Category: Chief Complaints

Question Of The Day #60

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most likely cause for this patient’s condition? 
  • A) Pyelonephritis
  • B) Hypovolemic shock
  • C) Distributive shock
  • D) Ureteral stone

This first-trimester pregnant patient presents with generalized weakness, nausea, and vomiting.  She is hypotensive and tachycardic with no sign of urinary infection on the urinalysis.  The many ketones in the urine indicate the patient has inadequate oral nutrition and is breaking down muscle and adipose tissue for energy.  This is likely related to the persistent vomiting the patient is experiencing.  This patient has hyperemesis, a common condition in the first trimester of pregnancy that is caused by rising levels of beta-human chorionic gonadotropin (BHCG).  Treatment for this patient should include IV hydration and antiemetics.  Admission criteria for these patients includes intractable vomiting despite antiemetic administration, over 10% maternal weight loss, persistent ketone or electrolyte abnormalities despite rehydration, or uncertainty in the diagnosis. 

The fluid losses caused by vomiting in this condition result in hypovolemic shock (Choice B).  Distributive shock (Choice C) is caused by other conditions, like sepsis, anaphylaxis, and neurogenic shock.  A ureteral stone (Choice D) is unlikely as the patient does not report any abdominal, back, or flank pain.  The urinalysis also does not show any hematuria, which is a common sign of a ureteral stone.  Pyelonephritis (Choice A) can cause vomiting and septic shock which can result in hypotension and tachycardia.  However, there is no sign of infection in the urinalysis provided, no fever, and no back or flank pain.  The best answer is choice B.  

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #60," in International Emergency Medicine Education Project, October 22, 2021, https://iem-student.org/2021/10/22/question-of-the-day-60/, date accessed: June 6, 2023

Question Of The Day #59

question of the day
~ Joseph Ciano, USA ~ Leave a comment
38 - atrial fibrillation

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

  • A) Pulmonary embolism
  • B) Cardiac arrythmia
  • C) Dehydration
  • D) Systemic infection

This patient presents to the Emergency Department with palpitations, generalized weakness, and shortness of breath after discontinuing all her home medications.  She has hypotension, marked tachycardia, and pulmonary edema (crackles on lung auscultation).  The 12-lead EKG demonstrates atrial fibrillation with a rapid ventricular rate.  This patient is in a state of cardiogenic shock and requires prompt oxygen support, blood pressure support, and heart rate control. 

Pulmonary embolism (Choice A) can sometimes manifest as new atrial fibrillation with shortness of breath and tachycardia, but pulmonary embolism initially causes obstructive shock.  If a pulmonary embolism goes untreated, it can progress to right ventricular failure, pulmonary edema, and cardiogenic shock.  This patient has known atrial fibrillation and stopped all her home medications.  The abrupt medication change is a more likely cause of the patient’s cardiogenic shock.  Dehydration (Choice D) and systemic infection (Choice D) are less likely given the above history of abruptly stopping home maintenance medications.  Untreated cardiac arrythmia (Choice B) is the most likely cause for this patient’s pulmonary edema and cardiogenic shock. 

The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.  

 

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #59," in International Emergency Medicine Education Project, October 15, 2021, https://iem-student.org/2021/10/15/question-of-the-day-59/, date accessed: June 6, 2023

Question Of The Day #58

question of the day
~ Joseph Ciano, USA ~ Leave a comment
720 - variceal bleeding

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

  • A) 1000mL IV Normal saline
  • B) 1 Unit Packed Red Blood Cells
  • C) IV Ceftriaxone
  • D) IV Pantoprazole

This cirrhotic patient presents to the Emergency Department with epigastric pain after an episode of hematemesis at home.  His initial vital signs are within normal limits.  While waiting in the Emergency Department, his clinical status changes.  The patient has a large volume of hematemesis with hypotension and tachycardia.  This patient is now in hemorrhagic shock from an upper gastrointestinal bleed and requires immediate volume resuscitation.  The most common cause of upper gastrointestinal bleeding is peptic ulcer disease, but this patient’s cirrhosis history and large volume of hematemesis should raise concern for an esophageal variceal bleed.  IV Pantoprazole (Choice D) is a proton pump inhibitor that helps reduce bleeding in peptic ulcers, but it does not provide benefit in esophageal varices.  Volume repletion is also a more important initial step than giving pantoprazole.  IV Ceftriaxone (Choice C) helps reduce the likelihood of infectious complications in variceal bleed patients.  This has a mortality benefit and is a recommended adjunctive treatment.  However, rapid volume resuscitation is a more important initial step.  IV crystalloid fluids, like normal saline (Choice A), are helpful in patients with hypovolemic shock (i.e., dehydration, vomiting), distributive shock (i.e., sepsis, anaphylaxis), and obstructive shock (i.e., tension pneumothorax, etc.).  Hypovolemic shock due to severe hemorrhage (hemorrhagic shock) requires blood products, not crystalloid fluids which can further dilute blood and cause coagulopathy.  Administration of packed red blood cells (Choice B) is the best next step in management in this case.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #58," in International Emergency Medicine Education Project, October 8, 2021, https://iem-student.org/2021/10/08/question-of-the-day-58/, date accessed: June 6, 2023

Question Of The Day #57

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

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

  • A) Hypovolemic shock
  • B) Distributive shock
  • C) Obstructive shock
  • D) Cardiogenic shock

This young female presents with dizziness, fatigue, nausea, generalized abdominal pain, hypotension, tachycardia, and a positive urine pregnancy test.  The anechoic (black) areas on the bedside ultrasound indicate free fluid (blood) in the peritoneal space.  See the image below for clarification. Yellow arrows indicates free fluids.

This patient is in a state of physiologic shock.  Shock is an emergency medical state characterized by cardiovascular or circulatory failure.  Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure.  Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic.  The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap.  The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam.  Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management. 

This patient’s condition is caused by a presumed ruptured ectopic pregnancy and intraperitoneal bleeding.  This is considered hypovolemic/hemorrhagic shock (Choice A). The other types of shock in Choices B, C, and D are less likely given the clinical and diagnostic information in the case.  The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.  

 

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #57," in International Emergency Medicine Education Project, October 1, 2021, https://iem-student.org/2021/10/01/question-of-the-day-57/, date accessed: June 6, 2023

Question Of The Day #56

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

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

  • A) Hypovolemic shock
  • B) Distributive shock
  • C) Obstructive shock
  • D) Cardiogenic shock

This trauma patient arrives with hypotension, tachycardia, absent unilateral lung sounds, and distended neck veins. This should raise high concern for tension pneumothorax, which is a type of obstructive shock (Choice C). This diagnosis should be made clinically without X-ray imaging. Bedside ultrasound can assist in making the diagnosis by looking for bilateral lung sliding, if available. Treatment of tension pneumothorax should be prompt and includes needle decompression followed by tube thoracostomy. Other types of shock outlined in Choices A, B, and D do not fit the clinical scenario with information that is given.

Recall that shock is an emergency medical state characterized by cardiovascular or circulatory failure. Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure. Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic. The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap. The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam. Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management. The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.

 

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #56," in International Emergency Medicine Education Project, September 24, 2021, https://iem-student.org/2021/09/24/question-of-the-day-56/, date accessed: June 6, 2023

Question Of The Day #55

question of the day
~ Joseph Ciano, USA ~ Leave a comment
738.2 - STEMI
Which of the following is the most likely cause for this patient’s condition?  
  • A) Hypovolemia
  • B) Systemic infection
  • C) Pulmonary embolism
  • D) Poor cardiac output

This patient presents with chest pressure at rest and an anterior ST segment elevation myocardial infraction (STEMI) seen on 12-lead EKG.  This patient should be given aspirin, IV fluids to increase the preload status, and receive immediate coronary reperfusion therapy.  This patient’s hypotension is likely due to infarction of the left ventricle causing poor cardiac output (Choice D).  This is known as cardiogenic shock.  The patient has been vomiting, but the acute onset of symptoms and STEMI on EKG make poor cardiac output (Choice D) more likely than hypovolemia (Choice A) as the cause for the patient’s condition.  Systemic infection (Choice B) and pulmonary embolism (Choice C) are also less likely given the clinical information in the case and the STEMI on EKG.  The best answer is Choice D.  Please see the chart below for further detailing of the different types of shock.   

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #55," in International Emergency Medicine Education Project, September 17, 2021, https://iem-student.org/2021/09/17/question-of-the-day-55/, date accessed: June 6, 2023

Question Of The Day #54

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most likely cause for this patient’s condition?
  • A) Hypovolemic shock
  • B) Distributive shock
  • C) Obstructive shock
  • D) Cardiogenic shock

This patient sustained significant blunt trauma to the chest, presents to the Emergency Department with hypotension, tachycardia, a large chest ecchymosis, and palpable sternal crepitus.  The ultrasound image provided shows a subxiphoid view of the heart with a large pericardial effusion.  In the setting of trauma, this should be assumed to be a hemopericardium.  This patient has cardiac tamponade, which is considered a type of obstructive shock (Choice C).  Treatment includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery.  The other shock types (Choices A, B, D) do not describe this patient’s presentation.  Please see the chart below for further description of the different shock types and therapies.

 

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #54," in International Emergency Medicine Education Project, September 10, 2021, https://iem-student.org/2021/09/10/question-of-the-day-54/, date accessed: June 6, 2023

Question Of The Day #53

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

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

  • A) Increased systemic vascular resistance (SVR)
  • B) Occult hemorrhage
  • C) Damage to the sympathetic nervous system
  • D) Tension pneumothorax

This patient endured a high-speed motor vehicle accident, arrives with hypotension and bradycardia, and has a C6 vertebral body fracture on imaging.  These details support a diagnosis of neurogenic shock, a type of distributive shock.

Shock is an emergency medical state characterized by cardiovascular or circulatory failure.  Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure.  Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic.  The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap.  The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam.  Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management.  The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.  

Neurogenic shock is caused by spinal cord damage above the T6 level.  Unlike other types of shock, neurogenic shock is characterized by hypotension and bradycardia (not tachycardia).  These vital sign abnormalities are caused by damage to sympathetic nervous system (Choice C).  Neurogenic shock has decreased systemic vascular resistance (warm extremities), not increased systemic vascular resistance (cool extremities) (Choice A).  Occult hemorrhage (Choice B) is always a concern in a trauma patient.  However, this would present with findings of hypovolemic/hemorrhagic shock (tachycardia, hypotension, cool extremities).  Tension pneumothorax (Choice D) is also unlikely as the patient has clear bilateral lung sounds on exam.  The best answer is Choice C.

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #53," in International Emergency Medicine Education Project, September 3, 2021, https://iem-student.org/2021/09/03/question-of-the-day-53/, date accessed: June 6, 2023

Question Of The Day #52

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) IV normal saline
  • B) IV diphenhydramine
  • C) IM epinephrine
  • D) Endotracheal intubation

This patient has anaphylactic shock, which falls under the category of distributive shock.  Anaphylactic shock is an acutely life-threatening type of allergic reaction that if left untreated, can progress to airway edema, asphyxiation, and death.  Exposure to a known or unknown allergen is the trigger for anaphylaxis.  Diagnosis of this condition requires the below criteria to be met:

  1. Acute onset of skin or mucosal changes (i.e., urticaria, tongue or lip swelling) AND hypotension or respiratory compromise (i.e., wheezing).

OR

  1. Dysfunction of two or more body systems after exposure to a presumed allergen:
    1. Skin/mucosa (i.e., urticaria, swelling of tongue or lips)
    2. Pulmonary (i.e., wheezing)
    3. Cardiovascular (i.e., hypotension)
    4. Gastrointestinal (i.e., vomiting or diarrhea)
    5. End-organ dysfunction

Management of anaphylaxis requires proper evaluation of the patient’s airway, respiratory status, and hemodynamics (“ABCs”).  Mainstays of therapy are intramuscular epinephrine (0.3mg in adults) and IV hydration.  Administration of epinephrine is a time sensitive and life-saving intervention.  Antihistamines, nebulized albuterol or salbutamol, and steroids are additional therapies that are commonly given.  Steroids are thought to prevent recurrent anaphylactic reactions, however, there is little data to support this.  Patients are typically monitored for 4-6 hours after administration of epinephrine to observe for changes in clinical status or the need for additional doses of epinephrine.  Patients who remain stable or improve after this observation period are able to be discharged home with a prescription for an epinephrine injector in the event of future anaphylaxis episodes. 

Intravenous normal saline (Choice A) and diphenhydramine (Choice B) are important therapies to administer in this patient, but intramuscular epinephrine (Choice C) is the most time-sensitive initial therapy to administer.  Without treatment, airway edema may progress and require endotracheal intubation (Choice D).  The patient’s clear voice and lack of stridor indicate that the patient does not need immediate intubation. 

Correct Answer: C

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #52," in International Emergency Medicine Education Project, August 27, 2021, https://iem-student.org/2021/08/27/question-of-the-day-52/, date accessed: June 6, 2023

Question Of The Day #51

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most likely cause for the patient’s condition?
  • A) Hypovolemic shock
  • B) Distributive shock
  • C) Obstructive shock
  • D) Cardiogenic shock

This patient is in a shock state caused by left-sided pyelonephritis.

Shock is an emergency medical state characterized by cardiovascular or circulatory failure.  Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure.  Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic.  The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap.  The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam.  Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management.  The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.   

The patient’s signs, symptoms, physical exam, and urine studies point towards an infectious etiology.  This patient is in septic shock, which is considered a type of distributive shock (Choice B).  Hypovolemic shock (Choice A), obstructive shock (Choice C), and cardiogenic shock (Choice D) are caused by other conditions reflected in the above table. 

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #51," in International Emergency Medicine Education Project, August 20, 2021, https://iem-student.org/2021/08/20/question-of-the-day-51/, date accessed: June 6, 2023

Infectious mononucleosis

Infectious mononucleosis
~ Nadine Schottler, Great Britain ~ Leave a comment

Case Presentation

A 16-year-old boy presents to A&E with a fever, an extremely sore throat, and a recent blotchy rash on his back that has been concerning him. He complains of feeling extremely tired and lethargic for the past two weeks. He denies having recently been in contact with anyone ill and confirms that he is up-to-date with his vaccinations. He mentions a visit with his local GP last week, where his doctor prescribed a dose of amoxicillin for a suspected throat infection. He has no other significant medical history. Upon further examination, his pharynx and tonsils appear inflamed with whitewash exudate and he has swollen neck lymph nodes in both the anterior and posterior triangles of the neck.

What is/are the most appropriate next step(s) in the patient’s management?

  • A) Reassure the patient and discharge
  • B) Perform a throat swab
  • C) Arrange a full blood count and a monospot test
  • D) Arrange a rapid antigen test for group A streptococcus

The answer is c) Arrange a full blood count and a monospot test

What is Glandular Fever?

Infectious mononucleosis, also known as glandular fever, is an infection resulting most commonly (80-90%) from an Epstein-Barr virus (EBV). About 95% of adults in the world have been infected with EBV; however, it is rare for it to progress into glandular fever. Glandular fever is most commonly seen in individuals aged 15-24, but can present in all age groups. The prevalence of glandular fever is estimated to be between 5-48 cases per 1000 persons. Glandular fever is rather rate in those under 10 or older than 30 (1/1000 persons), so it may not need to be in your top differentials in those age groups! In young adults, the likelihood of developing glandular fever from a primary EBV infection is about 50%; in older adults the chances of EBV infection progressing to glandular fever is slim.

For the most part, glandular fever is not contagious. It’s mostly spread through contact with saliva; such as by kissing, sharing food, or children putting things in their mouths. It can also be spread through sexual contact. Luckily, in most occurrences, glandular fever is self-limiting and lasts two to four weeks. The most common lasting effect is fatigue, which can continue from weeks to months.

When Should You Suspect Glandular Fever?

The classic ‘triad’ of symptoms for glandular fever are: 

  • Fever
  • Lymphadenopathy
  • Pharyngitis (‘sore throat’)

Bilateral posterior cervical lymphadenopathy is typical for glandular fever. Tonsils may also be enlarged, and exudate on the tonsils is described as ‘whitewash’. 

Additional signs and symptoms that could include:

  • Prodromal symptoms: 
    • Fatigue, chills, myalgia, headache
  • Palatal petechiae
    • 1-2mm in diameter and lasting 3-4 days
  • Abdominal pains 
  • Nausea and vomiting 
  • Non-specific rash
    • In this case, the patient had a maculopapular rash which is associated with EBV infection. It can be caused by the infection directly but more commonly presents after being treat with amoxicillin; patients should not take penicillin antibiotics when they have infectious mononucleosis. 
  • Splenomegaly 

If you see, or the patient tells you, of any of the following symptoms during their visit to the emergency department, it requires hospitalization! 

  • Difficulty swallowing 
  • Difficulty breathing 
  • Severe stomach/abdominal pain

These may suggest malignancy. Difficulty swallowing and breathing are most often due to inflamed tonsils and may require steroids. Severe stomach/abdominal pain might suggest a ruptured spleen. Refer to your local guidelines for investigation and treatment if these symptoms present. 

Differential Diagnoses

Viral pharyngitis

  • This is the most common alternative diagnoses
  • Viral pharyngitis tends to be more erythematous 
  • Exudate is not common with viral pharyngitis

Bacterial tonsillitis

  • Bacterial tonsillitis is more commonly described as having ‘speckled’ exudate on tonsils, compared to the ‘whitewash’ exudate on tonsils in glandular fever
  • Lymphadenopathy is usually limited to the upper anterior cervical chain, where in glandular fever, lymphadenopathy can be commonly seen in both anterior and posterior triangles

Other differentials could include other causes of lymphadenopathy, such as inflammation/infection, lymphoma, or leukemia. Alternative viral infections should also be considered (e.g. cytomegalovirus, acute toxoplasmosis, acute viral hepatitis, inter alia). 

Investigations If Glandular Fever Is Suspected

In children younger than 12, or a person who is immunocompromised, a blood test for EBV viral serology should be arranged (if the patient has been ill for seven days). 

In individuals older than 12, a full blood count with differential white cell count and a monospot test should be arranged in their second week of illness. Glandular fever is likely if:

  • The monospot test is positive
  • The full blood count has more than 20% atypical lymphocytes 

OR

More than 10% atypical lymphocytes and the lymphocyte count is more than 50% of the total white cell count.

Treatment

The patient only needs to be hospitalized if they have stridor, difficulty swallowing, are dehydrated, or there is a chance of potentially serious complications (such as a splenic rupture). Steroids should only be used if the patient shows to have difficulty breathing, otherwise, management should be conservative. If the patient doesn’t have any of these concerning signs, it is appropriate to advise the patient of their illness and discharge them for follow-up with their GP.

Some Recommendations To Patients

Some things you can advise the patient on for self-management of glandular fever include:

  • Symptoms usually only last 2-4 weeks 
  • Fatigue may be the last symptom to resolve
  • Relieve symptoms of pain and fever with paracetamol or ibuprofen
  • Encouraging normal daily routines and that exclusion from work or school is not necessary
  • Spreading of disease can be limited by avoiding kissing and not sharing eating utensils
  • They should return to the hospital if they suspect any serious complications (such increased difficulty to breath/swallow, or severe abdominal pain)

References and Further Reading

Cite this article as: Nadine Schottler, Great Britain, "Infectious mononucleosis," in International Emergency Medicine Education Project, August 16, 2021, https://iem-student.org/2021/08/16/infectious-mononucleosis/, date accessed: June 6, 2023

Question Of The Day #50

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) IV Physostigmine
  • B) IV Potassium iodide
  • C) IV Propranolol
  • D) PO Propylthiouracil (PTU)

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

This patient arrives hyperthermic, tachycardic in atrial fibrillation, diaphoretic, and altered with psychotic behavior.  Thyroid storm, the most severe manifestation of hyperthyroidism, should always be on the differential diagnosis in patients with fever and altered mental status.  Other considerations are sepsis, sympathomimetic overdose, anticholinergic overdose, serotonin syndrome, and pheochromocytoma. 

This patient has thyroid storm, a life-threatening endocrine emergency that requires prompt recognition and treatment.  Symptoms of thyroid storm include altered mental status, psychosis, seizures, coma, tachycardia, atrial fibrillation, high-output heart failure, dyspnea, vomiting, diarrhea, weight loss, and anterior neck enlargement.  Severe hyperthyroidism should have a low-undetectable TSH level with elevated T3/T4 levels, but in acute illness these levels may be unreliable.  For this reason, the diagnosis and treatment of thyroid storm should be based on clinical grounds.

An anticholinergic toxidrome can appear similar to this patient with tachycardia, hypertension, agitation, and altered mental status.  A key differentiating factor is diaphoresis.  Patients with anticholinergic ingestions should have dry skin, not wet skin. The treatment for anticholinergic toxicity is benzodiazepines and IV physostigmine (Choice A) if symptoms are unresponsive to benzodiazepines.  Physostigmine is not the best next step in this scenario. 

Treatment of thyroid storm is algorithmic.  First, beta blockade (Choice C) should be given to control the heart rate and block T4 to T3 conversion, next anti-thyroid medications (Methimazole or Propylthiouracil (Choice D)) should be given to block thyroid hormone synthesis, and lastly corticosteroids and inorganic iodine (Choice B) can be given to block release of stored thyroid hormone.  The best next step in managing this patient with thyroid storm is administration of IV Propranolol (Choice C).  Propranolol helps manage the tachycardia, systemic symptoms, and also inhibits conversion of T4 to T3. 

 Correct Answer: C

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References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #50," in International Emergency Medicine Education Project, August 13, 2021, https://iem-student.org/2021/08/13/question-of-the-day-50/, date accessed: June 6, 2023