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]

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 Empyema	Light 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 culture	Pleural LDH/serum LDH > 0.6
Pleural fluid glucose < 40	Pleural 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

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.

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.