A 50 year old male presents with 4 weeks of diarrhea and associated abdominal pain described as cramping. He reports multiple episodes of pale, loose and malodorous stools daily. He recently went fishing. His vitals are as followed: 70 bpm, BP: 125/80, RR 18, PO2: 98%. Temp 37.2. What vitamin deficiency would you worry about in this patient?

A. Vitamin

B. Niacin

C. Vitamin C

D. Riboflavin

Answer: Riboflavin

This patient is presenting with signs and symptoms consistent with giardiasis. Patients can have malabsorption and steatorrhea, and chronic infection can result in deficiency of fat soluble vitamins A, D, E, and K.  Malabsorption can also lead to deficiency in Vitamin B12 and folate.

Giardiasis is the most common cause of parasitic diarrheal infection in the US and is transmitted by fecal-oral route. It is associated with streams and daycares. Classic symptoms include, colicky abdominal pain and pale, loose, malodorous stools. Treatment is metronidazole.  

References: 

Singh KD, Bhasin DK, Rana SV, et al. Effect of Giardia lamblia on duodenal disaccharidase levels in humans. Trop Gastroenterol 2000; 21:174.

Bjoernsen, L. P., & Ebinger, A. (2016). Chapter 159 Foodborne and Waterborne Diseases In Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (8th ed). New York, NY: McGraw-Hill Education.

A 45 year old male with a history of autism, depression, and epilepsy presents for an overdose. He was found in his bedroom obtunded by family with empty pill bottles. His medication list includes valproic acid and fluoxetine. He was intubated by EMS for airway protection. His vital signs include Temp 98.0F, HR 108, BP 100/60, RR 16, SpO2 99% on 40% FiO2. On exam, he has a GCS of E1 V1T M4 with minimal sedation. Pupils are equal and reactive to light. There is no rigidity or clonus. Labs are notable for elevated LFTs and ammonia. Which of the following medications should be used for the treatment of this patient’s suspected overdose?

A: Cyproheptidine

B: Levo-carnitine

C: Meropenem

D: B & C

Answer: B & C (Levo-carnitine & Meropenem)

This patient’s presentation is consistent with valproic acid overdose. The most common exam finding is CNS depression which can range from drowsiness to coma. Serotonin syndrome classically presents with hyperthermia and clonus. Treatment of serotonin syndrome typically includes supportive care with benzodiazepines and cyproheptadine with consultation of a toxicologist. Treatment of valproic acid toxicity includes GI decontamination and levo-carnitine as it can increase metabolism of valproic acid, hasten resolution of coma, and prevent hepatic dysfunction. Newer studies have shown that concomitant use of carbapenems (specifically meropenem) with valproic acid causes drug-drug interactions that lead to decreased serum valproic acid concentrations. Dialysis can be considered for severe overdoses with hemodynamic instability or acidosis that does not respond to initial therapy.

References:

LoVecchio F. Anticonvulsants. 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. 

Al-Quteimat O, Laila A. Valproate Interaction With Carbapenems: Review and Recommendations. Hosp Pharm. 2020;55(3):181-187. doi:10.1177/0018578719831974Al-Quteimat, O., & Laila, A. (2020). Valproate Interaction With Carbapenems: Review and Recommendations. Hospital pharmacy, 55(3), 181–187. https://doi.org/10.1177/0018578719831974

Special shoutout to our ED pharmacists that educated us on this topic!

A 13 year old male presents to the emergency department for 2 days of abdominal pain and diarrhea. He has no past medical or surgical history other than a tooth extraction for which he recently completed a week of clindamycin. The abdominal pain is generalized and associated with greater than 5 episodes of watery diarrhea daily. He denies any vomiting or recent travel. Vitals signs are: HR 120, BP 108/60, T 38.3 C, RR 20, SpO2 99% RA. On exam, he is tired but non-toxic appearing and not in acute distress. Mucous membranes are dry, and his cap refill is between 2 to 3 seconds. His abdomen is minimally tender to palpation diffusely with no guarding or rigidity. IV access is obtained and fluid resuscitation is started. What is the appropriate antibiotic treatment for this patient’s suspected condition?

A: IV vancomycin and cefepime

B: PO metronidazole

C: PO vancomycin

D: PO vancomycin and IV metronidazole

Answer: PO metronidazole

This patient’s fever, abdominal pain, and profuse diarrhea in the setting of recent antibiotic use is worrisome for Clostridium difficile (C. Diff) infection. Oral metronidazole is the treatment of choice in mild to moderate cases of pediatric C. Diff colitis. It is first-line due to being less expensive than vancomycin and avoids the potential risk of developing vancomycin-resistant enterococci. IV vancomycin and cefepime are broad spectrum agents commonly used in sepsis but are not preferred for suspected C. Diff colitis. In addition, the combination lacks anaerobic coverage for gastrointestinal infections. PO vancomycin with or without IV metronidazole is reserved for recurrent or severe infection which includes hypotension, ileus, or inability to tolerate PO antibiotics. 

Pediatric Clostridium Difficile Colitis Treatment
All patients	Fluid resuscitation and electrolyte repletion Discontinue offending antimicrobial agents if possible
Mild to moderate disease	PO metronidazole
Severe disease	PO or rectal vancomycin + IV metronidazole

References:

Freedman S.B., & Thull-Freedman J (2020). Vomiting, diarrhea, and dehydration in 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.

A 60 year old male with a history of poorly controlled type 2 diabetes, hypertension, and hyperlipidemia presents for right foot pain. He noticed a few weeks ago that he developed a wound on the sole of his right foot which hurts with pressure. He denies any injury to the area or fevers. Vitals are within normal limits. Exam is notable for a shallow based ulcer with clean margins and no active drainage on the sole of his right foot. Which of the following positive physical exam findings, laboratory test, or imaging study has the highest positive likelihood ratio for osteomyelitis in this patient?

A: ESR > 70

B: MRI

C: probing to bone

D: ulcer area > 2 cm²

Answer: ESR > 70

This patient is presenting with a diabetic foot ulcer, a common complication of poorly controlled diabetes. While many physical exam features such as fever, pain, or purulence may be suggestive of osteomyelitis, an accurate diagnosis remains a challenge especially with co-existing diabetic neuropathy and blunted immune responses from diabetes. Although it is a non-specific marker of inflammation, an ESR > 70 mm/h has the highest likelihood ratio of osteomyelitis compared to other exam, laboratory, and imaging investigations as shown in the table below. This emphasizes the sensitivity and diagnostic utility of obtaining an ESR level in the emergency department to investigate for osteomyelitis in patients with diabetic foot ulcers. The gold standard test to diagnose osteomyelitis is a bone biopsy.

Positive Finding	Positive LR (95% CI)	Negative LR (95% CI)
Ulcer area > 2 cm²	7.2 (1.1 – 49)	0.48 (0.31 – 0.76)
“Probe to bone”	6.4 (3.6 – 11)	0.39 (0.20 – 0.76)
ESR > 70 mm/h	11 (1.6 – 79)	0.34 (0.06 – 1.90)
Plain radiograph	2.3 (1.6 – 3.3)	0.63 (0.51 – 0.78)
MRI	3.8 (2.5 – 5.8)	0.14 (0.08 – 0.26)

References:

Jalili M, Niroomand M. Type 2 Diabetes Mellitus. 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.

Mandell  JC, Khurana  B, Smith  JT, Czuczman  GJ, Ghazikhanian  V, Smith  SE: Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. Emerg Radiol 2017 Oct 20. doi: 10.1007/s10140-017-1564-9. [Epub ahead of print] [PubMed: 29058098]

A 30 year old female with a history of type 1 diabetes and past hospitalizations for diabetic ketoacidosis presents via EMS for altered mental status. History is limited as patient is altered and not answering questions appropriately. Vitals include Temp 100.4F, HR 116, BP 102/70, RR 30, SpO2 98% on room air. Exam shows an ill-appearing female with Kussmaul respirations and a non-focal neurologic exam. Labs are notable for 20K WBCs and serum glucose of 400. A lumbar puncture is performed to assess for meningitis. For this patient, which of the following CSF glucose values is within normal limits?

A: 60 mg/dL

B: 100 mg/dL

C: 260 mg/dL

D: 400 mg/dL

Answer: 260 mg/dL

This patient is presenting with signs and symptoms of diabetic ketoacidosis. While it is critical for the emergency physician to treat the hyperglycemia with volume resuscitation and insulin, it is also paramount to investigate for underlying causes such as infection. The glucose level in CSF is proportional to serum glucose values and should correspond to approximately 60-70% of serum glucose values. Thus, a CSF glucose value of 60 or 100 mg/dL in this patient is lower than expected and concerning for bacterial CNS infection. Higher than expected CSF glucose levels are non-specific and generally do not exceed 300 mg/dL.

References:

Lillian A. Mundt; Kristy Shanahan (2010). Graff’s Textbook of Routine Urinalysis and Body Fluids. Lippincott Williams & Wilkins. p. 237. ISBN 978-1582558752.

Seehusen DA, Reeves MM, Fomin DA (September 2003). “Cerebrospinal fluid analysis”. Am Fam Physician. 68 (6): 1103–8. PMID 14524396

A 74 year old male with a past medical history of advanced dementia and type 2 diabetes presents via EMS from his long term advanced care facility for cough and shortness of breath. Patient is AOx1 and intermittently follows commands at baseline. EMS reports that the facility nurse noticed that he was hypoxic and had a “nasty cough.” Vitals include Temp 100.6F, HR 110, BP 126/80, RR 22, SpO2 89% on room air. Exam shows a chronically ill, pale appearing older male in mild respiratory distress with a productive cough. Lung sounds are notable for crackles in the lower right lung. A chest x-ray demonstrates focal consolidations of the right middle and right lower lobes with a moderate sized pleural effusion above the right hemidiaphragm. Which of the following laboratory values is NOT part of the diagnostic criteria for an empyema?

A: pleural gram stain of culture

B: pleural LDH

C: pleural pH

D: pleural protein

Answer: pleural protein

This patient is presenting with pneumonia demonstrated by imaging results consistent with the clinical findings of fever, cough, and hypoxia. Pneumonia is the most common cause of an empyema which has specific diagnostic criteria distinct from the Light Criteria for pleural effusions. Approximately 40% of cases have negative cultures. Treatment is drainage and broad spectrum antibiotics with anaerobic coverage.

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; 2020.

Birkenkamp  K, O’Horo  JC, Kashyap  R,  et al: Empyema management: a cohort study evaluating antimicrobial therapy. J Infect 72: 537, 2016.

An 8 month old male born at 36 weeks without any complications with no medical problems who presents with wheezing, increased work of breathing, rhinorrhea and cough for the past 2 days. On exam, he has a low grade temperature, wheezing in all lung fields, subcostal retractions and nasal flaring. HR is 156 bpm, RR 70, Oxygen saturation is 90% on room air. Mother says other siblings in the house have had a cold the past few days. What is the next step in the management of this patient?

a. Administer IV dexamethasone

b. Administer broad spectrum IV antibiotics

c. Admit with supportive measures

d. Administer inhaled corticosteroids

Answer: Admit with supportive measures

This patient is presenting with acute signs and symptoms of bronchiolitis which include rhinorrhea, cough, wheezes, cough, crackles, use of accessory muscles, and nasal flaring. Babies born prematurely are at increased risk for severe bronchiolitis. Clinically, bronchiolitis occurs primarily <2 years of age, with a peak presentation between 6 and 12 months. 

Treatment for bronchiolitis includes supportive care measures: nasal suctioning and saline drops, oxygen, isotonic fluids, and ventilatory support if needed. Consider hospitalization if persistent increased work of breathing, inability to maintain hydration/feeding, or hypoxia. Beta agonists can be trialed if the patient has a family history suggestive of asthma or atopy. Corticosteroids are not recommended for routine use.

References:

Bjoernsen, L. P., & Ebinger, A. (2016). Chapter 124 Wheezing in Infants and Children In Tintialli’s Emergency Medicine: A Comprehensive Study Guide (8th ed). New York, NY: McGraw-Hill Education.

Cade A, Brownlee KG, Conway SP, et al. Randomised placebo controlled trial of nebulised corticosteroids in acute respiratory syncytial viral bronchiolitis. Arch Dis Child 2000; 82:126

A 30 year old non-pregnant female presents after a cat bite to her left hand. Vitals are within normal limits. The extremity is neurovascularly intact and shows two subcentimeter punctate lesions on the palmar surface of her hand. She reports an anaphylactic reaction to penicillin. Which of the following antibiotics is appropriate prophylactic treatment for this patient?

A: amoxicillin-clavulanate

B: clindamycin

C: cephalexin

D: doxycycline

Answer: doxycycline

Prophylactic antibiotic treatment is common practice of mammalian bites in the ED. Antibiotics should be tailored for coverage of streptococcal and staphylococcal bacteria as well as anaerobes and Pasteurella multocida. Amoxicillin-clavulanate is typically the antibiotic of choice but is contraindicated in patients with an anaphylactic allergy to penicillin. Clindamycin or cephalexin monotherapy do not reliably cover Pasteurella species. Doxycycline or dual therapy with clindamycin plus TMP-SMX or a fluoroquinolone are reasonable alternatives for penicillin-allergic patients.

References:

Quinn J (2020). Puncture wounds and bites. 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.

Presutti R. J. (2001). Prevention and treatment of dog bites. American family physician, 63(8), 1567–1572.

You are asked to see a patient with a known history of Left Ventricular Assist Device (LVAD) due to end stage heart failure who presents after becoming more confused in the Emergency Department waiting room. Per family the patient was originally presenting due to feeling lightheaded/fatigued recently. The patient does not have a pulse and the automatic/manual blood pressure cuff does not determine a blood pressure. Patient cannot follow commands but localizes to pain in all four extremities. Capillary refill < 2 seconds. What should be done next?

A. Begin chest compressions

B. Auscultate heart

C. Point of care echocardiogram

D. Portable CXR

Answer: Auscultate heart

The first thing that should be done for this patient is auscultate his heart to note if an audible “whirr” is present. If it is present, this would indicate that his LVAD is in fact operating. Patients who have an LVAD do not have a palpable pulse/blood pressure therefore in this population it does not indicate that their LVAD is currently not working/they are not perfusing. An ultrasound with doppler may be used to obtain a blood pressure reading. Chest compressions should be withheld until absolutely necessary given the chance to potentially dislodge the LVAD causing dysfunction or left ventricular rupture. The chance of chest compressions causing damage to LVAD can be minimized by paying attention to positioning of compressions and avoiding unnecessarily deep compressions. It would be reasonable to begin compressions if low perfusion state suggested by exam (mental status change, skin mottling, capillary refill >2 seconds). Auscultation of the heart would be the most timely and effective method in recognizing functionality of patient’s LVAD. Given patient’s exam concerning for altered mental status without other findings for low perfusion, CPR can briefly be held until further evaluation determines concern for hypoperfusion.

References:

Guglin, Maya (2018) “Approach to Unresponsive Patient with LVAD,” The VAD Journal: Vol. 4, Article 2.
DOI: https://doi.org/10.13023/VAD.2018.02
Available at: https://uknowledge.uky.edu/vad/vol4/iss1/2

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.382

Yuzefpolskaya M, Uriel N, Flannery M, Yip N, Mody K, Cagliostro B, Takayama H, Naka Y, Jorde UP, Goswami S, Colombo PC. Advanced cardiovascular life support algorithm for the management of the hospitalized unresponsive patient on continuous flow left ventricular assist device support outside the intensive care unit. Eur Heart J Acute Cardiovasc Care. 2016 Dec;5(8):522-526. doi: 10.1177/2048872615574107. Epub 2015 Mar 4. PMID: 25740223.

A 30 year old male with a history of active IVDU and previous MRSA endocarditis is presenting with tooth pain that has been worsening over several days. He denies fever, chest pain, or shortness of breath. Vital signs are: Temp 99.0F, HR 86, BP 148/76, RR 16, SpO2 98% RA. Exam shows track marks in the antecubital fossas bilaterally and no appreciable cardiac murmur. He has poor dentition overall with an appreciable area of fluctuance above the gums of tooth #4. Which of the following is appropriate management for this patient?

A: administer IV vancomycin followed by ED incision and drainage then discharge

B: consult oral maxillofacial surgery for drainage

C: draw blood cultures and admit for IV antibiotics

D: perform ED incision and drainage and discharge with clindamycin

Answer: administer IV vancomycin followed by ED incision and drainage then discharge

Patients with a history of prosthetic heart valves or infective endocarditis among other cardiac conditions are considered high-risk for developing endocarditis with dental procedures and surgical procedures on infected skin. In this patient, incision and drainage of the periapical abscess should be performed 30 to 60 minutes after receiving a dose of antibiotics with coverage against MRSA. OMFS does not need to be consulted for abscess drainage. There are no systemic symptoms such as fever at this time to suggest bacteremia for admission. 

References:

Brenner D, & Marco C.A., & Rothman R.E. (2020). Endocarditis. 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.