Category: Chief Complaints

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

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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

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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

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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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Question Of The Day #49

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) Sympathomimetic toxicity
  • B) Heat exhaustion
  • C) Heat stroke
  • D) Thyroid storm

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

Hyperthermia (or hypothermia) can cause altered mental status.  This patient arrives with altered mental status, severe hyperthermia, tachycardia, tachypnea, and hypotension.  The history of the patient running outside for exercise should raise concern for hyperthermia related to excess heat production due to overexertion.  This should narrow the differential diagnoses to heat exhaustion (Choice B) and heat stroke (Choice C).  Both heat exhaustion and heat stroke are marked by hyperthermia with temperatures often over 40ᵒC. Additional symptoms include weakness, nausea, vomiting, myalgias, syncope, and headache.  The differentiating factor between heat exhaustion and heat stroke is altered mental status and sweating.  Patients with heat exhaustion lack altered mental status and should still be able to thermoregulate through sweating.  On the contrary, heat stroke patients are more severely ill as they have altered mental status and can no longer thermoregulate with sweating.  The treatment in both conditions should be early and aggressive cooling measures.  This includes full body immersion in an ice bath, removal of clothes, and cold IV fluids.  Internal cooling with gastric, bladder, pleural, or peritoneal lavage with cold fluids can be done on more sick patients.  Antipyretic medications, like NSAIDs and paracetamol, have no benefit in patients with severe hyperthermia.  Evaluation for rhabdomyolysis, kidney failure, liver failure, sepsis, or other organ dysfunction should also be a part of the evaluation of hyperthermic patients.

Sympathomimetic toxicity (Choice A) is possible, but less likely as the skin is dry and the history of exercise outdoors.  Sympathomimetic toxicity manifests as diaphoresis, tachycardia, hypertension, hyperthermia, and sometimes altered mental status.  Thyroid storm (Choice D) is another possibility.  This diagnosis can also present with similar vital signs, hyperthermia, and altered mental status.  Again, the history of outdoor exercise should point more towards heat exhaustion vs heat stroke.

The diagnosis of this patient is heat stroke (Choice C) as he has altered mental status and lacks wet skin.

Correct Answer: C

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Question Of The Day #48

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) Hypercarbic respiratory failure
  • B) Hypoxic respiratory failure
  • C) Opioid overdose
  • D) Sepsis

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

The first step in managing this patient should be to treat the hypoxia with supplemental oxygen.  Prolonged hypoxia is dangerous and if left untreated, can cause brain damage.  Hypoxia can cause altered mental status, however, when this patient’s hypoxia is resolved, she remains somnolent and altered.  This should raise concern over an alternative etiology for the patient’s condition.      

The arterial blood gas demonstrates a low pH (acidosis), normal paO2, elevated paCO2 (hypercarbia), and a normal HCO3 (no metabolic compensation for acidosis).  The final interpretation of the ABG would be an acute respiratory acidosis without metabolic compensation.  Acute elevations of pCO2 can manifest as somnolence and altered mental status as seen in this patient.  This is known as hypercarbic or hypercapnic respiratory failure (Choice A).  This condition is caused by the inability to exhale CO2.  Risk factors include obstructive lung diseases (i.e., COPD), obesity, and obstructive sleep apnea.  Treatment involves treatment of hypoxia with supplemental oxygen, non-invasive positive pressure ventilation (i.e., BIPAP, CPAP, High Flow Nasal Cannula), and treatment of the underlying cause.

The patient’s arterial blood gas does not show hypoxic respiratory failure (Choice B).  Since treatment of the patient’s hypoxia does not improve the patient’s mental status, hypercarbic respiratory failure is more likely the underlying cause of the patient’s condition.  Opioid overdose (Choice C) can cause a similar ABG and patient presentation.  The normal size pupils and absent history of drug abuse makes this diagnosis less likely. Sepsis (Choice D) can trigger changes in mental status and cause respiratory failure, however, the absence of infectious symptoms and the presence of obesity and COPD support hypercarbic respiratory failure as the more likely underlying cause. 

Correct Answer: A

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Question Of The Day #47

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) 1000mL bolus of 0.9% NaCl
  • B) 25g of IV dextrose
  • C) 1mg of IV naloxone
  • D) 100mg of IV thiamine

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

The initial approach to all Emergency Department patients, especially those with abnormal vital signs, should include a primary survey (“ABCs”, or Airway, Breathing, Circulation).  This patient is breathing independently but at a significantly reduced rate and is hypoxic.  Hypoxia should prompt the administration of supplemental oxygen to the patient and reassessment of the SpO2.  The patient’s reduced respiratory rate, lethargy, and bilateral miosis (constricted pupils) should strongly hint at the possibility of opioid overdose.  Although the patient is lethargic and hypoxic, establishing a definitive airway (endotracheal intubation) should be avoided until after the antidote to opioid overdose is administered.  Naloxone is a mu-opioid receptor antagonist and functions as the antidote to opioid overdose.

 

Administration of 1000mL of 0.9% NaCl (Choice A) is unlikely to fix the patient’s clinical condition.  The patient needs naloxone to improve respiratory status.  25g of IV dextrose (Choice B) would be helpful if this patient’s altered mental status was from hypoglycemia.  A normal glucose level is provided in the question stem.  100mg of IV thiamine (Choice D) may be helpful in the case of Wernicke-Korsakoff Syndrome, a state of thiamine deficiency often associated with malnutrition and alcohol abuse.  Wernicke-Korsakoff Syndrome presents with vision disturbances, ataxia, and confusion.  Typically, this syndrome does not present with severe lethargy or depressed mental status as is seen in this patient.

The best next step in management is 1mg of IV naloxone (Choice C).  If given appropriately, naloxone can prevent the need for intubation.  Naloxone has a very short onset to action (~1min).  If suspicion for opioid overdose is high and there is an inadequate respiratory response after a single naloxone dose, repeat doses of naloxone are appropriate.  Naloxone can be administered in repeat boluses every 3-minutes to a total dose of 10mg IV.  Patients who respond appropriately to naloxone should be observed for recurrent respiratory depression as naloxone is cleared.  Need for repeat doses of naloxone indicates the need for a continuous naloxone infusion and hospital admission.  The typical infusion dose is 2/3 the “wake-up” dose given over 1 hour as a continuous infusion.  For example, if the patient responded to 1mg IV initially, the continuous infusion dose would be 0.6mg/hour of IV naloxone.

Correct Answer: C

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Question Of The Day #46

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) 1000mL of IV 0.9% NaCl
  • B) Noncontrast CT scan of head
  • C) 25g of IV dextrose
  • D) 150mL of 3% NaCl

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

The serum chemistry results provided show elevated BUN and Creatinine with a BUN/Cr ratio of 21.3.  A BUN/Cr ratio greater than 20 indicates decreased perfusion to the kidneys, also known as pre-renal azotemia, which can indicate dehydration, hypovolemia, or shock.  The serum chemistry also shows a severely low sodium level.  Hyponatremia can present with a variety of symptoms, including weakness, fatigue, myalgias, nausea, vomiting, headaches, altered mental status, focal neurologic deficits, seizures, or coma.  Hyponatremia can be acute or chronic, asymptomatic or symptomatic, and mild or severe.  Sodium levels below 120 mEq/L are severely low.  Neurologic symptoms, such as seizures, altered mental status, and focal neurologic deficits, are also considered severe.  Treatment should be based on patient symptoms, rather than the sodium level, as it can be difficult to assess how acute or chronic the hyponatremia state is on initial evaluation.  The presence of any severe neurologic symptoms as is seen in this scenario should prompt administration of hypertonic saline (3% NaCl).  This allows for rapid correction of serum sodium levels, which should in turn relieve the neurologic symptoms.  A 100-150mL IV bolus of 3% NaCl can be given a second time if symptoms continue after 5-10 minutes.  

Typically, hyponatremia should be corrected slowly to avoid central pontine myelinolysis.  Increases in sodium greater than 8mEq/L per 24hours should be avoided for this reason.  However, in the case of neurologic symptoms, rapid correction of sodium is opted for to prevent further damage.

Administration of “normal saline”, or 1000mL of IV 0.9% NaCl (Choice A), can increase the sodium level.  However, normal saline is not concentrated enough to rapidly increase the serum sodium to terminate neurologic symptoms.  A noncontrast CT scan of the head (Choice B) is a reasonable investigation for this altered patient, but hypertonic saline should be administered first if hyponatremia is known.  Administration of 25mg IV dextrose (Choice C), also known as “D50”, would be helpful in a patient with hypoglycemia and altered mental status. However, this patient is not hypoglycemic.

Administration of hypertonic saline (Choice D) is the best next step in this patient with severe hyponatremia and neurologic symptoms.

Correct Answer: D

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Question Of The Day #45

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) Administer IM haloperidol
  • B) Endotracheal intubation
  • C) Roll patient to lateral decubitus position and suction the airway
  • D) Obtain a 12-lead EKG

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’s altered mental status is likely due to a post-ictal state after a first-time seizure.  A seizure occurs when the brain is in a state of neuronal hyperactivity.  First time seizures can be caused by a variety of factors, such as hypoxia, hyperthermia, hypoglycemia, traumatic brain injury, brain tumors, meningitis, encephalitis, hyponatremia, or alcohol withdrawal.  It can sometimes be difficult to differentiate a seizure from a syncopal episode.  Both conditions cause loss of consciousness and both may include body convulsions.  Details that support a diagnosis of seizure over syncope include bowel or bowel incontinence, tongue biting, and confusion after regaining consciousness (post-ictal state).

Management of a patient having a seizure should focus initially on the ABCs (Airway-Breathing-Circulation) and terminating the seizure.  This involves first repositioning the patient to prevent aspiration.  A common maneuver is rolling the patient in the lateral decubitus position, performing a jaw thrust, and suctioning the airway (Choice C).  Administration of IM haloperidol (Choice A) is unlikely to terminate the seizure as it is an antipsychotic, not an antiepileptic medication.  Obtaining a 12-lead EKG (Choice D) is an important aspect of evaluating a patient with a potential seizure, however, the next best step in this seizing patient should focus on the ABCs and terminating the seizure.  Endotracheal intubation (Choice B) may be necessary in this patient to protect the airway, but patient repositioning (Choice C) and antiepileptic (i.e., benzodiazepines) administration are important initial steps prior to considering intubation.  The best next step in this scenario is Choice C.

 Correct Answer: C

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Question Of The Day #44

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

Which of the following is the most appropriate next investigation to confirm this patient’s diagnosis?

  • A) Lumbar puncture
  • B) 12-lead EKG
  • C) MRI of brain
  • D) Noncontrast CT scan of head

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

The information provided indicates that the patient’s headache was maximal at onset, severe, associated with vomiting, and led to a deteriorating mental status ultimately requiring intubation.  This history is very concerning for intracranial bleeding, especially subarachnoid hemorrhage (SAH).  The majority of atraumatic SAHs are caused by the rupture of a saccular aneurysm.  This causes the leakage of blood into the subarachnoid space.  Symptoms of a SAH are sudden onset headache that is maximal intensity at onset (“thunderclap headache”), syncope, vomiting, seizures, and any neurological deficits.  Risk factors for SAH are age over 50years-old, family history of SAH, alcohol abuse, tobacco smoking, Marfan Syndrome, Ehlers-Danlos Syndrome, and Polycystic Kidney Disease.  Diagnosis of SAH takes into account the patient’s history, physical exam, and risk factors. 

Patients that arrive in the Emergency Department under 6hours since symptom onset should initially get a noncontrast CT scan of the head (Choice D).  When a noncontrast head CT is performed in this time window, its sensitivity reaches 98-100%.  Noncontrast head CTs performed within the first 24hrs since headache onset have a sensitivity of about 90%.  Patients with signs and symptoms concerning for SAH who have a negative CT head should get a lumbar puncture (Choice A) to evaluate for xanthochromia.  This is especially important if the patient’s symptoms have been for over 6 hours.  A 12-lead EKG (Choice B) can show ST and T wave changes, but an EKG alone cannot be used to make a diagnosis of SAH.  A brain MRI (Choice C) can make the diagnosis of SAH, but a CT scan would be preferred due to greater CT scan accessibility, cost, and the shorter time of this imaging test.  The best next investigation would be a noncontrast CT of the head (Choice D).

Correct Answer: D

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Question Of The Day #43

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

Which of the following is the most likely cause for this patient’s altered mental status?

  • A) Diabetic ketoacidosis
  • B) Sepsis
  • C) Intracerebral hemorrhage
  • D) Hypothyroidism

This patient presents to the Emergency Department with altered mental status and fever.  Altered mental status 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 has confusion, fever, lower abdominal pain, dysuria, and no focal neurological deficits on exam.  Diabetic ketoacidosis (Choice A) is unlikely as the patient does not have marked hyperglycemia (>250mg/dL (13.8mmol/L)), polyuria, or polydipsia.  Intracranial hemorrhage (Choice C) is unlikely as the patient has no headache, history of trauma, focal neurologic deficits, or coma.  Severe hypothyroidism (Choice D), known as myxedema coma, can cause altered mental status.  This condition is marked by somnolence or coma, hypothermia, nonpitting edema on the hands and feet, dry skin, macroglossia (enlarged tongue), and hair loss.  This patient does not have symptoms consistent with severe hypothyroidism. 

Sepsis (Choice B), especially in elderly individuals, can cause altered mental status.  The patient’s fever, confusion, lower abdominal pain, and dysuria all point to a likely diagnosis of urosepsis.  Sepsis is the most likely cause of this patient’s disoriented state.  Treatment with early IV hydration and antibiotics will help remedy the patient’s altered mental status.  Correct Answer: B

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Question Of The Day #42

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 insulin continuous infusion
  • B) IV hypertonic 3% NaCl
  • C) IV 0.9% NaCl bolus
  • D) IV insulin bolus

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 has a markedly elevated glucose level.  All patients with altered mental status should have a point of care glucose test as both hypoglycemia and severe hyperglycemia can cause altered mental status.  Some diagnoses to consider in this patient are diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).  Both of these diagnoses can present with hyperglycemia and altered mental status, but HHS more often presents with higher glucose levels (greater than 600mg/dL (33mmol/L)) and more pronounced Central Nervous System depression.  Patients with HHS may have severe somnolence to the point of coma and may require intubation for airway protection.  In both DKA and HHS, patients are severely dehydrated by osmotic diuresis.  High glucose levels in the serum create an osmotic gradient that causes increased urination and fluid loss.  The first step in treatment for DKA and HHS is volume resuscitation. 

IV fluids (Choice C) should be given prior to the initiation of insulin therapy (Choices A and D).  After adequate IV hydration and correction of electrolyte derangements, insulin can be started to normalize glucose levels.  Bolus doses of IV insulin (Choice D) are harmful in both DKA and HHS and increase the risk of cerebral edema development.  For this reason, an IV insulin continuous infusion (Choice A) is always preferred over an insulin bolus (Choice D).  IV hypertonic 3% NaCl (Choice B) is the treatment for severe hyponatremia causing altered mental status or seizure.  Severe hyperglycemia can cause pseudohyponatremia, but this can be corrected for using the standard sodium correction formula (see references below).  The question stem provides an explanation for this patient’s altered mental status (hyperglycemia), so hypertonic saline should not be given with the information provided.  IV fluid administration (Choice C) is the next best step. Correct Answer: C

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References

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