Category: Question Of The Day

Question Of The Day #4

question of the day
~ Joseph Ciano, USA ~ Leave a comment
question of the day 4

Which of the following is the most appropriate next step in management for this patient‘s condition?

  • A) Lumbar Puncture
  • B) IV 1000mL 0.9% NaCl
  • C) IV Ceftriaxone
  • D) Non-contrast CT head

This patient describes her headache as severe, sudden-onset, and different than her prior headaches. These clues on history should raise concern for a subarachnoid hemorrhage (SAH) as the cause of her headache. Choice A (Lumbar Puncture) helps evaluate headaches caused by meningitis, pseudotumor cerebri (idiopathic intracranial hypertension), and SAH. Choice B (IV 1000mL 0.9% NaCl) is sometimes used to treat headaches, like migraines, but this patient should first receive another testing as there is a concern for SAH. Choice C (IV Ceftriaxone) is the correct initial treatment for bacterial meningitis, but this patient has a higher pretest probability for SAH. Choice D (Non-contrast CT head) is the right answer. Non-contrast CT scan of the brain performed within 6 hours of headache onset have high sensitivity to rule out aneurysmal SAH. The sensitivity of the non-contrast CT scan diminishes to 91-93% at 24hours after headache onset and continues to decrease after this to 50% sensitivity at seven days after pain onset. Lumbar puncture is recommended for a patient with a negative CT scan, high pretest probability for SAH, and presentation after 6 hours of headache onset. Findings on Lumbar Puncture that support the diagnosis of SAH include Xanthochromia (yellow appearance of the CSF due to blood breakdown) and inadequate clearing of red blood cells in the CSF between tubes 1 and 4. Treatment for SAH includes blood pressure control, seizure prophylaxis, and neurosurgical consultation, and nimodipine to prevent vasospasm and rebleeding. The Hunt and Hess scoring system can be used to predict clinical outcomes for patients with SAH. Correct Answer: D

Reference

Nelson AM, Mase CA, Ma O. Spontaneous Subarachnoid and Intracerebral Hemorrhage. “Chapter 166: Spontaneous Subarachnoid and Intracerebral Hemorrhage”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

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Question Of The Day #3

question of the day
~ Joseph Ciano, USA ~ Leave a comment
question of the day 3

Which of the following is the most appropriate next step in management for this patient‘s condition?

  • A) IV 1,000mL of 0.9% NaCl
  • B) IV 50mL of 25g dextrose solution
  • C) IV 250mL of 3% NaCl
  • D) IV 40mg Furosemide

Choice A (IV 1,000mL of 0.9% NaCl) is an isotonic crystalloid fluid helpful in a patient with depleted intravascular volume (i.e., dehydration). This patient is clinically dehydrated (dry oral mucosa and mild tachycardia); however, hypertonic 3% NaCl is a more appropriate initial treatment. Choice B (IV 50mL of 25g dextrose solution, or commonly known as “D50”) is an appropriate treatment for a patient with hypoglycemia. Checking a glucose level is a crucial part of the initial assessment of all patients with altered mental status, but this patient has a reported normal glucose level. Choice D (IV 40mg Furosemide) is a diuretic that would worsen this patient’s dehydration and acute kidney injury. This patient has severe hyponatremia along with neurological symptoms (coma and seizure). Hyponatremia plus neurologic symptoms, like vomiting, seizures, reduced consciousness, cardiorespiratory arrest, necessitate rapid correction of sodium with hypertonic (3%) NaCl solution. 3% NaCl solution can be infused 100-150mL over 15-20min and repeated up to 3 doses total. A serum sodium level should be measured after each administration of 3% NaCl in order to limit the increase in the sodium level to no more than 8-12 mEq/L over the first 24hours. This is done to reduce the risk of osmotic demyelination syndrome. Correct Answer: C

Reference

Petrino R, Marino R. Fluids and Electrolytes. “Chapter 17: Fluids and Electrolytes”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

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Question Of The Day #2

question of the day
~ Joseph Ciano, USA ~ Leave a comment
question of the day 2

Which of the following is the most appropriate next step in management for this patient‘s condition?

  • A) Synchronized Cardioversion
  • B) Asynchronized Cardioversion
  • C) Transcutaneous Pacing
  • D) Intravenous 1 mg Adrenaline

The patient in this scenario has decompensated into cardiac arrest from Ventricular Tachycardia (Vtach). The patient’s history of heart failure puts him at risk for cardiac arrhythmias. It is important to be suspicious of transient cardiac dysrhythmias for any patients who present to the Emergency Department with syncope and no prodromal symptoms. A lack of prodromal symptoms (i.e., diaphoresis, dizziness, nausea) prior to syncope should raise concern for a possible cardiac etiology of the syncope. Choice A (Synchronized Cardioversion) would be the correct management for patients with Vtach with a pulse or patients with tachyarrhythmias and hemodynamic instability (i.e., hypotension). Choice C (Transcutaneous Pacing) would be the correct management for patients with bradyarrhythmia and hemodynamic instability. If Transcutaneous Pacing is ineffective at increasing the heart rate, and the patient remains hemodynamically unstable, the next step would be Transvenous Pacing. But, our case is pulseless ventricular tachycardia, so there is no indication for transcutaneous pacing. Choice D (Intravenous adrenaline 1 mg) may be helpful in a patient with cardiac arrest with Pulseless Electrical Activity or Asystole, VTach, or VFib, but this is not the best initial action. The ACLS algorithm indicates that all patients with cardiac arrest due to Pulseless Ventricular Tachycardia or Ventricular Fibrillation should receive Asynchronized Cardioversion (Choice B). Asynchronized Cardioversion is also called defibrillation. CPR may be initiated prior to cardioversion if defibrillation pads are not attached to the patient.

Reference

Long B, Koyfman A, Anantharaman V, Lim S, Ong MH, Kenneth T, Manning JE. “Chapter 24: Cardiac Resuscitation”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9thed. McGraw-Hill.

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Question Of The Day #1

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient‘s condition?

  • A) Begin an Unfractionated Heparin drip
  • B) Administer 20mg of IV Labetalol
  • C) Administer 324mg of Aspirin
  • D) Call a Cardiology consultation

The patient in this scenario has an aortic dissection until proven otherwise. Administering anticoagulation (Choice A: Unfractionated Heparin Drip) would be the correct treatment for a pulmonary embolism. Although the patient has mild tachycardia and tachypnea on the exam, characteristics of the history and exam point closer to a diagnosis of aortic dissection. Features of the history that support a diagnosis of aortic dissection include pain described as “tearing”, “ripping”, or sharp pain radiating to the back. Other characteristics include unequal blood pressures in the extremities or neurological symptoms. Aortic dissections that migrate proximally may cause cardiac tamponade or a STEMI if they involve the coronary arteries. Choice C (Aspirin) would be the treatment for Acute Coronary Syndrome. Choice D (Call a Cardiology consultation) would not be appropriate for a patient with aortic dissection. A cardiothoracic surgical consultation would be appropriate in a patient with an aortic dissection involving the ascending aorta (Type A aortic dissection). Aortic dissections distal to the left subclavian artery that involve the descending aorta (Type B aortic dissection) are typically managed medically with blood pressure control. Choice B (IV Labetalol) is the correct answer as Aortic Dissections require aggressive blood pressure control with a goal of less than 120/80 mmHg. Beta-blockers, like Labetalol, are considered first-line therapy as they provide both alpha and beta-adrenergic receptor blockade. This allows the reduction of blood pressure without a reflex tachycardia response. Esmolol is an alternative therapy. Beta-blockers decrease vessel shearing forces that could worsen intimal vessel tearing. If beta-blockers alone cannot control blood pressure sufficiently, other medications can be included in the treatment regimen, like nicardipine, nitroglycerin, nitroprusside.

Reference

Johnson GA, Prince LA. “Chapter 59: Aortic Dissection and Related Aortic 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, 9th ed. McGraw-Hill.

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