Board Review

Board Review with Dr. Alex Hilbmann

A 28 year old female G4P2 at 8 weeks gestation presents to the Emergency Department after vomiting almost four times daily for the past week. She denies any recent fevers, abdominal pain, pelvic pain, or vaginal bleeding. Vital signs include: Temp 37.2 C, HR 105, BP 93/62, SpO2 100%. On exam, she is uncomfortable appearing with dry mucous membranes and intermittently dry heaving into an emesis bag. Blood serum results are pending. Urinalysis reveals 1+ ketones with elevated specific gravity. What is the next best step in management?

A. 0.9% normal saline

B. Prophylactic electrolyte repletion

C. 5% dextrose and 0.9% normal saline

D. Antiemetic and PO challenge

Answer: 5% dextrose and 0.9% normal saline

This pregnant patient is most likely experiencing hyperemesis gravidarum given her presentation of multiple episodes of vomiting, volume depletion, and ketonuria. The treatment for hyperemesis gravidarum includes 5% glucose in IV fluids, anti-emetic drugs, and correction of any electrolyte abnormalities. Nothing should be given by mouth until patient’s nausea is controlled, and although this patient will ultimately benefit from antiemetic administration with the hopes that she will tolerate PO, her signs of volume depletion and ketonuria suggest immediate treatment with 5% dextrose in 0.9% normal saline or lactated ringer solution.

Management of Hyperemesis Gravidarum
First line: pyridoxine (vitamin B6) – pregnancy drug class A
Add on: doxylamine – pregnancy drug class A
Adjuncts: ondansetron, metoclopramide – pregnancy drug class B
IV fluids with dextrose


References: Tintinalli, J., Ma, O., Yealy, D., Meckler, G., Cline, D., Thomas, S. and Stapczynski, J., 2020. Tintinalli’s emergency medicine. 9th ed. [New York]: McGraw-Hill Education, pp.621-622.

Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 153. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 126(3):e12-24

Image Review

What’s the Diagnosis? By Dr. Carlos Cevallos

A 55 year old male with a past medical history of colon cancer on chemotherapy presents with a chief complaint of right lower extremity pain/discoloration to his calf and thigh as well shortness of breath that has developed over the past 48 hours. A physical exam reveals dopplerable DP and PT pulses. The right calf and thigh is visualized as in the image below. What’s the diagnosis?

Answer: Phlegmasia Cerulea Dolens (PCD) – a near-total occlusion of the major deep venous system of an extremity as well as the majority of microvascular collateral veins of the extremity. 

PCD occurs on a spectrum with phlegmasia albans dolens (PAD): thrombosis of the deep venous system with patency of the collateral veins and venous gangrene: when there is complete obstruction of venous outflow with irreversible capillary involvement and muscle infarction. It is differentiated from PAD by a pale/white limb versus a dusky/cyanotic limb in PCD. 

Clinical Features: Triad of swelling, pain, cyanosis. Limb can develop firmness and there is a risk for arterial compromise and compartment syndrome. Thrombosis can extend into the IVC and it is often accompanied by pulmonary embolism with the incidence reported to vary from 12-40%.  

Diagnosis: Clinical history/exam in conjunction with imaging. Gold standard diagnosis is contrast venography, however often due to difficulty and length of time to attain this ultrasound venography is often preferred. CT-venogram is useful for visualization of extension of thrombus in the IVC. 

Management: Immediate elevation of affected extremity above the level of the heart to encourage return of circulation. Anticoagulation with unfractionated IV heparin bolus at 10-15 units/kg followed by an infusion titrated to an aPTT of 1.5-2 times the lab control value. Immediate vascular/interventional radiology consultation for possibly thrombectomy versus catheter-directed thrombolysis. If no service is available and transfer is unable to be arranged within 6 hours then consider systemic fibrinolytics if no contraindications are present. 

Case Continued: Duplex ultrasound, CT-venogram, and CTA Chest on our patient revealed DVT of the major deep veins of the right lower extremity that extended into the IVC as well as bilateral pulmonary embolisms. He was started on heparin and had a mechanical thrombectomy of the right iliofemoral/IVC DVT. He was able to be discharged on apixaban several days later. 


Cline, D., Ma, O. J., Meckler, G. D., Stapczynski, J. S., Thomas, S. H., Tintinalli, J. E., Yealy, D. M., & Kline, J. A. (2020). Venous Thromboembolism Including Pulmonary Embolism. In Tintinalli’s emergency medicine: A comprehensive study guide (pp. 389–398). essay, McGraw-Hill Education. 

Gardnella, L., & Falk, J. (n.d.). Phlegmasia Alba and cerulea Dolens – StatPearls – NCBI Bookshelf. Phlegmasia Alba and Cerulea Dolens. 

Perkins, J. M., Magee, T. R., & Galland, R. B. (1996). Phlegmasia caerulea dolens and venous gangrene. British Journal of Surgery, 83(1), 19–23. 

Board Review

Board Review with Dr. Edward Guo

A professional football player has a helmet-to-helmet collision with an opposing player. He falls to the ground and has a one minute episode during which he is posturing with his upper extremities flexed and lower extremities extended. His eyes are open and blinking. Teammates gather around him and he is muttering “chicken nuggets, chicken nuggets”. What is his Glasgow Coma Scale score during this time?

A: 8

B: 9

C: 10

D: 11

Answer: 10 (E4 V3 M3)

Eye OpeningVerbal ResponseBest Motor Response
1 – None1 – None1 – None
2 – To pain2 – Incomprehensible sounds2 – Extensor or decerebrate posture
3 – To sound3 – Inappropriate words3 – Flexor or decorticate posture
4 – Spontaneous4 – Confused but answers questions4 – Withdraws from pain
5 – Oriented 5 – Localizes pain (crosses midline)
6 – Obeys commands


Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-84. doi:10.1016/s0140-6736(74)91639-0

Cameron P.A., & Knapp B.J., & Teeter W (2020). Trauma in adults. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Image Review

From the EMDaily Archives: What’s the Diagnosis? By Dr. Rebecca Fieles

A 44 year old male presents for left foot and ankle pain. He was running and stepped into a hole, stating he heard a “crack”. He has been unable to bear weight since the injury. On exam, his left lower extremity is neurovascularly intact. He has swelling and marked bony tenderness of both the lateral and medial malleoli and heel. X-rays of the left foot is obtained and shown below. What’s the diagnosis?

Answer: Comminuted Calcaneal Fracture


  • Most commonly due to high axial load injuries such as fall from height or MVC
  • Most common tarsal fracture


  • Diffuse pain, swelling, and ecchymosis after trauma
  • Often unable to bear weight
  • Deformity of heel or plantar arch on exam
  • Mondor’s sign – ecchymosis/hematoma that tracks along sole of foot
    • Pathognomonic for calcaneal fracture


  • Plain radiographs of ankle/foot
  • Harris view: calcaneus in axial view
  • Non-contrast CT of foot/ankle is gold standard and assists with surgical planning
  • Sander’s Classification (based on CT)
    • Type I: All intra-articular fractures that have < 2 mm displacement, regardless of number of fracture lines or fragments
    • Type II: Two bony fragments involving posterior facet
    • Type III: Three bony fragments including depressed middle fragment
    • Type IV: Four comminuted bony fragments

ED Treatment

  • Analgesia, ice, elevation
  • Splinting, often with bulky Jones dressing
  • Orthopedics consultation
    • Most intra-articular fractures require surgical repair
    • Most extra-articular fractures can be managed conservatively with 10-12 weeks of casting and non-weight bearing


Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471

Advanced Cases

Surgical Airway by Dr. Julia Shamis

A 58-year-old male with past medical history of neurofibromatosis status presents 4 days after emergent neuro IR embolization of a left occipital artery branches after feeling a pop in his surgical site followed by left-sided facial numbness radiating down to the left shoulder with word-finding difficulties. A large, expanding neck hematoma was noted on the left anterior neck. Patient was taken immediately for a CTA to attempt to identify the source of hemorrhage, and upon completion of CT imaging, the patient experienced cardiac arrest. Orotracheal intubation was unsuccessful due to the anatomic distortion from the expanding neck hematoma. Patient underwent emergent surgical cricothyroidotomy and achieved ROSC immediately thereafter.

Surgical Cricothyroidotomy PEARLS:

Indication: can’t intubate, can’t oxygenate, can’t ventilate

  • Generally after three attempts failed at orotracheal intubation and unable to maintain oxygenation
  • No oral access, masseter spasm, clenched teeth, trismus, structural deformities, laryngospasm, massive hemorrhage, mass effect/displacement of trachea, airway swelling, facial trauma, foreign bodies that cannot be removed from airway safely, no viable connection between upper and lower airway

Equipment: chlorhexidine or povidone iodine solution, 11 blade scalpel, bougie, ET tube

Procedure: The “knife, finger, bougie” technique

  • Palpate the cricothyroid membrane located inferior to the laryngeal prominence (i.e. Adam’s apple)
  • Stabilize the larynx using your thumb and middle finger while palpating the membrane with your index finger
  • Make a vertical incision along the cricothyroid membrane from the thyroid cartilage to the bottom of the cricoid cartilage. Palpate again with the index finger to confirm the cricothyroid membrane. Make a horizontal stab incision through the cricothyroid memrane and extend the incision 1 cm laterally
  • Remove the scalpel and insert the index finger into the trachea. Use your finger as a guide to pass the bougie through the opening. Continue insertion of the bougie until it “hangs up” in the lower pulmonary tract
  • Pass the tracheostomy tube or ET tube over the bougie to secure the airway.


Boland C, Nasr NF, Voronov GG. Cricothyroidotomy. In: Reichman EF. eds. Reichman’s Emergency Medicine Procedures, 3e. McGraw Hill; 2018.

Walls R, Murphy M. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams; 2012.

Milner S, Bennett J. Emergency cricothyrotomy. The Journal of Laryngology & Otology. 1991;105(11):883-885.

Holmes J, Panacek E, Sakles J, Brofeldt B. Comparison of 2 Cricothyrotomy Techniques: Standard Method Versus Rapid 4-Step Technique. Annals of Emergency Medicine. 1998;32(4):442-446.

Board Review

Board Review with Dr. Edward Guo

A 19 year old male with no past medical history is brought in by EMS due to a report from his college roommate for strange activity. Over the last week, the patient has skipped all of his classes and barricaded himself in his room. He states that the FBI is tracking him and plan to kidnap him. Vitals are within normal limits. Exam shows a disheveled appearing male. He eventually attempts to run out of the emergency department but is tackled by security. Verbal de-escalation is not successful. Which of the following intramuscular medications is contraindicated for the management of this patient? 

A: haloperidol

B: ketamine

C: lorazepam

D: olanzapine

Answer: ketamine

This patient presenting with disorganized behavior and paranoid delusions is concerning for an acute psychotic episode. Ketamine is an agent commonly used for sedation that is absolutely contraindicated in patients with known or suspected schizophrenia even if it is currently well controlled due to the risk of emergence reactions and worsening psychosis. Haloperidol, olanzapine, lorazepam are agents commonly used for the management of acute psychosis and agitation.

Ketamine for Procedural Sedation or Agitation
ContraindicationsAllergy to drug
Age < 3 months old
Known or suspected schizophrenia
Dosing1-2 mg/kg IV
4-6 mg/kg IM
Adverse effectsLaryngospasm or apnea associated with rapid push
Nausea & vomiting
Emergence reaction


Ali S, & Poonai N (2020). Pain management and procedural sedation for infants and children. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Myers J.G., & Kelly J (2020). Procedural sedation and analgesia in adults. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Wilson M (2020). Acute agitation. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Image Review

What’s the Diagnosis? By Dr. Kane McKenzie

A 78 year old female presents to the ED from a cardiac rehabilitation facility with increasing shortness of breath and a productive cough. She was discharged from the hospital two weeks ago after having a coronary stent placed which was complicated by pneumonia and developing heart failure. She was discharged on PO amoxicillin-clavulanate. Vitals are notable for a heart rate of 101 and are otherwise within normal limits. 

Labs are remarkable for an elevated WBC of 18.55 and elevated NT-ProBNP of 2155. Point-of-care cardiac ultrasound shows a normal ejection fraction. Right sided point-of-care lung ultrasound findings are shown below. What’s the most likely diagnosis, and what pathognomonic ultrasound “sign” is seen?

Answer: Pneumonia; Hepatization of the lung

  • Normally, lung is not well visualized on ultrasound because the alveoli are filled with air which does not transmit ultrasound beams well to produce an image.
    • Aerated lung will produce horizontal “A lines”, a reverberation artifact from the result of sound waves bouncing between the skin and pleural line.
  • With consolidation of the lung or pneumonia, ultrasound beams are able to travel through the purulent or fluid filled alveoli.
    • The lung will appear hypoechoic and heterogeneous, resembling the liver, hence the term “hepatization of the lung.”


Dawson M, Mallin M. Introduction to Bedside Ultrasound: Volume 1. Emergency Ultrasound Solutions; 2013. 

Durant A, Nagdev A. Ultrasound detection of lung hepatization. West J Emerg Med. 2010;11(4):322-323

Advanced Cases

Euglycemic DKA by Dr. Sarah Perelman

A 45 year old male with a history of alcohol use disorder, diabetes on insulin, glipizide, and empagiflozin presents with chest pain and shortness of breath. 3 days ago, he drank 20 beers and then started vomiting. Last night, he developed chest pain and headache. Today, he has been feeling short of breath.

Vital signs: BP 126/70, HR 90, Temp 98.7F, RR 35, SpO2 99%. EKG is normal. Accucheck 182.

On exam, he is generally uncomfortable appearing and tachypneic with increased work of breathing. He has dry mucous membranes and clear lung sounds bilaterally. There is mild tenderness to palpation over the epigastric area.

Labs are notable for:

  • VBG: pH 7.08, pCO2 20, HCO3 9
  • BMP: Na 121, BUN 23, creatinine 1.12
  • Ethanol, salicylates, and acetaminophen levels undetectable
  • Lactate 1.3
  • Beta-hydroxybutyrate 9.8
  • Urine: 4+ ketones, normal specific gravity

Differential diagnosis includes: Euglycemic DKA, Alcoholic Ketoacidosis, Starvation Ketosis, and Toxic Alcohol Ingestion


  • Started with 1L NS bolus  
  • Insulin infusion @ 0.1 u/kg/hr 
  • Thiamine, folate supplementation 
  • GMAWs protocol for expected alcohol withdrawal 
  • Critical Care consultation


  • Symptoms of acidosis: nausea, vomiting, headache, abdominal pain, generalized weakness, Kussmaul respirations (tachypnea with belly breathing and clear lungs)
  • Differential diagnosis for anion gap metabolic acidosis: uremia (high BUN/creat), lactic acidosis (sepsis/shock), ketoacidosis (DKA vs. alcoholic vs starvation), ingestion (salicylate vs. acetaminophen)
  • Euglycemic DKA: a rare disorder in which glucose level is relatively normal (<250) but ketoacidosis develops
  • Consider eDKA in pregnancy, type 1 diabetes, alcohol abuse, liver failure, starvation, but most notably in patients taking SGLT2 inhibitors (-“flozin”)
    • Treatment: D5NS + insulin, replete K if needed 
  • Euglycemic DKA and alcoholic ketoacidosis can be very difficult to distinguish, as alcohol use and poor PO intake can precipitate euglycemic DKA. In anyone with diabetes presenting like the case above who is on an SGLT2 inhibitor and impaired liver function, have a low threshold to start insulin to help drive the glucose into cells once glucose >180.


Gabor, KD., Cline, DM. “Acid-Base Disorders.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (73-78).

Howard RD, Bokhari SRA. Alcoholic Ketoacidosis. [Updated 2021 Dec 12]. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

Mehta, A., Emmett M. “Fasting Ketosis and Alcoholic Ketoacidosis.” UpToDate. October, 2020.

Nyce, A. Byrne, R., Lubkin, C. Chansky, M. “Diabetic Ketoacidosis.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (1433-1441).

Image Review

What’s the Diagnosis? By Dr. Daniel Petrosky

A 44 year old woman with a past medical history of kidney stones and diabetes presents to the ED with 3 days of intermittent flank pain for which Tylenol is not helping. On exam, she is crying and in pain with some tenderness in RLQ and suprapubic area. No CVA tenderness noted. She denies fever and dysuria. A CT abdomen and pelvis with IV contrast was obtained and shown below. What’s the diagnosis?

Answer: bilateral emphysematous pyelonephritis (Findings: bilateral xanthogranulomatous pyelonephritis. Right perinephric stranding. Gas within both renal collecting systems and urinary bladder.)

This is a severe necrotizing infection of the kidney parenchyma. Primarily, cases occur in those with uncontrolled diabetes (95%) and a secondary factor is kidney obstruction (25-40%). The usual bacteria involved is E. Coli (69%) or K. Pneumoniae (29%). If caught early medical management of kidney function and antibiotics is the primary mode of treatment. Failure of initial treatment can lead to a nephrectomy.

  • Class 1: gas in the collecting system only
  • Class 2: gas in the renal parenchyma without extension to extrarenal space
  • Class 3A: extension of gas or abscess to perinephric space
  • Class 3B: extension of gas or abscess to pararenal space
  • Class 4: bilateral EPN or solitary kidney with EPN

Management: admit for IV antibiotics and urological consult

This particular case has Proteus as the infective species as evident by staghorn calculi and urine culture. Because of preserved kidney function (Cr 0.87) and WBC (4.45), Urology elected to monitor and treat infection first and schedule outpatient procedure for stone removal to prevent urosepsis.


Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27;160(6):797-805. doi: 10.1001/archinte.160.6.797. PMID: 10737279.

Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011 May;107(9):1474-8. doi: 10.1111/j.1464-410X.2010.09660.x. Epub 2010 Sep 14. PMID: 20840327.

Advanced Cases

Metformin Overdose by Dr. Eugene Marrone

51 y/o male with a PMH of DM presented with an out of hospital cardiac arrest after a suicide attempt, found to have a lactate of 26.9, bicarb of 3, and pH <6.8. After collateral from the family, it was found that he overdosed on metformin. 


Precise amount of metformin required to do this is unclear, but seems to be high (e.g., >20 grams). The main effect of metformin is inhibition of the mitochondrial transport chain complex-I, which essentially poisons the mitochondria.


  • Vitals: The following abnormalities may be seen:
    • Hypothermia
    • Hypotension progressing to vasopressor-refractory shock can occur
  • GI symptoms often predominate: Nausea, vomiting, diarrhea, epigastric pain.
  • Delirium, decreased consciousness.


  • Supportive care, can consider bicarb 
  • Hemodialysis! Main indications:
    • Lactate >15-20 mM
    • pH <7.0-7.1
    • Failure to improve despite standard supportive measures


Calello DP, Liu KD, Wiegand TJ, Roberts DM, Lavergne V, Gosselin S, Hoffman RS, Nolin TD, Ghannoum M; Extracorporeal Treatments in Poisoning Workgroup. Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med. 2015 Aug;43(8):1716-30. doi: 10.1097/CCM.0000000000001002 [PubMed]

Wang GS, Hoyte C. Review of Biguanide (Metformin) Toxicity. J Intensive Care Med. 2019 Nov-Dec;34(11-12):863-876. doi: 10.1177/0885066618793385 [PubMed]