Question Of The Day #100

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

This patient arrives to the Emergency department with 1 week of melena and fatigue.  His medication list includes an antiplatelet and an anticoagulant medication.  There is tachycardia and melena noted on examination.  This patient likely has an upper GI bleed based on his signs and symptoms with peptic ulcer disease as the most common cause.  The patient’s anticoagulation serves as a risk factor for GI bleeding and is an important contributing factor in this scenario.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Gastroenterology consultation for emergent endoscopy (Choice B) is not necessary as the patient is not acutely unstable.  He may need a diagnostic and therapeutic endoscopy during an inpatient admission, but the GI consultants do not need to be called emergently for this procedure.  An acutely unstable upper GI bleed patient, such as a patient with hemodynamic instability, requiring intubation for airway protection, receiving multiple blood product transfusions, or with brisk (rapid) bleeding on exam should prompt GI consultation for an emergent endoscopy for source control.  Surgery consultation for gastrectomy (Choice C) is not a first-line treatment for upper GI bleeding.  Gastroenterology should first perform a diagnostic and therapeutic endoscopy for most upper GI bleed patients.  Surgical esophageal transection, gastrectomy, colectomy, and other surgical procedures are last resort measures to control GI bleeding.  Administration of IV Ceftriaxone (Choice D) is not needed in this scenario and should not be given routinely in upper GI bleeds.  This patient has no infectious signs or symptoms.  Antibiotics, such as Ceftriaxone or quinolones, should be given to upper GI bleed patients with chronic liver disease (i.e., cirrhosis), or presumed gastroesophageal variceal bleeds.  Antibiotics have been found to have a mortality benefit in this patient population with GI bleeds. 

The best next step in management is to treat the patient’s tachycardia with normal saline (Choice A) for volume resuscitation.  This patient may eventually need blood products, but crystalloid IV fluids are okay to start until the Complete Blood Count results return.  This patient is not in overt hemorrhagic shock, so blood products can be held until there is evidence that the hemoglobin is below 7g/dL.  Reversal of the patient’s anticoagulation with Vitamin K and fresh frozen plasma may also be needed depending on the INR level.  Reversal can wait until coagulation studies are complete since the patient is not acutely unstable. An unstable patient should have their anticoagulant reversed immediately. Correct Answer: A

References

 
 
Cite this article as: Joseph Ciano, USA, "Question Of The Day #100," in International Emergency Medicine Education Project, August 12, 2022, https://iem-student.org/2022/08/12/question-of-the-day-100/, date accessed: December 3, 2022

Question Of The Day #99

question of the day

Complete Blood Count

Result

(Reference Range)

BUN

36.2

5 -18 mg/dL

Creatinine

1.1

0.7 – 1.2 mg/dL

Hemoglobin

9.2

13.0 – 18.0 g/dL

Hematocrit

27.6

39.0 – 54.0 %

Which of the following is the most appropriate advice for this patient’s condition?

This patient arrives to the Emergency department after a single hematemesis episode.  On exam he has a borderline low blood pressure and tachycardia.  The laboratory results demonstrate an elevated BUN and a low hemoglobin and hematocrit.  The patient’s vital signs in combination with the laboratory values point towards a diagnosis of an upper GI bleed with early signs of hemorrhagic shock.  The history of alcohol abuse also should raise concern for possible gastro-esophageal variceal bleeding as the cause of the GI bleed.

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Although this patient is not acutely unstable, his vital signs are abnormal and he should receive volume resuscitation and close observation in the Emergency department.  After initial resuscitation and treatment, it is sometimes difficult to know the best disposition for the patient (admit versus discharge).  The Glasgow-Blatchford Score isa validated risk satisfaction tool used to assist in determining the disposition of patients with an upper GI bleed.  The scoring criteria and instructions on how to use the score are below.

Glasgow-Blatchford Score

 

A validated risk stratification tool for patients with upper GIB

Scoring Criteria

Numerical Score

BUN (mg/dL)

<18.2

18.2-22.3

22.4-28

28-70

>70

 

0

+2

+3

+4

+6

Hemoglobin (g/dL) for men

>13

12-13

10-12

<10

 

0

+1

+3

+6

Hemoglobin (g/dL) for women

>12

10-12

<10

 

0

+1

+6

Systolic blood pressure (mmHg)

>110

100-109

90-99

<90

 

0

+1

+2

+3

Other criteria

Pulse >100 beats/min

Melena present

Syncope

Liver disease history

Cardiac failure history

 

+1

+1

+2

+2

+2

Instructions:

Low risk= Score of 0.  Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery. Consider admission for any score over 0. 

This patient has a Glasgow-Blatchford score of 15, and should not be discharged home.  A plan to discharge with gastroenterology follow up in 1 week (Choice A) or discharge with instructions to return if there are repeat hematemesis episodes (Choice B) should not be followed. This patient may have future hematemesis episodes in the Emergency department, be at risk for aspiration, require endotracheal intubation, and become more hypotensive.  A Sengstaken-Blakemore tube (Choice C) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Placement of this tube is considered an invasive procedure that is only used after a patient has been endotracheally intubated to prevent aspiration.  Once placed correctly, the balloons in the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube is used as a last resort measure prior to endoscopic treatment for presumed gastro-esophageal variceal bleeds. 

The best advice for this patient would be to admit the patient for monitoring and endoscopy (Choice D).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #99," in International Emergency Medicine Education Project, August 5, 2022, https://iem-student.org/2022/08/05/question-of-the-day-99/, date accessed: December 3, 2022

Question Of The Day #98

question of the day
Which of the following is the most likely cause for this patient’s condition?

This man presents to the Emergency department with epigastric pain and hematemesis.  His exam shows hypotension, tachycardia, pale conjunctiva, and a tender epigastrium and left upper quadrant.  This patient likely has an upper GI bleed based on his signs and symptoms. 

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Risk factors for GI bleeds include alcohol use, anticoagulant use, NSAID (non-steroidal anti-inflammatory drug) use (i.e., ibuprofen, aspirin, naproxen), recent gastrointestinal surgery or procedures, prior GI bleeds, and a history of conditions that are associated with GI bleeds (i.e., gastritis, peptic ulcers, H. Pylori infection, ulcerative colitis, Chron’s disease, hemorrhoids, diverticulosis, or GI tract cancers).  Fatty meals (Choice A) can trigger gastroesophageal reflux disorder (GERD) symptoms or biliary colic symptoms from cholelithiasis.  However, fatty meals do not increase the risk for GI bleeding.  Physiological stress, such as sepsis or bacteremia (Choice B), can increase the risk for GI bleeding.  This patient does not have any infectious exam signs or symptoms that would support the presence of bacteremia. Acetaminophen use (Choice D) can cause liver failure if taken in excess, but acetaminophen does not cause GI bleeding.  NSAIDs, unlike Tylenol, are associated with GI bleeding. 

Systemic steroid use (Choice C) can increase the risk for GI bleeding and is the likely cause of this patient’s upper GI bleed. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #98," in International Emergency Medicine Education Project, July 29, 2022, https://iem-student.org/2022/07/29/question-of-the-day-98/, date accessed: December 3, 2022

Question Of The Day #97

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

This patient arrives to the Emergency department after multiple episodes of hematemesis.  Her exam shows tachycardia, borderline hypotension, and mild tachypnea.  While in the Emergency department the patient decompensates after more hematemesis episodes and develops altered mental status.  This patient has an upper GI bleed most likely from a gastroesophageal variceal bleed.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

This patient with a depressed mental status needs to have a definitive airway established to prevent aspiration with bloody vomitus.  IV Pantoprazole (Choice B) is used in upper GI bleeds from peptic ulcers but has no role in this acutely ill variceal bleed patient.  The airway should be established prior to medications, such as pantoprazole are considered.  A cricothyrotomy (Choice D) would establish an airway, but this is an invasive approach to airway management and not the best approach in this patient.  A cricothyrotomy involves piercing a needle or scalpel in the anterior neck (cricothyroid membrane) to establish an airway surgically.  This procedure is performed in special situations where a patient cannot be intubated through the trachea (i.e., angioedema of the lips and tongue, facial mass, facial trauma) and cannot ventilate independently (i.e., depressed mental status).  This patient does not meet the criteria for this invasive procedure.  Endotracheal intubation should be attempted first on this patient.  A Sengstaken-Blakemore tube (Choice A) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Once placed correctly, the balloons on the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube should be placed only after intubating a patient and is used as a last resort measure prior to endoscopic treatment.  The best next step in management of this patient is to perform endotracheal intubation (Choice C) for airway protection. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #97," in International Emergency Medicine Education Project, July 22, 2022, https://iem-student.org/2022/07/22/question-of-the-day-97/, date accessed: December 3, 2022

Question Of The Day #96

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

This patient arrives to the Emergency department with upper abdominal pain and hematemesis.  The exam demonstrated hypotension, tachycardia, pale conjunctiva, and abdominal ascites. The patient decompensates during the exam requiring endotracheal intubation for airway protection. This patient has an upper GI bleed most likely from gastro-esophageal varices given her history of liver cirrhosis and stigmata of chronic liver disease.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  First line antibiotics are IV ceftriaxone or IV ciprofloxacin.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  

An abdominal paracentesis (Choice A) is not the best next step in this unstable cirrhotic patient.  Antibiotics are routinely given in gastro-esophageal variceal bleeds due to their mortality benefit, so there is no need for an emergent paracentesis to evaluate for spontaneous bacterial peritonitis (SBP) with an ascitic fluid sample. IV Tranexamic acid (Choice C) is an anti-fibrinolytic agent with pro-coagulative effects.  Its use is recommended in post-partum hemorrhage and traumatic hemorrhages, but it has no utility in the setting of GI bleed.  Early gastroenterology consultation for endoscopy is preferred over general surgery consultation (Choice D).  Surgery consultants can assist in a TIPS procedure (Transjugular intrahepatic portosystemic shunt) to reduce portal hypertension, esophageal resection, or gastrectomy, but less invasive endoscopic therapies with GI specialists are preferred over these procedures.

IV Ceftriaxone (Choice B) is the best next step in this scenario due to the mortality benefit of antibiotics in chronic liver disease patients with variceal bleeds.      

Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

    

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #96," in International Emergency Medicine Education Project, July 8, 2022, https://iem-student.org/2022/07/08/question-of-the-day-96/, date accessed: December 3, 2022

Question Of The Day #95

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

16.2

4.0 – 10.5 X 103/mL

Hemoglobin

10.8

13.0 – 18.0 g/dL

Hematocrit

32.4

39.0 – 54.0 %

Platelets

220

140 – 415 x 103/mL

Which of the following is the most likely diagnosis for this patient’s condition?

This patient arrives to the Emergency department with bright red bloody stools and lower abdominal pain.  The exam shows fever, tachycardia, and left-sided abdominal tenderness.  The laboratory results provided show leukocytosis and anemia.  This patient likely has a lower GI bleed based on her signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices provided are causes of lower GI bleeding and are possible in this patient.  However, that patient’s signs, symptoms, and risk profile make certain diagnoses less likely than others.  Diverticulosis (Choice A) is the most common cause of lower GI bleeding.  Diverticulosis often occurs in older patients and should not be associated with pain or fever, which support a diagnosis of an inflammatory or infectious etiology (i.e., diverticulitis, Shigellosis, ulcerative colitis, chron’s disease, etc.).  This patient is young and has fever and leukocytosis, making diverticulosis less likely.  Colon malignancy (Choice B) is also possible but is less likely given the patient’s young age, the presence of fever, and the acute onset of symptoms over 2 days.  Colon malignancy tends to cause slow GI bleeding over a longer period of time, rather than acutely over 2 days.  Ischemic colitis (Choice C), such as mesenteric ischemia, is less likely in a young patient without any cardiac risk factors or recent abdominal surgeries. 

Ulcerative colitis (Choice D) is the most likely diagnosis in this scenario.  Peak incidence for ulcerative colitis occurs in the second and third decades of life, and women are more likely than men to have this diagnosis.  Definitive diagnosis requires a biopsy and colonoscopy, but a CT scan of the abdomen and pelvis can show findings consistent with ulcerative colitis for a new diagnosis.  Treatment of an ulcerative colitis flare includes general supportive care, IV steroids, and IV antibiotics if there is concern for a concurrent infectious process.  Intestinal perforation and toxic megacolon also should be evaluated for with CT imaging.    

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #95," in International Emergency Medicine Education Project, July 1, 2022, https://iem-student.org/2022/07/01/question-of-the-day-95/, date accessed: December 3, 2022

Question Of The Day #94

question of the day

Complete Blood Count

Result

(Reference Range)

WBC Count

4.5

4.0 – 10.5 X 103/mL

Hemoglobin

5.3

13.0 – 18.0 g/dL

Hematocrit

15.9

39.0 – 54.0 %

Platelets

138

140 – 415 x 103/mL

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

This patient arrives to the Emergency Department with bright red bloody stools in the setting of warfarin use.  His exam shows hypotension and tachycardia.  The laboratory results show a low hemoglobin and hematocrit, but no INR or other coagulation studies are provided.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, or other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia and reversal of the patient’s anticoagulation.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

This patient’s platelet level is just below the lower limit of normal, so administration of a platelet transfusion (Choice A) would not be the next best step.  Platelet administration should be considered if the platelet count is below 50,000-100,000, or if a massive transfusion protocol is initiated to prevent coagulopathy.  No INR value is provided in the question stem, but prompt reversal of warfarin should not be delayed for an INR level (Choice D).  Reversal of warfarin should be promptly initiated when a patient is unstable (i.e., hypotensive GI bleed, traumatic wound hemorrhage, intracranial bleed, etc.).  Medication reversal in these settings includes both IV Vitamin K 10mg and IV Fresh Frozen Plasma 10-20cc/kg.  IV Vitamin K helps reverse the Vitamin K antagonistic effect of Warfarin, but it does not acutely provide new Vitamin K-dependent coagulation factors (Factors X, V, II, VII).  IV Vitamin K gives the liver the ‘materials’ needed to regenerate these coagulation factors, but this process takes time.  Fresh frozen plasma contains ‘ready-to-use’ coagulation factors that will help control the hemorrhage acutely.  For this reason, both Vitamin K and FFP are given together in an unstable patient.  An alternative to fresh frozen plasma (FFP) is prothrombin complex concentrate (PCC), which is a concentrated version of coagulation factors.  PCC is not broadly available in all countries, and is generally more expensive than FFP. 

The management of stable patients with a supratherapeutic INR includes holding warfarin doses and sometimes providing PO Vitamin K, depending on the INR level.  Administration of IV Vitamin K only (Choice C) is not the correct treatment in this scenario.  IV Vitamin K and IV Fresh Frozen Plasma (Choice B) is the best next step to reverse this patient’s anticoagulant. 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #94," in International Emergency Medicine Education Project, June 24, 2022, https://iem-student.org/2022/06/24/question-of-the-day-94/, date accessed: December 3, 2022

Question Of The Day #93

question of the day

Which of the following is the most appropriate next step in management?

This patient arrives to the Emergency Department with bright red bloody stools and generalized abdominal pain.  His exam shows hypotension, tachycardia, a diffusely tender abdomen, and pale conjunctiva.  He also takes warfarin daily for anticoagulation.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, ischemic colitis (i.e., mesenteric ischemia), and other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

A CT Angiogram of the abdomen and pelvis (Choice A) may be helpful in clarifying the etiology and site of the patient’s bleeding, but this is not the best next step in management.  The patient’s shock state first should be managed prior to any imaging studies.  Gastroenterology consultation for colonoscopy (Choice B) may be important later in this patient’s management, but it is not the best next step in management. His shock state should be treated prior to calling any consultants. An IV Pantoprazole infusion (Choice C) is helpful in upper GI bleeds due to peptic ulcer disease.  Proton pump inhibitor medications, like pantoprazole, help reduce findings of ulcer bleeding during endoscopy.  Proton pump inhibitor use has been controversial in upper GI bleeds as there is no evidence that their use decreases mortality, decreases blood product requirements, or ulcer rebleeding, but these medications are often given due to their generally small risk profile.

 

The best next step for this patient in hemorrhagic shock is administration of packed red blood cells (Choice D).  He also should have reversal of his warfarin with IV Vitamin K and fresh frozen plasma to prevent continued bleeding.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #93," in International Emergency Medicine Education Project, June 17, 2022, https://iem-student.org/2022/06/17/question-of-the-day-93/, date accessed: December 3, 2022

Question Of The Day #92

question of the day

Which of the following is the most likely cause of this patient’s condition?

This elderly patient arrives to the Emergency Department with painless hematochezia.  His exam shows borderline hypotension, tachycardia, and a normal abdominal exam.  This patient most likely has a lower gastrointestinal bleed based on his signs and symptoms.  A brisk (fast) upper GI bleed is also possible but is less likely.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices listed above are potential causes of bright red bloody stools.  Peptic ulcer disease (Choice C) is the most common cause of upper GI bleeding worldwide, not lower GI bleeding.  However, a profusely bleeding peptic ulcer can cause rapid blood transit through the GI tract to form hematochezia rather than melena.  The patient lacks any risk factors or symptoms of peptic ulcer disease, such as upper abdominal pain, hematemesis, NSAID use, or prior H. pylori infection.  Ischemic colitis, or mesenteric ischemia (Choice A), is often associated with abdominal pain and cardiac risk factors (i.e., atrial fibrillation).  Colon cancer (Choice B) is also possible, but typically colon malignancy causes slow, chronic bleeding, rather than acute large volume bloody stools with signs of shock as in this patient.  The most common cause of lower GI bleeding worldwide is diverticulosis (Choice D).  This is the most likely diagnosis in this patient with painless hematochezia.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #92," in International Emergency Medicine Education Project, June 10, 2022, https://iem-student.org/2022/06/10/question-of-the-day-92/, date accessed: December 3, 2022

Question Of The Day #91

question of the day

Which of the following is the most likely cause of this patient’s condition?

This patient arrives to the Emergency Department with upper abdominal pain and hematemesis.  He occasionally takes ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), which is a risk factor for GI bleeding. His examination shows tachycardia.  This patient likely has an upper gastrointestinal bleed given his signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding.  

All choices listed above are potential causes of upper GI bleeding, with the exception of GERD (Choice D).  Erosive gastritis and esophagitis can cause an upper GI bleed, but GERD is not a cause of upper GI bleed.  The patient lacks risk factors for esophageal varices (Choice A), such as chronic liver disease, cirrhosis, or alcohol abuse.  Gastric malignancy (Choice B) is possible, but less likely given the patient’s young age and lack of risk factors mentioned in the question stem for gastric malignancy (i.e., prior H. pylori infection, tobacco smoking, chronic gastritis, weight loss, lymphadenopathy, etc.).  The most common worldwide cause of upper GI bleeding is peptic ulcer disease (Choice C).  For this reason, Choice C is the best answer.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #91," in International Emergency Medicine Education Project, June 3, 2022, https://iem-student.org/2022/06/03/question-of-the-day-91/, date accessed: December 3, 2022

Question Of The Day #90

question of the day
366 - pneumonia-middle lobe

Which of the following is the most likely cause of this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with shortness of breath, productive cough, and fever for 5 days.  On exam, the patient is febrile, tachycardic, and has a low SpO2 on room air.  The lung exam demonstrates focal rhonchi at the right base.  The chest X-ray demonstrates a consolidation at the right middle lobe that obscures the right heart boarder.  The consolidation is highlighted with a red star in the patient’s X-ray below.

Lung consolidations have multiple causes, including pneumonia, malignancy, heart failure, pulmonary emboli, and septic emboli from endocarditis.  Septic pulmonary emboli (Choice A) can present with cough, fever, and difficulty breathing, but often have multiple foci of consolidations on chest X-ray.  This patient has a single area of consolidation.  This patient also lacks the typical risk factors for septic emboli, like IV drug use, recent dental procedures, structural heart disease, or prosthetic heart valves.  An infected pleural effusion (Choice B), also known as an empyema, is shown as a blunted or hazy right costo-diaphragmatic angle.  This patient’s X-ray shows no fluid in both costo-diaphragmatic recesses to indicate the presence of a pleural effusion.  A pulmonary embolism (Choice D) often presents with clear lungs on auscultation and a normal chest X-ray.  However, if the pulmonary embolism progresses to a pulmonary infarct, a wedge-shaped opacity can be seen on the X-ray.  This patient’s X-ray lacks this finding.  The most likely cause for this patient’s symptoms is a right middle lobe pneumonia (Choice C).  She should receive IV fluids, antipyretics, supplemental oxygen, and IV antibiotics.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #90," in International Emergency Medicine Education Project, May 27, 2022, https://iem-student.org/2022/05/27/question-of-the-day-90/, date accessed: December 3, 2022

Question Of The Day #89

question of the day

Which of the following is the most appropriate next step in management?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with acute shortness of breath, an urticarial rash, hypotension, tachycardia, swelling of the lips and tongue, and wheezing on lung exam.  This patient is in anaphylactic shock and requires prompt treatment with epinephrine.  Anaphylaxis is an IgE-mediated life-threatening allergic reaction that by definition affects two or more body systems (i.e., skin/mucosa, pulmonary, cardiovascular, gastrointestinal, etc.).  This patient has involvement of the skin (urticarial rash, mucosal swelling), cardiovascular system (hypotension and tachycardia), and pulmonary system (wheezing).  Symptoms of anaphylaxis may include urticaria, shortness of breath, wheezing, facial or airway swelling, vomiting or diarrhea, and abdominal pain.  Anaphylaxis is a clinical diagnosis and does not require vital signs to be unstable in order to be diagnosed.  Once diagnosed, the most time sensitive and lifesaving treatment is epinephrine.  The recommended initial dose for epinephrine is 0.3-0.5mg intramuscularly in the thigh for adults.  Epinephrine doses can be repeated every 5-15 minutes if there is no improvement after the initial dose. Antihistamines, like Diphenhydramine (Choice D) or famotidine may be helpful as adjunctive treatments, but they are not lifesaving.  Steroids, like Dexamethasone (Choice C), are also routinely given in anaphylaxis with the theory that they can prevent “rebound” allergic reactions.  Again, steroids are not acutely lifesaving and should be given after IM epinephrine.  IV epinephrine can be given in a patient unresponsive to IM epinephrine at a dose of 1-5mcg/min.  A dose of IV Epinephrine 1mg (1000mcg) (Choice A) is the dose of Epinephrine used during cardiac arrest and is too high of a dose to use in anaphylaxis.  The best initial step in management is IM Epinephrine 0.3mg (Choice B).  

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #89," in International Emergency Medicine Education Project, May 20, 2022, https://iem-student.org/2022/05/20/question-of-the-day-89/, date accessed: December 3, 2022