Friday Board Review

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

A 30 year old obese female presents to the emergency department for a persistent headache. You have a high suspicion for idiopathic intracranial hypertension and perform a lumbar puncture. The opening pressure is 28 cm H2O. Approximately how much volume of CSF should be removed to reach a target CSF pressure of 20 cm H2O prior to removal of the spinal needle?

A: 4 mL

B: 8 mL

C: 16 mL

D: 20 mL

Answer: 8 mL

Part of the diagnostic criteria for idiopathic intracranial hypertension in adults includes an elevated opening pressure > 25 cm H2O on lumbar puncture. The feared complication is permanent vision loss from papilledema. Treatment includes removal of CSF which can also provide relief of headache symptoms. As a general rule, removal of 1 mL of CSF will lower the CSF pressure by about 1 mL H2O. It is recommended to remove the desired amount of CSF and then re-measure the CSF pressure prior to removal of the spinal needle. Excess removal of CSF can result in intracranial hypotension and a low pressure headache.

References:

Fiorito-Torres  F, Rayhill  M, Perloff  M: Idiopathic intracerebral hypertension (IIH)/pseudotumor: removing less CSF is best (I9-1.006). Neurology 82 (10 Suppl): I9–1.006, 2014.

Koyfman A, Long B. Headache. 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.

Thurtell, Matthew & Bruce, Beau & Newman, Nancy & Biousse, Valérie. (2010). An Update on Idiopathic Intracranial Hypertension. Reviews in neurological diseases. 7. e56-68. 10.3909/rind0256.

Friday Board Review

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

A 40 year old male with a past medical history of polysubstance use, epilepsy, and housing insecurity presents to the emergency department for drug intoxication. His ED course is uncomplicated, and he is deemed ready for discharge 3 hours after his initial presentation. Upon handing him his discharge paperwork, he appears to trip and fall to the ground. He then demonstrates diffuse shaking of his entire body with his eyes tightly shut, not responding to external stimuli. The episode lasts approximately 2 minutes, and he afterward remains unresponsive to stimuli. Vital signs and point-of-care glucose are within normal limits. Physical exam shows no obvious injuries. Which of the following laboratory tests is most helpful in determining if the patient had an epileptic seizure?

A: Creatine kinase

B: Lactic acid

C: Potassium

D: White blood cell count

Answer: Lactic acid

Distinguishing between true epileptic seizures, psychogenic non-epileptic seizures (PNES), and convulsions following a syncopal episode can be difficult. PNES is psychogenic in nature and has highly variable features which may include forceful closing of the eyelids, side-to-side movements, or shrieking. An elevated serum lactic acid concentration obtained shortly after the event has been shown to help differentiate true epileptic seizures from PNES or convulsions following syncope. Creatine kinase levels typically do not rise early after a seizure and are furthermore not specific in the setting of falls or trauma. Potassium levels are not expected to be elevated following an uncomplicated seizure. An elevated white blood cell count may be due to several non-specific reasons including infection, trauma, steroid use, or stress response. Definitive diagnosis is determined using electroencephalography (EEG).

References:

Kornegay J. Seizures and Status Epilepticus in Adults. 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.

Patel J, Tran QK, Martinez S, Wright H, Pourmand A. Utility of serum lactate on differential diagnosis of seizure-like activity: A systematic review and meta-analysis. Seizure. 2022;102:134-142. doi:10.1016/j.seizure.2022.10.007

Friday Board Review

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

A 30 year old male with a history of cardiac arrest with ischemic encephalopathy status post tracheostomy and gastrostomy placement presents from a long-term care facility for a feeding tube problem. His nurse was bathing and performing dressing changes when the patient’s gastrostomy tube fell out. He has otherwise had no fever or vomiting, and his last bowel movement was earlier today. Vital signs are within normal limits. On exam, he appears comfortable. Patient is non-verbal and does not follow commands. There is a patent gastrostomy stoma in his left upper quadrant with no surrounding erythema or drainage. Old charts state that general surgery created the gastrostomy 6 weeks ago with a 16-french tube. Which of the following is the most appropriate initial management?

A: Consult General Surgery for gastrostomy tube replacement

B: CT abdomen and pelvis

C: insert a 14-french gastrostomy tube

D: insert a 16-french gastrostomy tube

Answer: Insert a 16-french gastrostomy tube

Artificial stomas are at risk for premature closure if the tube has been accidentally removed. Closure may begin quickly (within hours) depending on how mature the tract is. It is important for the emergency physician to be knowledgeable of the maturity of different surgical stomas and when consultation is necessary. In general, gastrostomy tracts mature after 2 to 3 weeks and then afterward can be replaced in the emergency department. Using the previous size tube is preferred to prevent leakage around the tract with a smaller diameter tube. CT of the abdomen and pelvis is unlikely to change management given the patient is asymptomatic. If the gastrostomy tract is immature or a 16-french tube is difficult to insert, then it would be indicated to consult general surgery for replacement. Do not attempt to push through resistance due to the risk of creating a false tract. In that case, attempting to insert a smaller size tube is advised to keep the original tract patent.

Type of Surgical StomaTime to Mature
Tracheostomy7 to 10 days
Gastrostomy2 to 3 weeks
Cystostomy (suprapubic)4 to 6 weeks (little evidence, varies based on provider)

References:

Witting MD. Gastrointestinal Procedures and Devices. 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.
Buscaglia  JM: Common issues in PEG tubes—what every fellow should know. Gastrointest Endosc 64: 970, 2006. [PubMed: 17140906]

Friday Board Review

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

A 40 year old female with a history of kidney stones with a left ureteral stent placed 2 years ago presents for urinary pain associated with increased urge and frequency. She denies fever or flank pain. It does not feel similar to her previous kidney stones. Vital signs are within normal limits. On exam, she is comfortable appearing and has mild suprapubic tenderness to palpation. Point-of-care pregnancy test is negative. Urinalysis results with 3+ leukocyte esterase, 2+ nitrites, and 105 WBCs/HPF. Which of the following is the appropriate management of this patient’s condition?

A: Admit for IV antibiotics

B: Consult urology for stent removal

C: CT of the abdomen and pelvis

D: Discharge with oral antibiotics

Answer: discharge with oral antibiotics

This patient is presenting with findings consistent with acute cystitis, a urinary tract infection localized to the bladder. Urinalysis findings with elevated leukocyte esterase, nitrites, and WBCs with clinical symptoms are supportive of the diagnosis. Treatment of minor urinary tract infections in patients with ureteral stents is oral antibiotics and do not require stent removal. If pyelonephritis or systemic infection with a ureteral stent is suspected, consultation with urology, IV antibiotics, and radiographic imaging to determine the location of the stent is warranted. 

References:

Askew KL. Urinary Tract Infections and Hematuria. 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; 2020.

Josephson EB, Azan B. Complications of Urologic Procedures and Devices. 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; 2020.

Friday Board Review

Board Review by Dr. Hilbmann (Edited by Dr. Parikh)

A 22 year old female G1P0 with no pmhx who presents to the Emergency Department with nausea and vomiting. The patient is 11 weeks pregnant and has experienced nausea and occasional vomiting throughout her pregnancy but for the past three days she has been progressively worse and has not been able to keep any food or liquids down without vomiting. You are given her ECG, what is a finding you are looking for due to her recent presentation?


A. Hyperacute T waves
B. Shortened PR Interval
C. Prolonged QT interval
D. ST-Elevation in aVR

Answer: C.
Due to this patient’s increased vomiting, most likely due to her pregnancy, it is possible that she may be experiencing electrolyte imbalances secondary to the loss of gastrointestinal contents. Most commonly hypokalemia, hypocalcemia, and hypomagnesemia can result from continuous vomiting. In addition to blood tests, which take time to result, the levels of these three electrolytes can be evaluated with ECG as well. Physicians should evaluate for increased p waves, prolonged PR interval, ST depression, u waves, and a prolonged QT interview.

References:
Mitchell SJ, Cox P. ECG changes in hyperemesis gravidarum. BMJ Case Rep. 2017;2017(bcr2016217158) doi: 10.1136/bcr-2016-217158.
Popa SL, Barsan M, Caziuc A, Pop C, Muresan L, Popa LC, Perju-Dumbrava L. Life-threatening complications of hyperemesis gravidarum. Exp Ther Med. 2021 Jun;21(6):642. doi: 10.3892/etm.2021.10074. Epub 2021 Apr 16. PMID: 33968173; PMCID: PMC8097228.
Image per @medicalce via Twitter

Friday Board Review

Board Review by Alex Hilbmann

Vital signs:

T: 37⁰C HR: 71 bpm O2 Sat: 100% BP: 112/92

A 29 year old female reports to the emergency department for abnormal scant vaginal bleeding. Initially, she believed that the bleeding was an early menstrual period but it has now persisted longer than her usual menses with less volume. She denies any other complaints, including pelvic pain, fevers, or vaginal discharge. Patient has attended OB/GYN appointments yearly and denies any previous history of sexually transmitted infections or abnormal pap smears. Pelvic exam reveals scant bleeding from the cervical os with no adnexal or cervical tenderness. No masses are appreciated upon palpation of bilateral adnexa. Transvaginal ultrasound reveals no intrauterine pregnancy or adnexal abnormalities. Point of care urine pregnancy test is positive. Quantitative beta-hcg results at 542 miU/mL. Vital Signs listed above. What is the next best step in management of this patient?

  1. Consultation to OB/GYN for concern of ectopic pregnancy
  2. Official transvaginal ultrasound read by Radiology
  3. Administration of methotrexate and discharge home
  4. Discharge home with 2 day OB/GYN follow up

Answer: D.

Our patient is currently experiencing scant vaginal bleeding with no findings on transvaginal ultrasound, a positive pregnancy test, and a beta hcg below 1500 miU/mL.  1500 miU/mL is what is known as the “discriminatory zone” for transvaginal ultrasound (6,000 miU/mL for transabdominal). This discriminatory zone is a level of beta-hcg which an intrauterine pregnancy (IUP) would be expected to be seen on ultrasound. When beta-hcg is above the discriminatory zone, and therefore an IUP should be visible on ultrasound, the absence of an IUP on ultrasound suggests ectopic pregnancy until proven otherwise. With this patient however, we are below the discriminatory zone and therefore the absence of IUP (with no other findings suggesting ectopic pregnancy) does not make ectopic pregnancy a more likely diagnosis than pregnancy with implantation bleeding at this time. The beta hcg of an IUP should double by two days, whereas an ectopic pregnancy would decrease less than twofold. This can be assessed by the patient’s OB/GYN at her follow up, and given the patient’s stable condition she can be discharged home.

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.615-620.

Image:

Fadial, T., 2018. Differential Diagnosis of Ultrasound in Ectopic Pregnancy. [online] Differential Diagnosis of. Available at: <https://ddxof.com/ultrasound-in-ectopic-pregnancy/?sf_action=get_data&sf_data=all&_sf_s=ectopic> [Accessed 2 October 2022].

Friday Board Review

Board Review by Dr. Hilbmann (Edited by Dr. Parikh)

A 34-year-old male with past medical history of asthma and major depressive disorder presents to the emergency department with fever, tachycardia, and right lower extremity pain and swelling. The patient was recently hospitalized for an asthma exacerbation where there was a reported MRSA outbreak. Physical examination is concerning for cellulitis of right lower extremity. Home medications include albuterol and phenelzine. Patient reports an allergy to vancomycin which results in anaphylaxis. Which of the following antibiotics should be avoided when treating this patient’s infection?

A. Daptomycin

B. Linezolid

C. Ceftaroline

D. Trimethoprim-Sulfamethoxazole

Answer: B.

This patient is on a home medication of phenelzine, an antidepressant which belongs to the Monoamine Oxidase Inhibitor (MAOI) class. MAOIs are associated with tyramine reactions, serotonin syndrome, and other medication incompatibilities. It is not only important for emergency medicine physicians to be able to recognize the presentation of the complications of this drug class, but also not to cause a harmful reaction themselves. Emergency medicine physicians should not administer meperidine, dextromethorphan, linezolid, tramadol, propoxyphene, selective serotonin reuptake inhibitors (SSRIs), or selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) to patients on MAOIs due to risk of inducing serotonin syndrome. Emergency medicine physicians should be monitoring for clonus, hyperreflexia, tremor, seizures, agitation, pressured speech, or autonomic instability in all patients on MAOIs. Treatment of serotonin syndrome involves cessation of the affected drug, cyproheptadine, hydration, cooling, and benzodiazepines for seizure management.

Patients should avoid when taking MAOisPrescribers should avoid when patients taking MAOis
WineMeperidine
CheeseDextromethorphan 
CocaineLinezolid
MDMATramadol
Propoxyphene
SSRIs
SNRIs

Resources:

Flockhart DA. Dietary restrictions and drug interactions with monoamine oxidase inhibitors: an update. J Clin Psychiatry 2012; 73 Suppl 1:17.

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.1204-1208.