Friday Board Review

Friday Board Review with Dr. Ethan Anderson

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
Friday Board Review

Friday Boad Review with Dr. Ethan Anderson

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
Friday Board Review

Friday Board Review: Peds

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

Friday Board Review

Board Review by Dr. Vidhi Parikh

12-month-old who was born full term is brought in by mom after patient was found to be cyanotic. Patient with vaccines UTD. Patient has been teething and mom notes that she has been applying benzocaine teething gel. Patient on arrival to the ER has perioral and digital cyanosis. His vital signs are as follows: T- 98.6 rectal; HR- 140; RR- 35; BP- 94/56; SpO2- 89% on RA. Patient is given blow by O2 with no improvement to oxygenation. What is the diagnosis? 

  1. Patent Foramen Ovale
  2. Aspirin Toxicity 
  3. Methemoglobinemia 
  4. Iron toxicity 
  5. Carbon monoxide poisoning 

Answer: C. Methemoglobinemia 

Patient has methemoglobinemia from the application of benzocaine for teething. Methemoglobinemia occurs when iron is oxidized from the ferrous (Fe2+) to the ferric (Fe3+) state. The ferric hemes of the methemoglobin do not bind O2. The ferric heme in the hemoglobin also has an increased affinity to O2 and therefore causes the hemoglobin dissociation curve to shift to the left causing less oxygen delivery. 

Farkas, Josh. “Methemoglobinemia.” EMCrit Project, 2 Oct. 2021, emcrit.org/ibcc/methemoglobinemia/.

Madrazo, Lorenzo. “Methemoglobinemia.” The Intern at Work, 31 Oct. 2021, www.theinternatwork.com/infographics-2/2021/10/31/methemoglobinemia.

Swaminathan, Anand. “CORE EM: Methemoglobinemia.” EmDOCs.net – Emergency Medicine Education, 28 Dec. 2018, www.emdocs.net/core-em-methemoglobinemia/. Accessed 31 May 2024.

Friday Board Review

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

A 65 year old male with a past medical history of type 2 diabetes and hyperlipidemia presents via EMS as a stroke alert. Patient developed confused speech and right upper extremity weakness 1 hour ago. Vital signs and point of care glucose are within normal limits. CT head and CTA head and neck demonstrate no acute intracranial abnormalities, and thrombolytics are administered. Ten minutes later, the patient develops rapidly progressive tongue and lip swelling. There is no response to intramuscular epinephrine. What is the likely etiology of the patient’s change in condition?

A: Hemorrhagic transformation

B: IgE-mediated hypersensitivity to thrombolytics

C: Mast cell activation from IV contrast

D: Thrombolytic side effect

Answer: D. Thrombolytic side effect

This patient is most likely experiencing orolingual angioedema, a known side effect of thrombolysis that is overall rare but in some reports has an incidence as high as 17%. It is caused by complement and kinin pathway activation by plasminogen. Patients who are already taking ACE inhibitors are at increased risk. Treatment involves discontinuing thrombolysis and managing similarly to other causes of angioedema. 

It is unlikely that intracranial hemorrhage would cause airway swelling. IgE-mediated hypersensitivity reactions require an initial sensitization exposure which makes this answer unlikely without prior administration of thrombolytics. Mast cell activation from IV contrast is possible but would likely have response to intramuscular epinephrine in addition to other physical exam findings such as urticaria or wheezing. 

References:

Go S, Kornegay J. Stroke Syndromes. 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.

https://umem.org/educational_pearls/4096/

Astin, Matt. “TPA-Associated Angioedema- Rebel EM- Emergency Medicine Blog.”REBEL EM- Emergency Medicine Blog, https://www. Facebook.com/pages/Rebel-EM/1415156522048710, 3 Apr. 2014, https://rebelem.com/tpa-associated-angioedema/.

Friday Board Review

Board Review with Dr. Kat Kaminski

A 4-month old female born at full term otherwise healthy presents to the ED after parents observed her “turning blue” and “breathing funny” for less than a minute that spontaneously self-resolved. Parents report no recent fever or illness and say this has never happened before. Upon arrival to the ED patient appears to be well appearing and in no acute distress, afebrile and with reassuring vital signs and physical exam. Parents ask if they can take her home. What do you do?

A. Tell the parents the baby needs to be admitted to the pediatric floor

B. Monitor the baby on pulse oximetry for another 2 hours and then discuss possible discharge with the parents

C. Tell the parents the baby is fine and discharge to home

D. Tell the parents the baby needs to be admitted to the PICU

Answer: Monitor the baby on pulse oximetry for another 2 hours and then discuss possible discharge with the parents

This baby presents with a BRUE, a Brief Resolved Unexplained Event (formerly known as ALTE, Apparent Life-Threatening Event) as defined by:

  • Sudden, brief, and now resolved episode of one or more of the following in an infant < 1 year age:
    • Cyanosis or pallor
    • Absent, decreased, or irregular breathing
    • Marked change in tone (hyper- or hypotonia)
    • Altered responsiveness
    • No explanation for the event after full history and exam

And according to the most recent American Academy of Pediatrics guidelines, this patient is considered low risk according to the following criteria:

  • Age >60 days
  • Born >= 32 weeks’ gestation and corrected gestational age >=45 weeks
  • No CPR by trained medical provider
  • Event lasted <1 minute
  • First event

Therefore, this low risk patient may be safely discharged home with close pediatrician follow up after a period of observation and education provided to the parents about BRUEs. This is different than past practice where nearly all patients with BRUEs (then called ALTEs) were hospitalized. It should be noted that BRUEs can be related to a range of conditions both benign and more concerning. Possible etiologies include GERD, breath-holding spells, non-accidental trauma, and serious bacterial infection. The risk of a serious disorder presenting as a BRUE is unknown, therefore a thorough history and physical exam is essential.

References:

Joel S. Tieder, Joshua L. Bonkowsky, Ruth A. Etzel, Wayne H. Franklin, David A. Gremse, Bruce Herman, Eliot S. Katz, Leonard R. Krilov, J. Lawrence Merritt, Chuck Norlin, Jack Percelay, Robert E. Sapién, Richard N. Shiffman, Michael B.H. Smith, for the SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS, Pediatrics May 2016, 137 (5) e20160590; DOI: 10.1542/peds.2016-0590

Friday Board Review

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

A 40 year old female with a history of hyperlipidemia presents for abdominal pain. She has been having intermittent pain in her right upper quadrant after meals without vomiting or change in her bowel habits. Vital signs are within normal limits. She has mild tenderness to palpation to the right upper quadrant on exam with a negative Murphy’s sign. Point of care pregnancy test is negative. Her workup including CBC, BMP, LFTs, and lipase are unremarkable. A right upper quadrant ultrasound demonstrates numerous gallstones without evidence of cholecystitis. Which of the following is recommended for first line treatment of this patient’s suspected condition?

A: Acetaminophen

B: Gabapentin

C: Ketorolac

D: Morphine

Answer: Ketorolac

This patient is presenting with biliary colic which occurs by a gallstone causing periodic obstruction of the cystic duct. Management includes symptom control and outpatient surgical referral for cholecystectomy. NSAIDs are first line therapy. When administered parenterally, NSAIDs have similar analgesic effect compared to opioids for biliary colic. In addition, NSAIDs reduce the rate of short term complications such as acute cholecystitis. 

Acetaminophen is an antipyretic that has analgesic properties but is not first line for biliary colic. Gabepentin is typically used for neuropathic pain such as diabetic neuropathy or shingles. Opioids such as morphine are reserved for when NSAIDs are not effective in reducing pain but are not first line due to safety and side effects such as hypoventilation. It is known that opioids cause sphincter of Oddi spasm, but the clinical significance of this is unclear. 

References:

Besinger B, Stehman CR. Pancreatitis and Cholecystitis. 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.

Colli  A, Conte  D, Valle  SD, Sciola  V, Fraquelli  M: Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic. Aliment Pharmacol Ther 35: 1370, 2012. [PubMed: 22540869]

Friday Board Review

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

A 72 year old male with a past medical history of Parkinson’s disease and type 2 diabetes presents for progressive cough and shortness of breath for 3 days. Vitals include Temp 100.8F, HR 110, BP 126/80, RR 22, SpO2 89% on room air. Lung sounds are notable for crackles in the lower right lung. A chest x-ray shows focal consolidations of the right middle and right lower lobes with a moderate sized right pleural effusion. Aspiration of the pleural effusion demonstrates grossly purulent fluid with a pleural pH of 7.1. Which of the following antibiotic regimens is NOT appropriate for initial treatment of this patient’s condition?

A: Ampicillin & gentamicin

B: Cefepime & metronidazole

C: Ceftriaxone & ampicillin-sulbactam

D: Vancomycin & piperacillin-tazobactam

Answer: Ampicillin & gentamicin

This patient is presenting with pneumonia complicated by an empyema based on the pleural fluid findings. The initial treatment of an empyema consists of drainage with broad spectrum antibiotics that will cover Staphylococcus and anaerobes. Ampicillin has poor sensitivity against Staphylococcus and weak coverage of gram-negative organisms. Gentamicin is a potent aminoglycoside with good sensitivity against MSSA and gram-negatives but has poor anaerobic coverage. In addition, aminoglycosides have poor penetration into the pleural space. 

Cefepime, ceftriaxone, ampicillin-sulbactam, piperacillin-tazobactam have good sensitivity against MSSA. Vancomycin has additional coverage against MRSA. Metronidazole, ampicillin-sulbactam, and piperacillin-bactam have good coverage of anaerobic organisms.

Diagnostic Criteria for EmpyemaLight Criteria for Exudative Pleural Effusion (requires 1 of the following)
Aspiration of grossly purulent fluid plus one of the following:Pleural protein/serum protein > 0.5
    Positive gram stain or culturePleural LDH/serum LDH > 0.6
    Pleural fluid glucose < 40Pleural LDH > 2/3 upper limit of normal serum LDH
    Pleural pH < 7.2
    Pleural LDH > 1000

References:

Mace SE, Anderson E. Lung Empyema and Abscess. 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.

Vaudaux P, Waldvogel FA. Gentamicin inactivation in purulent exudates: role of cell lysis. J Infect Dis. 1980;142(4):586-593. doi:10.1093/infdis/142.4.586

Friday Board Review

Board Review by Dr. Christine Collins

A 60 year old male presents to the hospital in cardiac arrest. After recognition of ventricular fibrillation, you successfully achieve ROSC with early CPR and defibrillation. The patient remains comatose. What is recommended post-resuscitation for this patient?

A: Maintain temperature at 30 degrees Celsius for 24 hours

B: Obtain and electroencephalogram

C: Targeted glucose range 90-130

D: Maintain oxygen saturation at 100%

Answer: Obtain an electroencephalogram

After cardiac arrest, the American Heart Association recommends early coronary artery catheterization (if suspected cardiac etiology), maintenance of hypothermia (between 32 and 36 degrees for 24 hours), controlled reoxygenation >94%, and avoidance of hypotension. For comatose patients, it’s recommended to obtain EEG to assess for subclinical seizure. About 12-22% of patient’s after cardiac arrest that remain comatose have epileptiform activity, and this can lead to worsening neurologic outcomes if not detected.

References: 

Callaway CW, Donnino MW, Fink EL, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S465–82.

Krumholz A, Stern BJ, Weiss HD. Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus. Neurology 1988; 38:401.

Friday Board Review

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

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.