremities, altered mental status), and pulmonary congestion.
• The most common cause is an acute myocardial infarction (AMI), leading to severe left ventricular dysfunction. Other causes include Takotsubo, Peripartum Cardiomyopathy, Myocarditis, and Tachymyopathy

Choices:

• A) Intravenous fluids bolus: Fluid boluses are generally avoided in cardiogenic shock because the failing heart cannot effectively pump the excess fluid, which can worsen pulmonary edema. This patient already shows signs of volume overload (crackles in the lungs and jugular venous distension).
• B) Nitroglycerin infusion: Although nitroglycerin can reduce preload and improve ischemia in stable patients with myocardial infarction, it is contraindicated in this case due to the patient’s hypotension. Reducing preload or blood pressure further would worsen the shock.
• C) Norepinephrine infusion: This is the correct answer. In cardiogenic shock, vasopressors such as norepinephrine are used to maintain perfusion by increasing systemic vascular resistance and cardiac output. Norepinephrine is often preferred because it has strong vasoconstrictive effects and some inotropic support, making it suitable for patients in cardiogenic shock with hypotension.
• D) Non-invasive positive pressure ventilation (NIPPV): While NIPPV can help manage pulmonary edema and improve oxygenation, it does not address the underlying hypotension or poor cardiac output, which are the primary concerns in this case. This may be useful in conjunction with vasopressors but is not the initial definitive treatment for shock.

Takeaway: In patients with cardiogenic shock, the first-line treatment often includes vasopressors, such as norepinephrine, to stabilize blood pressure and ensure adequate organ perfusion while addressing the underlying cause (e.g., revascularization in myocardial infarction).

References:

• Tintinalli’s Emergency Medicine Manual, 9th Edition
• Internet Book of Critical Care

A 5-year-old boy presents to the emergency department with a two-day history of fever, sore throat, and difficulty swallowing. On examination, he has multiple small, grayish-white papulovesicular lesions on the soft palate, uvula, and tonsillar pillars. He is otherwise alert and well-hydrated with stable vital signs. Which of the following is the most likely diagnosis?

A) Peritonsillar abscess

B) Herpangina

C) Hand-foot-and-mouth disease

D) Infectious mononucleosis

E) Scarlet fever

Explanation:

Herpangina is characterized by the sudden onset of fever, sore throat, and dysphagia, accompanied by small, vesicular lesions on the posterior oropharynx, typically involving the soft palate, uvula, and tonsillar pillars. The lesions are grayish-white and may be surrounded by erythema. It is caused by Coxsackievirus group A, primarily affecting young children. Treatment is supportive, focusing on pain management and hydration. Peritonsillar abscess (choice A) presents with severe throat pain, trismus, and unilateral tonsillar swelling. Hand-foot-and-mouth disease (choice C) manifests with oral ulcers and vesicles on the hands and feet. Infectious mononucleosis (choice D) presents with fever, sore throat, lymphadenopathy, and atypical lymphocytosis. Scarlet fever (choice E) presents with a sandpaper-like rash and strawberry tongue, secondary to group A Streptococcus infection.

Therefore, the correct answer is B) Herpangina

References: Tintinalli’s Emergency Medicine Manual, 9th Edition