A 60 year old male with a past medical history of colon adenocarcinoma presents for left leg swelling after a road trip. He denies fever, chest pain, or shortness of breath. Vital signs are within normal limits. On exam, the left lower extremity is neurovascularly intact with a palpable distal pulse. There is swelling and pitting edema of the left thigh and calf compared to the right. Compartments are soft and there is full range of motion without difficulty. Which of the following is the recommended treatment of his suspected condition?

A: Low molecular weight heparin (LWMH)

B: Rivaroxaban

C: Unfractionated heparin (UFH)

D: Warfarin

Answer: Low molecular weight heparin

This patient is likely experiencing a deep vein thrombosis of his lower extremity given his multiple risk factors and exam findings. Therapeutic anticoagulation should be initiated in the emergency department as the patient follows up outpatient. According to the American Society of Clinical Oncology guidelines, the recommended treatment of venous thromboembolism (VTE) in patients with cancer is LMWH. 

Rivaroxaban is a reasonable alternative but is associated with an increased risk of bleeding compared to LMWH. Subcutaneous UFH is not recommended for the outpatient treatment of acute VTE due to unpredictable bioavailability and effect requiring frequent monitoring. Warfarin causes an initial pro-thrombotic phase due to inhibition of protein C that would be potentially harmful in the case of active VTE which is why warfarin is typically co-administered with a secondary anticoagulant until the INR is in the desired therapeutic range for 2 consecutive days.

References:

Key NS, Khorana AA, Kuderer NM, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2020;38(5):496-520. doi:10.1200/JCO.19.01461

Kline JA. Venous Thromboembolism Including Pulmonary Embolism. 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.
Slattery DE, Pollack, Jr CV. Thrombotics and Antithrombotics. 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.

Treatment of Venous Thromboembolism in Patients with Cancer: Subgroup Analysis of the Matisse Clinical Trials, www.researchgate.net/publication/24261105_Treatment_of_venous_thromboembolism_in_patients_with_cancer_Subgroup_analysis_of_the_Matisse_clinical_trials. Accessed 19 Apr. 2024. 

A 43-year-old female with a past medical history of myasthenia gravis presents to the emergency department with shortness of breath. She was just diagnosed with a urinary tract infection and being treated by her PCP with antibiotics. Prior to her developing dyspnea, the patient also mentions experiencing blurry vision and difficulty chewing. She appears in respiratory distress on exam with an SpO2 of 83% on room air. After intubation, what is the most urgent treatment for this patient?

1. Ceftriaxone with Azithromycin
2. Methylprednisolone
3. Physostigmine
4. Plasma Exchange

Answer is D.  Given this patient’s past medical history and symptoms she is most likely in myasthenic crisis, possibly exacerbated by her recent UTI. Ceftriaxone and Azithromycin (A) which could be used to treat community acquired pneumonia would not be helpful in this patient. While corticosteroids (B) are utilized in patients with myasthenic crisis, 60-80 mg of prednisone is usually the corticosteroid of choice, this treatment would not rapidly change the patient’s clinical status. Physostigmine (C.) is an acetylcholinesterase inhibitor often utilized for anticholinergic toxicity. Pyridostigmine is an acetylcholinesterase inhibitor often used as long acting treatment for myasthenia gravis. Treatment for myasthenic crisis includes treating any contributing factors (infection), beginning rapid therapy with plasma exchange or IVIG, and high dose steroids or other immunomodulators. You may want to consider discontinuing acetylcholinesterase inhibitors medications temporarily (as they can increase respiratory secretions) until beginning immunomodulating therapy. 

References:

Wendell LC, Levine JM. Myasthenic crisis. Neurohospitalist. 2011 Jan;1(1):16-22. doi: 10.1177/1941875210382918. PMID: 23983833; PMCID: PMC3726100.

Myasthenia Gravis (no date) REBEL EM – Emergency Medicine Blog. Available at: https://rebelem.com/rebel-review/rebel-review-93-myasthenia-gravis/myasthenia-gravis/ (Accessed: 11 April 2024). 

A postpartum 34 year old female with a past medical history of hypertension presents for shortness of breath. Symptoms have been progressive over one month. She called EMS today when she was too short of breath to walk up one flight of stairs to care for her 13 week old infant. She denies fever, cough, chest pain, or recent illness and is not taking any oral contraceptives. Vital signs include Temp 99.0F, HR 96, BP 170/90, RR 22, SpO2 95% on room air. On exam, she has conversational dyspnea with no increased work of breathing. There are rales at the bilateral lung bases and 2+ pitting edema of the bilateral lower extremities. A bedside echocardiogram is notable for a dilated left ventricle with reduced ejection fraction. Which of the following is the most likely etiology of her symptoms? 

A: Cardiac infiltrative disease

B: Coronary artery atherosclerosis

C: Venous thromboembolism

D: None of the above

Answer: None of the above

This patient is likely presenting with peripartum cardiomyopathy, a rare but potentially fatal complication of pregnancy. The cause is unknown and most commonly occurs in the last month of gestation or within 5 months of delivery. The presenting symptoms and overall management of the condition are similar to other causes of congestive heart failure. Most patients will recover normal ejection fraction within the first 6 months of delivery. Ventricular dysrhythmias caused by persistent dilated cardiomyopathy may warrant an implantable defibrillator-pacemaker.

Cardiac infiltrative diseases such as amyloidosis or sarcoidosis most commonly cause diastolic dysfunction, not systolic dysfunction. Coronary artery disease is the most common cause of congestive heart failure but is unlikely in a 34 year old with minimal risk factors. A pulmonary embolism would cause right heart failure, not left ventricular systolic dysfunction.

 

Peripartum Cardiomyopathy

Most commonly occurs in last month of pregnancy or within 5 months of delivery

Dilated cardiomyopathy without previous heart disease

Treat similarly to other causes of congestive heart failure

Majority of patients recover normal ejection fraction

References:

Young JS. Maternal Emergencies After 20 Weeks of Pregnancy and in the Peripartum Period. 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.

Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016 Apr 5;133(14):1397-409. doi: 10.1161/CIRCULATIONAHA.115.020491. PMID: 27045128.

“Peripartum Cardiomyopathy – Summary 1. Definition …” GrepMed, 16 Sept. 2020, www.grepmed.com/images/10231/peripartum-treatment-diagnosis-management-cardiomyopathy. Accessed 4 Apr. 2024.

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43-year-old with woman with history of insulin dependent diabetes and HTN who presents with vision loss of her L eye. Patient states 1 day prior she initially had blurred vision, followed by sudden vision loss 2 hours after the onset of symptoms. Patient with a frontal headache but denies any weakness or numbness. Vitals are as follows: BP- 145/90; HR- 98; T- 98.7; SpO2- 98% on RA; RR- 17. Visual acuity: 20/60 on the R, 20/200 on the L. Patient with intact extra ocular movements and pupils are equal and reactive to light. Fundoscopic exam of the L eye is shown below: 

What is the diagnosis? 

1. Central retinal vein occlusion 
2. Central retinal artery occlusion 
3. Bacterial Endocarditis 
4. Diabetic Retinopathy 
5. Macular Degeneration 

Answer: A

Patient initially started with blurred vision which then progresses to sudden vision loss which is characteristic of central retinal vein occlusion whereas in central retinal artery occlusion it presents with sudden vision loss. What is pathognomonic on the fundoscopic exam is the blood and thunder appearance. Usually with retinal artery occlusion, a macular cherry red spot is seen. Cotton wool spots are pathognomonic for diabetes/HTN and Roth spots for Endocarditis. 

“Central Retinal Artery Occlusion (CRAO) vs Central …” GrepMed, 1 Oct. 2018, www.grepmed.com/images/3719/centralretinal-management-crao-crvo-ophthalmology.

Diagnosis and management of central retinal vein occlusion. (2020, May 28). American Academy of Ophthalmology. https://www.aao.org/eyenet/article/diagnosis-of-central-retinal-vein-occlusion

A 30 year old male presents with a displaced right ankle bimalleolar fracture. He is undergoing procedural sedation in the emergency department using midazolam and fentanyl for fracture-dislocation reduction. During the procedure, he becomes apneic and hypoxic. The hypoxia improves with bag valve ventilation, but he becomes progressively more difficult to ventilate. There is absence of chest rise despite increasing positive pressure. What is the likely cause of this patient’s presentation?

A: Laryngospasm

B: Musculoskeletal stiffness

B: Opioid induced hypoventilation

C: Pneumothorax

Answer: Musculoskeletal stiffness

This patient is likely experiencing Rigid Chest Syndrome, a rare but potentially fatal side effect of synthetic opioids causing skeletal muscle rigidity. The exact mechanism is unknown but is related to the dose and administration. It is commonly seen at high doses (> 3 mcg/kg of fentanyl) and with rapid IV push but has been reported with low doses as well. Treatment includes use of propofol for muscle relaxation or naloxone for reversal of opioid agonism. Neuromuscular paralysis and intubation may be required in refractory cases.

Laryngospasm is a known adverse reaction of ketamine administration which usually responds to first-line maneuvers such as jaw thrust or bag valve ventilation. Hypoventilation is a common side effect of opioids but should not cause chest wall rigidity. While uncommon, a pneumothorax may be caused by excessive positive pressure, but at least unilateral chest rise should be visualized with ventilation.

References:

Myers JG, Sutherland J. Procedural Sedation and Analgesia 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.

Çoruh  B, Tonelli  MR, Park  DR: Fentanyl-induced chest wall rigidity case report. Chest 143: 1145, 2013. [PubMed: 23546488.

Patel, Nishika. “Wooden Chest Syndrome.” CriticalCareNow, 5 Aug. 2021, criticalcarenow.com/wooden-chest-syndrome/. Accessed 22 Mar. 2024.

A 66 year old female reports to the emergency department with right arm pain after slipping on ice and trying to catch herself while falling forward. The patient is in incredible pain and has an obvious deformity of the right forearm upon presentation. An x-ray of the right forearm is shown below. What injury does the patient have?

A. Colles Fracture

B. Monteggia Fracture

C. Galeazzi Fracture

D. Smith Fracture

Answer is C. The x-ray shows a distal third radial fracture with disruption of the distal radioulnar joint space, which is a Galeazzi fracture. A Colles Fracture (A) is a distal radius fracture with dorsal displacement whereas a Smith Fracture (D) is a distal radius fracture with volar displacement. Both fractures frequently do not involve significant disruption of the radioulnar joint. A Monteggia fracture (B) is a fracture of the proximal ulna which results in radial head dislocation. For a Galeazzi fracture, the anterior osseous nerve (a branch of the median nerve) is often affected and function should be assessed by asking the patient to perform an “Okay” sign with first and second digit of affected arm.  Orthopedic Surgery consultation is necessary in adults as treatment is an open reduction and internal fixation (ORIF). If open fracture is present Cefazolin should be administered and if the wound is > 10 cm, appears contaminated, or involves seawater/freshwater/farming equipment Gentamicin should also be administered.

Picture from:

https://www.orthobullets.com/trauma/1029/galeazzi-fractures

Resources:

Atesok KI, Jupiter JB, Weiss AP. Galeazzi fracture. J Am Acad Orthop Surg. 2011 Oct;19(10):623-33. doi: 10.5435/00124635-201110000-00006. PMID: 21980027.

Garg R, Mudgal C. Galeazzi Injuries. Hand Clin. 2020 Nov;36(4):455-462. doi: 10.1016/j.hcl.2020.07.006. PMID: 33040957.

Mills, Trevor J.. “Forearm Fractures.” (2013). https://www.semanticscholar.org/paper/Forearm-Fractures-Mills/dead0398468fc50a88349251a8cb8a49b88f838f

A 28 year old male presents for finger pain. He works in construction and accidentally poked his right index finger with a stray nail a few days ago. Since then, the palmar aspect of his fingertip has become progressively more swollen and painful. Vital signs are within normal limits. On exam, the right upper extremity is neurovascularly intact with full range of motion. There is erythema, fluctuance, and severe pain to palpation over the distal pulp of his second digit. There is no pain to palpation proximally along the finger. What organism is the most common cause of this patient’s diagnosis?

A: Methicillin-resistant S. aureus (MRSA)

B: Methicillin-sensitive S. aureus (MSSA)

C: Pseudomonas aeruginosa

D: Streptococcus pyogenes

Answer: Methicillin-resistant S. aureus (MRSA)

This patient is presenting with a felon, a subcutaneous pyogenic infection of the distal finger or thumb. The infection typically results from a minor puncture wound which later becomes an abscess confined to the small compartments of the finger pad. Treatment commonly involves incision and drainage in addition to oral antibiotics. Thus, it is extremely important that the antibiotics appropriately cover MRSA as improperly treated felons may worsen to cause flexor tenosynovitis or osteomyelitis. MSSA and Streptococcus pyogenes are other common causes of felons but not as common as MRSA. Pseudomonas is not a common cause of felons.

References:

Wilson  PC, Rinker  B: The incidence of methicillin-resistant Staphylococcus aureus in community-acquired hand infections. Ann Plast Surg 62: 513, 2009. [PubMed: 19387151]  
Germann CA. Nontraumatic Disorders of the Hand. 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.

A 66 year old male with a past medical history of type 2 diabetes presents to the emergency department for head injury. He was the restrained driver when he swerved his car to avoid a child that ran into the street to retrieve a ball. He was driving approximately 15 mph in his neighborhood and swerved onto grass. He hit his head on the driver side window and complains of a headache. He was able to ambulate out of the vehicle and denies loss of consciousness, vomiting, or use of blood thinners. Vital signs are normal. On exam, he is neurologically intact and has ecchymosis to the left forehead. Which of the following is appropriate justification to obtain head imaging according to the Canadian CT Head Rule?

A: Dangerous mechanism

B: Headache

C: Patient age 

D: Rule does not apply to this patient

Answer: Rule does not apply to this patient

The Canadian CT Head Rule is a widely used clinical decision tool that emergency physicians frequently utilize to screen for significant head injuries. In the external validation trial, it was found to be 100% sensitive in detecting both clinically important brain injuries and injuries that required neurosurgical intervention. This patient does not meet the inclusion criteria for its use. If he did meet the inclusion criteria, his age would be an appropriate justification of head imaging as a high risk criteria. Headache is not part of the decision tool. His injury also does not meet the medium risk dangerous mechanism. 

MDCalc states, “Patients with minimal head injury (i.e., no history of loss of consciousness, amnesia, and confusion) generally do not need a CT scan. For example, patients over 65 years old may not need a CT scan just based on their age if they do not have the history mentioned above. When a patient fails the CCHR, use clinical judgment on whether a CT scan is necessary.”

Canadian CT Head Rule
Inclusion Criteria	Exclusion Criteria
Head injury with GCS 13-15 and at least one of the following:	Age < 16 years
Loss of consciousness	Use of blood thinners
Amnesia to head injury event	Seizure after injury
Witnessed disorientation

References:

Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. doi:10.1016/s0140-6736(00)04561-x

https://www.mdcalc.com/calc/608/canadian-ct-head-injury-trauma-rule

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.

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