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