A 50 year old male with past medical history of hypertension, type 2 diabetes, and coronary artery disease with multiple prior stents presenting with shortness of breath and fatigue. Vitals demonstrate BP 70/50, HR 79 bpm, RR 26, O2 sat 88% on room air, Temp 36C. On exam, the patient has bilateral rales and 2+ pitting edema. Heart sounds are muffled. Distal pulses are weak, and extremities are cool to the touch. Bedside echocardiogram demonstrates significantly decreased cardiac output with minimal ventricular wall motion. EKG demonstrates ST elevations in anterior leads. What is the most appropriate vasopressor to initiate at this time?

A: dobutamine

B: dopamine

C: epinephrine

D: norepinephrine

E: phenylephrine

Answer: norepinephrine

This patient is demonstrating signs of cardiogenic shock in the setting of acute myocardial infarction. The most common cause of cardiogenic shock is acute ischemia. Other causes include valvular malfunctions, ventricular septal defect, ventricular free-wall rupture, right ventricular infarction, myocarditis, septic shock, arrhythmia, toxicity. The initial step in this case is correction of acute ischemia by activating the cath lab or thrombolytics depending on your facility. In regards to vasopressors, studies have demonstrated norepinephrine is most beneficial in patients with profound hypotension. Dopamine was traditionally used, however, it may increase heart rate and worsen cardiac demand. Epinephrine should be avoided if possible due to increased vasoconstriction with ischemia and arrhythmias. Dobutamine has inotropic effects that are beneficial for cardiac output but does not improve systemic vascular resistance. The combination of norepinephrine and dobutamine may be considered as well. 

Overview of Vasopressors by Dr. Rachel Jennings and Dr. Haney Mallemat

References:

Hochman JS, Buller CE, Sleeper LA, et al. Cardiogenic shock complicating acute myocardial infarction–etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?. J Am Coll Cardiol. 2000;36(3 Suppl A):1063-1070. doi:10.1016/s0735-1097(00)00879-2

A 70 year old male with a past medical history coronary artery disease, heart failure with reduced ejection fraction, and severe aortic stenosis presents via EMS for shortness of breath. History is limited due to acute respiratory distress while patient is on CPAP. Vital signs are: BP 88/60, HR 120, T 36.7, RR 30, SpO2 90% on PEEP 8 and FiO2 100%. On exam, he is in severe respiratory distress with accessory muscle usage and speaks in 2 word phrases. There is a prominent systolic ejection murmur over the right second intercostal space. Rales are heard at the lung bases bilaterally, and there is 4+ pitting edema of the lower extremities. EKG shows sinus tachycardia. Which of the following is the preferred resuscitation strategy to optimize hemodynamics prior to intubation? 

A: bolus 1 liter isotonic fluids

B: epinephrine infusion 

C: norepinephrine infusion

D: phenylephrine infusion

E: push dose epinephrine prior to induction

Answer: phenylephrine infusion

This patient is presenting in acute hypoxic respiratory failure likely secondary to pulmonary edema related to acute on chronic heart failure. Patients with severe aortic stenosis are preload dependent to maintain coronary and systemic perfusion. Thus, typical management with positive airway pressure and nitrates should be used cautiously. In hypotensive patients with aortic stenosis, phenylephrine is the vasopressor of choice due to its pure alpha-1 agonist effects to increase diastolic blood pressure and coronary perfusion. Reflex bradycardia is also beneficial to allow for more diastolic filling time. Inotropes such as epinephrine are not recommended due to tachycardia and increased myocardial oxygen demand. Norepinephrine is a reasonable alternative but not the preferred agent. Fluid administration is likely to worsen this patient’s hemodynamics and respiratory status by volume overload.

References:

Goertz AW, Lindner KH, Schutz W, Schirmer U, Beyer M, Georgieff M. Influence of phenylephrine bolus administration on left ventricular filling dynamics in patients with coronary artery disease and patients with valvular aortic stenosis. Anesthesiology. 1994;81(1):49-58.

A 64 year old male with a past medical history of diabetes mellitus, coronary artery disease, and congestive heart failure is being evaluated for chest pain. His initial vital signs are within normal limits. His EKG is unchanged from previous showing a narrow-complex sinus rhythm. While he is in the emergency department, he reports feeling palpitations. The cardiac monitor records a monomorphic, wide-complex tachycardia at a rate of 140 beats/minute while his blood pressure is 132/80. What is the first-line medication for treatment of this patient’s condition?

A: adenosine

B: amiodarone

C: epinephrine

D: magnesium sulfate

E: procainamide

Answer: procainamide

This patient with a history of extensive cardiac disease is likely experiencing stable ventricular tachycardia (VT). The PROCAMIO study in 2017 demonstrated that procainamide is likely superior to amiodarone for termination of wide-complex tachycardia and associated with fewer major adverse cardiac events. Adenosine is commonly used in the management of supraventricular tachycardias but is unlikely to terminate a tachycardia of ventricular origin. Epinephrine is used for pulseless VT as part of the ACLS algorithm. Magnesium sulfate is used for polymorphic VT also known as Torsades De Pointes but is not first-line for monomorphic VT.

References:

Ortiz, M., Martín, A., Arribas, F., Coll-Vinent, B., Del Arco, C., Peinado, R., Almendral, J., & PROCAMIO Study Investigators (2017). Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. European heart journal, 38(17), 1329–1335. https://doi.org/10.1093/eurheartj/ehw230

A 28 year old female G4P2 at 8 weeks gestation presents to the Emergency Department after vomiting almost four times daily for the past week. She denies any recent fevers, abdominal pain, pelvic pain, or vaginal bleeding. Vital signs include: Temp 37.2 C, HR 105, BP 93/62, SpO2 100%. On exam, she is uncomfortable appearing with dry mucous membranes and intermittently dry heaving into an emesis bag. Blood serum results are pending. Urinalysis reveals 1+ ketones with elevated specific gravity. What is the next best step in management?

A. 0.9% normal saline

B. Prophylactic electrolyte repletion

C. 5% dextrose and 0.9% normal saline

D. Antiemetic and PO challenge

Answer: 5% dextrose and 0.9% normal saline

This pregnant patient is most likely experiencing hyperemesis gravidarum given her presentation of multiple episodes of vomiting, volume depletion, and ketonuria. The treatment for hyperemesis gravidarum includes 5% glucose in IV fluids, anti-emetic drugs, and correction of any electrolyte abnormalities. Nothing should be given by mouth until patient’s nausea is controlled, and although this patient will ultimately benefit from antiemetic administration with the hopes that she will tolerate PO, her signs of volume depletion and ketonuria suggest immediate treatment with 5% dextrose in 0.9% normal saline or lactated ringer solution.

Management of Hyperemesis Gravidarum

First line: pyridoxine (vitamin B6) – pregnancy drug class A

Add on: doxylamine – pregnancy drug class A

Adjuncts: ondansetron, metoclopramide – pregnancy drug class B

IV fluids with dextrose

References:

References: 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.621-622.

Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 153. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 126(3):e12-24

A professional football player has a helmet-to-helmet collision with an opposing player. He falls to the ground and has a one minute episode during which he is posturing with his upper extremities flexed and lower extremities extended. His eyes are open and blinking. Teammates gather around him and he is muttering “chicken nuggets, chicken nuggets”. What is his Glasgow Coma Scale score during this time?

A: 8

B: 9

C: 10

D: 11

Answer: 10 (E4 V3 M3)

Eye Opening	Verbal Response	Best Motor Response
1 – None	1 – None	1 – None
2 – To pain	2 – Incomprehensible sounds	2 – Extensor or decerebrate posture
3 – To sound	3 – Inappropriate words	3 – Flexor or decorticate posture
4 – Spontaneous	4 – Confused but answers questions	4 – Withdraws from pain
	5 – Oriented	5 – Localizes pain (crosses midline)
		6 – Obeys commands

References:

Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-84. doi:10.1016/s0140-6736(74)91639-0

Cameron P.A., & Knapp B.J., & Teeter W (2020). Trauma in adults. 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 19 year old male with no past medical history is brought in by EMS due to a report from his college roommate for strange activity. Over the last week, the patient has skipped all of his classes and barricaded himself in his room. He states that the FBI is tracking him and plan to kidnap him. Vitals are within normal limits. Exam shows a disheveled appearing male. He eventually attempts to run out of the emergency department but is tackled by security. Verbal de-escalation is not successful. Which of the following intramuscular medications is contraindicated for the management of this patient? 

A: haloperidol

B: ketamine

C: lorazepam

D: olanzapine

Answer: ketamine

This patient presenting with disorganized behavior and paranoid delusions is concerning for an acute psychotic episode. Ketamine is an agent commonly used for sedation that is absolutely contraindicated in patients with known or suspected schizophrenia even if it is currently well controlled due to the risk of emergence reactions and worsening psychosis. Haloperidol, olanzapine, lorazepam are agents commonly used for the management of acute psychosis and agitation.

Ketamine for Procedural Sedation or Agitation
Contraindications	Allergy to drug Age < 3 months old Known or suspected schizophrenia
Dosing	1-2 mg/kg IV 4-6 mg/kg IM
Adverse effects	Laryngospasm or apnea associated with rapid push Nausea & vomiting Emergence reaction

References:

Ali S, & Poonai N (2020). Pain management and procedural sedation for 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.

Myers J.G., & Kelly J (2020). Procedural sedation and analgesia in adults. 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.

Wilson M (2020). Acute agitation. 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 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.

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.

A ten year old male with no past medical history presents after a witnessed fall. He was attempting a kickflip on his skateboard when he fell backwards hitting his head. His friends state he lost consciousness for about two seconds immediately following the event. He was wearing a helmet. The patient reports feeling better now with only mild pain to palpation at his occiput. He denies vomiting. His vitals are normal for his age. Exam shows no obvious signs of injury, and he is neurologically intact, eating and ambulating without difficulty. According to the PECARN Pediatric Head CT rule, what is the appropriate management of this patient?

A: discharge now

B: observe for 2 hours and discharge if he remains asymptomatic

C: observe for 4 hours and discharge if he remains asymptomatic

D: obtain CT head

Answer: observe for 4 hours and discharge if he remains asymptomatic

The PECARN Pediatric Head CT rule is a widely accepted decision tool with sensitivities nearing 100% for detecting clinically important traumatic brain injury in children. This patient does not meet criteria for immediate CT imaging such as altered mental status, GCS < 15, or signs of basilar skull fracture. Due to the history of loss of consciousness, it is recommended to observe the patient in the ED for 4 to 6 hours for any signs of deterioration prior to discharge. It is important to distinguish length of LOC in age groups <2 and ≥2 years old.

References:

Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Jr, Atabaki, S. M., Holubkov, R., Nadel, F. M., Monroe, D., Stanley, R. M., Borgialli, D. A., Badawy, M. K., Schunk, J. E., Quayle, K. S., Mahajan, P., Lichenstein, R., Lillis, K. A., Tunik, M. G., Jacobs, E. S., Callahan, J. M., Gorelick, M. H., … Pediatric Emergency Care Applied Research Network (PECARN) (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet (London, England), 374(9696), 1160–1170. https://doi.org/10.1016/S0140-6736(09)61558-

Image from: https://www.aliem.com/pecarn-relevance-importance-pediatric-emergency-care/pecarn-head-injury-both-infographics/

A thirty year old female with a history of poorly controlled type 1 diabetes and gastroparesis presents for 1 day of severe abdominal pain, nausea, and vomiting. The patient states that she cannot keep anything down including fluids and has been vomiting all day. Her last bowel movement was today. She denies missing any insulin doses. Vital signs are: Temp 98.2F, HR 98, BP 130/80, RR 18, SpO2 98% RA. POC glucose is 182. She appears to be in obvious discomfort and is pacing circles in the room as well as intermittently dry heaving into an emesis bag. Her abdomen is soft but she notes tenderness to palpation diffusely, worst over the epigastric area. Which of the following medications has been shown to decrease need for admission and additional analgesic administration for patients with this condition?

A: erythromycin

B: haloperidol

C: hydromorphone

D: metoclopramide

E: odansetron

Answer: haloperidol

Gastroparesis is a chronic disorder characterized by delayed gastric emptying without a mechanical obstruction. It is commonly associated with diabetes although a considerable percentage of cases are idiopathic. In a 2017 observational study, haloperidol was shown to have a significant decrease in the rate of admission and analgesia administration in patients with gastroparesis. Odansetron, metoclopramide, and erythromycin are anti-emetics and prokinetic agents for gastroparesis but have no proven benefit in admission rates and pain control. Hydromorphone is a potent analgesic but has no anti-emetic properties and has a common side effect of nausea. 

Management of Gastroparesis

IV fluids, electrolyte repletion Anti-emetics: haloperidol, odansetron, metoclopramide Prokinetics: metoclopramide, erythromycin Glycemic control Identifying triggers

References:

Ramirez, R., Stalcup, P., Croft, B., & Darracq, M. A. (2017). Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. The American journal of emergency medicine, 35(8), 1118–1120. https://doi.org/10.1016/j.ajem.2017.03.015

An unidentified male estimated to be approximately 20 years old presents via EMS shortly after a gunshot wound to the leg. Upon arrival, he is belligerent, uncooperative with care, and subsequently intubated. Exam shows a penetrating wound to the left anterior thigh with copious pulsatile bleeding. His extremities are cool with diminished pulses throughout. FAST is negative. A compression bandage is applied. Vital signs after 1 unit of packed red blood cells are: HR 150, BP 74/52, RR 16, SpO2 99% on 40% FiO2. At this time, which of the following is indicated for the management of this patient? 

A: CT angiogram of the extremity

B: intravenous tranexamic acid

C: norepinephrine infusion

D: platelet transfusion

Answer: intravenous tranexamic acid

This patient is in hemorrhagic shock secondary to an arterial injury from a gunshot wound. The CRASH-2 trial in 2010 demonstrated that administration of intravenous tranexamic acid within 3 hours of injury for adult trauma patients with significant bleeding decreases mortality when compared to placebo. The patient is unstable with hard signs of vascular injury and should be taken immediately to the operating room. Definitive management should not be delayed for imaging. Norepinephrine and other vasopressors are not indicated as the patient is already vasoconstricted from volume loss. Additional units of packed red blood cells, not platelets, are more appropriate at this time as he is being prepared for surgical exploration and repair.

Hard Signs of Vascular Injury (ABCDE)

Active pulsatile hemorrhage

Bruit or palpable thrill

Can’t feel distal pulse

Distal ischemia

Expanding hematoma

References:
CRASH-2 trial collaborators, Shakur, H., Roberts, I., Bautista, R., Caballero, J., Coats, T., Dewan, Y., El-Sayed, H., Gogichaishvili, T., Gupta, S., Herrera, J., Hunt, B., Iribhogbe, P., Izurieta, M., Khamis, H., Komolafe, E., Marrero, M. A., Mejía-Mantilla, J., Miranda, J., Morales, C., … Yutthakasemsunt, S. (2010). Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet (London, England), 376(9734), 23–32. https://doi.org/10.1016/S0140-6736(10)60835-5