Question Of The Day #35

question of the day
qod35
29.2 - small bowel obstruction 2
Which of the following is the most likely cause for this patient’s condition?

This patient presents to the emergency department with generalized abdominal pain, nausea, vomiting, and constipation. The physical exam demonstrates tachycardia and a distended and diffusely tender abdomen. The patient has three prior abdominal surgeries. The upright abdominal X-ray shows multiple dilated loops of small bowel with air-fluid levels. The information provided by the history, physical exam, and diagnostic imaging collectively supports a diagnosis of small bowel obstruction.

Small bowel obstruction (SBO) is a mechanical blockage to forward flow through the intestines. The majority of SBOs are caused by post-operative scar tissue formation (adhesions), but other causes include hernias, intra-abdominal malignancies, foreign bodies, and Crohn’s disease. Symptoms include intermittent colicky abdominal pain, abdominal distension, nausea and vomiting, and constipation. Some patients may be able to pass stool and flatus early in the timeline of an SBO or if the obstruction is partial, rather than complete. Typical exam findings in SBO are a diffusely tender abdomen and high-pitched bowel sounds. Findings of abdominal rigidity, guarding, or fever should raise concern about possible intestinal perforation, peritonitis, or intestinal necrosis. Diagnosis is made clinically in combination with diagnostic imaging, such as abdominal X-rays, CT scanning, or ultrasound. CT scans have better sensitivity and specificity in diagnosing an SBO than Xray. Abdominal ultrasound is more sensitive and specific in diagnosing SBO than CT scan, but this test requires a skilled practitioner to get high-quality results. Treatment of SBO involves IV hydration, surgical consultation for possible operative intervention, pain medications, antiemetics, and electrolyte repletion. Nasogastric tube placement for gastric decompression is helpful in patients who have marked abdominal distension, intractable vomiting, or have risks for aspiration (i.e. altered mental status).

The most common cause of SBO is adhesions (Choice B), not malignancy (Choice A). Diabetic ketoacidosis (Choice C) can present with abdominal pain, nausea, and vomiting. However, DKA becomes more likely when the glucose is elevated over 250mg/dL. The presence of air-fluid levels and dilated small bowel on X-ray imaging also supports SBO over DKA. Delayed gastric emptying (Choice D) is the cause of gastroparesis, a diagnosis that can also present as nausea and vomiting. The other signs, symptoms, and imaging results make SBO a more likely diagnosis than gastroparesis.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #35," in International Emergency Medicine Education Project, April 16, 2021, https://iem-student.org/2021/04/16/question-of-the-day-35/, date accessed: April 18, 2021

Question Of The Day #34

question of the day
qod34

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

This patient is pregnant in the first trimester presenting to the Emergency department with right lower quadrant pain. Any first trimester pregnant patient with abdominal pain should be evaluated for ectopic pregnancy. Other causes of this symptom include ovarian torsion, ovarian cyst rupture, pelvic inflammatory disease, tubo-ovarian abscess, urinary tract infection, ureterolithiasis, colitis, or appendicitis. An intra-uterine pregnancy is confirmed on transvaginal ultrasound which excludes ectopic pregnancy from the differential. Ovarian pathologies are also investigated on the ultrasound and are not discovered. 

Another common diagnosis based on the patient’s pain location, young age, and markedly tender abdomen is acute appendicitis. The most common presenting symptom in appendicitis is right lower quadrant pain. Other signs include fever, anorexia, nausea, or vomiting.  Pregnant women may present with back or flank pain, rather than right lower quadrant pain, as the uterus may displace the appendix in the abdomen. There is no single symptom or laboratory test that can reliably exclude the diagnosis of appendicitis. The gold standard test for acute appendicitis diagnosis is a CT scan of the abdomen with IV contrast dye. PO or PR contrast are additionally used in some institutions based on preference and protocols.  In children, appendiceal ultrasound is performed first to avoid excessive radiation exposure and financial cost. CT scanning (Choice A) is similarly avoided in first-trimester pregnancy to diagnose appendicitis, although it is the test of choice in non-pregnant adults. MRI imaging of the abdomen and pelvis (Choice C) is another diagnostic option for pregnant patients, but this is not recommended until an ultrasound is performed. IV antibiotics (Choice D) may be needed to treat appendicitis or other abdominal infections, but this patient lacks a definitive diagnosis or signs of sepsis or shock which would support emergent antibiotics. The best next step to further evaluate the cause of this patient’s symptoms is conducting an appendiceal ultrasound (Choice B). If this study is non-conclusive or is not available, an MRI should be performed. 

Emergency department treatment for acute appendicitis is IV antibiotics, IV hydration, and surgical consultation for appendectomy. Immediate surgery may be avoided in patients who present several days after symptom onset or with a ruptured appendix. These cases are treated with IV antibiotics, IV hydration, bowel rest, and close monitoring.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #34," in International Emergency Medicine Education Project, April 9, 2021, https://iem-student.org/2021/04/09/question-of-the-day-34/, date accessed: April 18, 2021

Question Of The Day #33

question of the day
qod33
AAA CT scan possible rupture

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

This elderly male patient presents to the emergency department with abdominal pain. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries a higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging. Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection. The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The syncopal event and signs of shock should raise concern for a more serious etiology of the patient’s symptoms. The CT image provided shows a dilated aorta filled with contrast dye and a large surrounding intra-luminal thrombus. An infrarenal abdominal aorta measuring over 3cm is considered aneurysmal. This patient’s abdominal aorta measures approximately 7cm from outer wall to outer wall using the scale provided on the right-hand side of the image. The green measurement line in the image below shows the size of the aorta from outer wall to outer wall (includes thrombus).

The diagnosis for this patient is a ruptured abdominal aortic aneurysm (AAA). This condition carries a high mortality and is often lethal without prompt surgical intervention (Choice A). Administration of blood products is helpful if there are signs of hemorrhagic shock as in this patient. Antibiotics, like IV Vancomycin and Piperacillin-Tazobactam (Choice B), are not helpful in the management of this diagnosis. Endotracheal intubation (Choice C) is needed prior to operative intervention, but Emergency department management should focus on volume resuscitation and close communication with the surgical team for operative repair. IV Heparin (Choice D) may be beneficial in acute mesenteric ischemia from an embolic etiology (i.e. Atrial fibrillation), but anticoagulation would worsen this patient’s hemorrhagic shock.

AAAs can present to the Emergency department without any symptoms and be discovered incidentally on imaging or on physical exam as a pulsatile abdominal mass. Other presentations include severe back pain (the abdominal aorta is retroperitoneal) and circulatory shock. Rupture of a AAA can be large and result in rapid decompensation and death, or bleeding can be contained in the retroperitoneal space with transiently stable vital signs. Risk factors for AAA formation are male sex, tobacco use, hypertension, increased patient age, Marfans syndrome, or Ehlers-Danlos syndrome. The diagnosis of AAA is clinical and includes the use of bedside aortic ultrasound or CT aortic angiogram imaging. Treatment for AAA depends on aortic size and patient symptoms. Operative repair is indicated for any AAA over 5.5cm diameter in men, over 5.0cm diameter in women, or any size if there are signs of shock or concern for AAA rupture.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #33," in International Emergency Medicine Education Project, April 2, 2021, https://iem-student.org/2021/04/02/question-of-the-day-33/, date accessed: April 18, 2021

Question Of The Day #32

question of the day
qod32

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

This patient has intermittent epigastric abdominal pain with nausea and vomiting that radiates to the back. He has a history of alcohol abuse, but lacks tremors or tongue fasciculations to demonstrate signs of active alcohol withdrawal. Laboratory testing reveals pre-renal acute kidney injury (BUN/Creatinine ratio >20), elevated liver function tests with a hepatocellular pattern (AST>ALT in 2:1 ratio), and a markedly elevated lipase.  This information supports a diagnosis of acute pancreatitis. Administration of IV midazolam, a benzodiazepine, would be an appropriate next step if the patient had signs or symptoms of alcohol withdrawal. Alcohol withdrawal can begin as early as 6 hours after refraining from alcohol intake in a chronic alcohol user.  Information regarding alcohol intake is not provided in the question, but objective clinical signs indicating withdrawal are not present on exam. Ordering a CT scan of the abdomen and pelvis (Choice B) is not required in making the diagnosis of acute pancreatitis.  A CT scan can be helpful if you are considering an alternative diagnosis (i.e. AAA, abdominal abscess, etc) or if there is concern for sepsis or fulminant pancreatitis. 

 

Diagnosis of pancreatitis is made clinically based on the history and physical exam, risk factors for the disease, and laboratory testing.  Pancreatitis typically presents as upper abdominal pain that radiates to the flanks and back.  Nausea and vomiting are frequent accompanying symptoms. The disease can range from mild symptoms to severe symptoms with pancreatic necrosis, multi-organ failure, shock, and Acute Respiratory Distress Syndrome (ARDS). Serum lipase testing is more specific than amylase for pancreatitis. Lipase is elevated in pancreatitis.  Risk factors for the disease include gallstones, alcohol use, abdominal trauma, recent ERCP, hypertriglyceridemia, pancreatic ischemia, scorpion envenomation, certain viral infections (Mumps, CMV), hypercalcemia, and certain medications (sulfonamides, azathioprine, valproic acid, etc).  The most common cause of first-time pancreatitis is gallstones. A gallbladder ultrasound should always be performed in patients with a gallbladder who present with pancreatitis. A surgical consultation (Choice C) for gallbladder removal would be warranted if this patient had gallstone pancreatitis, but the patient has a history of a cholecystectomy. The likely cause of this patient’s pancreatitis is his alcohol abuse which causes direct pancreatic injury and inflammation. Treatment of pancreatitis includes IV hydration (Choice D), analgesia, antiemetics, and monitoring for electrolyte abnormalities. Avoiding food or liquid intake (NPO) for “pancreatic rest” has been recommended historically for all cases of pancreatitis, however there is not robust evidence to support this practice.  Routine antibiotics are not recommended for acute pancreatitis, unless there are signs of sepsis.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #32," in International Emergency Medicine Education Project, March 26, 2021, https://iem-student.org/2021/03/26/question-of-the-day-32/, date accessed: April 18, 2021

Question Of The Day #31

question of the day
qod31
CT bowel wall thickness - m

Which of the following is the most likely diagnosis causing this patient’s symptoms?

This elderly female patient presents to the emergency department with acute onset of severe abdominal pain, vomiting, and diarrhea. Compared to younger patients, abdominal pain in an elderly patient has a higher likelihood of being due to a surgical emergency or from a diagnosis that carries a higher mortality. Elderly patients may have more nonspecific associated symptoms that may make it difficult to confirm a dangerous diagnosis without advanced imaging.  Additionally, elderly patients do not always have a fever or elevated white blood cells during an abdominal infection.  The differential diagnosis of abdominal pain in an elderly patient should be broad and encompass conditions related to many body systems.

The patient in this question has pain that is reported as being significantly high in relation to the minimal amount of abdominal tenderness provoked by the physical exam. This finding, known as “pain out of proportion” should raise concern for an ischemic etiology of the patient’s pain.  Ruptured appendicitis (Choice A) is less likely as the patient lacks clinical signs of peritonitis (i.e. diffuse tenderness with guarding, fever, hypotension, signs of shock).  Appendicitis, although not impossible in an elderly individual, is a diagnosis that occurs more often in younger patients. Ruptured abdominal aortic aneurysm (Choice B) typically results in death rapidly from hemorrhagic shock. This patient lacks signs of shock (hypotension, tachycardia, altered mental status), and her aorta on CT scan is not enlarged or aneurysmal (see image below).  Ureterolithiasis (Choice D), or a stone in the ureter, typically manifests as unilateral intermittent flank pain with hematuria. The question stem does not report a history of prior stones, and a first-time stone at an elderly age is not likely. 

Given the patent’s advanced age, her “pain out of proportion”, acute onset, risk factors for thromboembolic disease (Atrial fibrillation), the most likely diagnosis is acute mesenteric ischemia (Choice C). X-ray imaging can be used prior to CT angiogram imaging, but CT imaging is more specific and sensitive in making the diagnosis.  X-ray imaging may show bowel dilation, ileus, or pneumatosis intestinalis (air in bowel wall) in severe cases.  Lactate and D-Dimer testing can be used in the evaluation of these patients, but neither test is specific for mesenteric ischemia and reliable enough to rule out the disease. CT angiogram imaging of the abdomen and pelvis is the gold-standard diagnostic test for mesenteric ischemia.  Early CT findings include bowel wall thickening (seen on this patient’s imaging), dilated bowel, mesenteric edema, or ascites. Late CT findings include pneumoperitoneum, portal venous gas, and pneumatosis intestinalis.  Treatment of acute mesenteric ischemia is fluid resuscitation, broad spectrum antibiotics, surgical consultation, and consideration for anticoagulation.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #31," in International Emergency Medicine Education Project, March 19, 2021, https://iem-student.org/2021/03/19/question-of-the-day-31/, date accessed: April 18, 2021

Question Of The Day #30

question of the day
qod30

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

This patient arrives to the Emergency department with the return of spontaneous circulation (ROSC) from a ventricular fibrillation cardiac arrest. His regaining of pulses was likely due to his limited downtime, prompt initiation of CPR, and prompt diagnosis and treatment of ventricular fibrillation with electrical defibrillation. Important elements of emergency post-ROSC care include avoiding hypotension, hypoxia, hyperthermia, and hypo or hyperglycemia. Maintaining proper perfusion to the brain and peripheral organs is crucial in all ROSC patients. A 12-lead EKG should always be obtained early after ROSC is achieved in order to look for signs of cardiac ischemia. Cardiac catheterization should be considered in all post-ROSC patients, but especially in patients with cardiac arrest from ventricular fibrillation or ventricular tachycardia.

Patients who achieve ROSC can vary markedly in terms of their clinical exam. Some patients may be awake and conversive, while others are comatose and non-responsive. The neurological exam immediately post-ROSC does not predict long-term outcomes, so decisions on prognosis should not be based on these factors in the emergency department. For this reason, resuscitation efforts should not be considered medically futile in this scenario (Choice A). Vasopressors (Choice B) are medications useful in post-ROSC patients who have signs of hemodynamic collapse, such as hypotension. This patient is not hypotensive and does not meet the criteria for initiation of vasopressors. A CT scan of the head (Choice D) is a study to consider in any patient who presents to the emergency department with collapse to evaluate intracranial bleeding (i.e., subarachnoid bleeding). Although not impossible, the history of chest pain before collapse makes brain bleeding a less likely cause of death in this patient. Targeted Temperature Management (Choice C), also known as Therapeutic Hypothermia, is the best next step in this patient’s management.

Targeted Temperature Management involves a controlled lowering of the patient’s body temperature to 32-34ᵒC in the first 24 hours after cardiac arrest. This treatment has been shown to improve neurologic and survival outcomes. The theory behind this treatment is that hypothermia post-ROSC reduces free radical damage and decreases cerebral metabolism. Data behind targeted temperature management shows the greatest benefit in cardiac arrest patients due to ventricular fibrillation, but arrest from ventricular tachycardia, pulseless electrical activity, and asystole may also show benefit. Adverse effects of this treatment include coagulopathy, bradycardia, electrolyte abnormalities (i.e., hypokalemia), and shivering. Important contraindications to this treatment are an awake or alert patient (post-ROSC GCS >6), DNR or DNI status, another reason to explain comatose state (i.e., intracranial bleeding, spinal cord injury), age under 17 years old, a poor functional status prior to the cardiac arrest (i.e., nonverbal, bedbound), or an arrest caused by trauma. Correct Answer: C

References

 

Cite this article as: Joseph Ciano, USA, "Question Of The Day #30," in International Emergency Medicine Education Project, March 12, 2021, https://iem-student.org/2021/03/12/question-of-the-day-30/, date accessed: April 18, 2021

Question Of The Day #29

question of the day
qod29
842 - Wide QRS complex tachycardia

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

This patient presents to the emergency department with seven days of severe vomiting, diarrhea, tachycardia, and borderline hypotension. The clinician should be concerned about dehydration and potential electrolyte derangements induced by the vomiting and diarrhea. Certain electrolyte derangements can put a patient at risk for cardiac dysrhythmias, so ordering a 12-lead EKG is an important step in evaluating any patient with a potential electrolyte disturbance. Dangerous electrolyte disturbances that can predispose a patient to cardiac dysrhythmias include hyperkalemia, hypokalemia, hypomagnesemia, and hypocalcemia. Signs of hyperkalemia on the EKG include peaked T waves, absent or flattened P waves, widened QRS complexes, or a sine wave morphology. Low potassium, magnesium, and calcium can all prolong the QT interval and predispose the patient to polymorphic ventricular tachycardia (Torsades de Pointes). Hypokalemia on EKG may also be associated with a U wave, which is an upward wave that follows the T wave.

This patient’s 12-lead EKG shows a wide-complex tachycardia with QRS complex “twisting” around the isoelectric line and varying QRS amplitudes. These EKG signs, along with the inferred history of severe electrolyte abnormalities, support a diagnosis of Torsades de Pointes (TdP). Another risk factor for TdP is a history of congenital prolonged QT syndromes. Similar to monomorphic ventricular tachycardia, TdP should always be treated with electrical cardioversion if there are any signs of instability (i.e., altered mental status, SBP <90mmHg). A pulseless patient with TdP always necessitates unsynchronized cardioversion, also known as defibrillation. This patient may have briefly syncopized or potentially underwent cardiac arrest. Intravenous Amiodarone (Choice A) and Procainamide (Choice B) are contraindicated in TdP as both of these agents can further prolong the QT interval. These agents can be used in a stable patient with monomorphic ventricular tachycardia. Intravenous Ciprofloxacin (Choice C) is a quinolone antibiotic that is useful for treating infections from gram-negative bacteria. This may be beneficial for this patient, especially if there is a concern for bacterial gastroenteritis. However, quinolone antibiotics also can prolong the QT interval, and this medication will not acutely stabilize this patient. Intravenous Magnesium Sulfate (Choice D) shortens the QT interval and is the preferred therapy for a TdP patient with a pulse. Correct Answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #29," in International Emergency Medicine Education Project, March 5, 2021, https://iem-student.org/2021/03/05/question-of-the-day-29/, date accessed: April 18, 2021

Question Of The Day #28

question of the day
qod28

EKG#1

710 - hyperkalemia

EKG#2

855 - bradycardia

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

This patient presents to the emergency department with vague and nonspecific symptoms of nausea, fatigue, and palpitations. The initial EKG (EKG #1) demonstrates a wide-complex tachycardia (QRS >120msec) with a regular rhythm. The differential diagnosis for wide-complex tachyarrhythmias include ventricular tachycardia (monomorphic ventricular tachycardia), torsades de pointes (polymorphic ventricular tachycardia), coarse ventricular fibrillation, supraventricular tachycardias with aberrancy (i.e. underlying Wolf Parkinson White Syndrome or Ventricular Bundle Branch Block), electrolyte abnormalities (i.e., Hyperkalemia), and from medications (i.e., Na channel blocking agents). If the history is unclear or the patient shows signs of instability, Ventricular tachycardia should always be the assumed tachyarrhythmia. This is managed with electrical cardioversion or with medications (i.e., amiodarone, procainamide, lidocaine), depending on the patient’s symptoms and hemodynamic stability.

The prior EKG for the patient (EKG #2) is helpful in showing that the patient does not have a wide QRS complex at baseline. There also are no EKG signs of Wolf Parkinson White Syndrome (Choice B) on EKG #2, making this choice incorrect. Signs of this cardiac pre-excitation syndrome on EKG include a shortened PR interval and a delta wave (slurred upstroke at the beginning of the QRS complex). Anxiety (Choice D) can cause sinus tachycardia and be a symptom associated with any arrhythmia, but it is not the underlying cause for this patient’s bizarre wide-complex tachydysrhythmia. On a closer look, the patient’s EKG (EKG #1) demonstrates tall, peaked T waves in the precordial leads. This supports a diagnosis of hyperkalemia. Other signs of hyperkalemia on EKG include flattened or absent P waves, widened QRS complexes, or a sine wave morphology. A common underlying cause of hyperkalemia is renal disease (Choice C). Ischemic heart disease (Choice A) is a common underlying cause for ventricular tachycardia. Ventricular tachycardia is less likely in this case given the presence of peaked T waves and the lack of fusion beats, capture beats, or signs of AV dissociation on the 12-lead EKG. Correct Answer: C 

References

  • Brady W.J., & Glass III G.F. (2020). Cardiac rhythm disturbances. Tintinalli J.E., Ma O, Yealy D.M., Meckler G.D., Stapczynski J, Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=218687685
  • Burns, E. (2020). Ventricular Tachycardia – Monomorphic VT. Life in The Fast Lane. Retrieved from https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #28," in International Emergency Medicine Education Project, February 26, 2021, https://iem-student.org/2021/02/26/question-of-the-day-28/, date accessed: April 18, 2021

Question Of The Day #27

question of the day
qod27
756.1 - palpitation - SOB

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

This patient has a narrow-complex, regular tachycardia that is causing the sensation of palpitations. The clinical history, rapid heart rate, and 12-lead EKG provide enough information to diagnose this patient with supraventricular tachycardia, also known as “SVT.” Supraventricular tachycardias refer to a broad range of arrhythmias, including sinus tachycardia, atrial fibrillation, atrial flutter, multifocal atrial tachycardia, and AV nodal re-entry tachycardia. This scenario specifically depicts an AV nodal re-entry tachycardia (AVNRT). AVNRT is a common type of SVT that can occur spontaneously or is triggered by sympathomimetic agents (i.e., cocaine, amphetamines), caffeine, alcohol, exercise, or beta-2 agonists using in asthma treatment (i.e., albuterol, salbutamol). AVNRTs are narrow-complex tachycardias with rates that range from 120-280bpm. P waves are typically absent in AVNRTs, but rarely they may be present as retrograde inverted P waves located immediately before or after the QRS complex. Symptoms experienced by the AVNRT patient may include pre-syncope, syncope, dizziness, palpitations, anxiety, or mild shortness of breath. Patients with AVNRTs are more likely to be young and female over male.

QRS complexes in AVNRTs are often narrow (<120msec), however, wide QRS complexes may be present in AVNRTs if there is a concurrent bundle branch block or Wolff-Parkinson White Syndrome. AVNRTs are often stable and do not require electric cardioversion. Signs that indicate instability and necessitate cardioversion are hypotension (SBP <90mmHg), altered mental status, or ischemic chest pain (more common if known history of ischemic heart disease). This patient lacks all of these signs and symptoms.

Treatment of AVNRT focuses on restoring the patient to normal sinus rhythm, which leads to resolution of symptoms. First-line medications for AVNRTs are short-acting AV nodal blocking agents, like adenosine (Choice A). Beta-blockers or calcium channel blockers act as second-line agents for patients who do not respond to adenosine. Metoprolol is a beta-blocker (Choice C) and Diltiazem is a calcium channel clocker (Choice D). Prior to any medications, vagal maneuvers should always be attempted first in a stable patient with AVNRT. The Valsalva maneuver (Choice B), or “bearing down,” is a commonly used vagal maneuver in the termination of AVNRTs. Other vagal maneuvers include the carotid massage or the Diving reflex (place bag of ice and water on face). Correct Answer: B

References

  • Brady W.J., & Glass III G.F. (2020). Cardiac rhythm disturbances. Tintinalli J.E., Ma O, Yealy D.M., Meckler G.D., Stapczynski J, Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=218687685
  • Burns, E. (2020). Supraventricular Tachycardia (SVT). Life in the Fast Lane. Retrieved from https://litfl.com/supraventricular-tachycardia-svt-ecg-library/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #27," in International Emergency Medicine Education Project, February 19, 2021, https://iem-student.org/2021/02/19/question-of-the-day-27/, date accessed: April 18, 2021

Question Of The Day #26

question of the day
qod26
38 - atrial fibrillation

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

This patient presents to the emergency department with palpitations, a narrow complex tachycardia (<120msec), and an irregularly irregular rhythm. A close look at this patient’s EKG reveals the absence of discrete P waves and QRS complexes that are spaced at varying distances from each other (most apparent in lead V6). These signs support a diagnosis of Atrial Fibrillation, or “AFib.” Atrial Fibrillation is an arrhythmia characterized by an irregularly irregular rhythm, the absence of P waves with a flat or undulating baseline, and narrow QRS complexes. Wide-QRS complexes may be present in AFib if there is a concurrent bundle branch block or Wolff-Parkinson White Syndrome. AFib is caused by the electric firing of multiple ectopic foci in the atria of the heart. This condition is triggered by a multitude of causes, including ischemic heart disease, valvular heart disease, dilated or hypertrophic cardiomyopathies (likely related to this patient’s congestive heart failure history), sepsis, hyperthyroidism, excess caffeine or alcohol intake, pulmonary embolism, and electrolyte abnormalities.

The main risk in AFib is the creation of thrombi in the atria as they fibrillate, resulting in emboli that travel to the brain and cause a stroke. The CHA2DS2VASc scoring system is used to risk stratify patients and determine if they require anticoagulation to prevent against thrombo-embolic phenomenon (i.e. stroke). This patient has a high CHA2DS2VASc score, so she would require anticoagulation. In addition to anticoagulation, A fib is treated with rate control (i.e. beta blockers or calcium channel blockers), rhythm control (i.e. anti-arrhythmic agents), or electrical cardioversion. Electrical cardioversion (choice A) is typically avoided when symptoms occur greater than 48 hours, since the risk of thrombo-emboli formation is higher in this scenario. An exception to this would be a patient with “unstable” AFib. Signs of instability in any tachyarrhythmia are hypotension, altered mental status, or ischemic chest pain. This patient lacks all of these signs and symptoms. Although this patient lacks signs of instability, this patient’s marked tachycardia should be addressed with medical treatment. General observation (Choice C) is not the best choice for this reason. Intravenous adenosine (Choice D) is the best choice for a patient with supraventricular tachycardia (SVT). This is a narrow-complex AV nodal re-entry tachycardia with rates that range from 120-280bpm. SVT also lacks discrete P waves. A key factor that differentiates A fib from SVT is that SVT has a regular rhythm, while AFib has an irregular rhythm. Intravenous metoprolol (Choice B) is the best treatment option listed in order to decrease the patient’s heart rate.

References

  • Brady W.J., & Glass III G.F. (2020). Cardiac rhythm disturbances. Tintinalli J.E., Ma O, Yealy D.M., Meckler G.D., Stapczynski J, Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=218687685
  • Burns, E. (2020) Atrial Fibrillation. Life in The Fast Lane. Retrieved from https://litfl.com/atrial-fibrillation-ecg-library/

 

Cite this article as: Joseph Ciano, USA, "Question Of The Day #26," in International Emergency Medicine Education Project, February 12, 2021, https://iem-student.org/2021/02/12/question-of-the-day-26/, date accessed: April 18, 2021

Question Of The Day #25

question of the day
qod25
835 - 3rd degree heart block

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

This patient has marked bradycardia on exam with a borderline low blood pressure. These vital sign abnormalities are likely the cause of the patient’s dizziness. Bradycardia is defined as any heart rate under 60 beats/min. The most common cause of bradycardia is sinus bradycardia (Choice A). Other types of bradycardia include conduction blocks (i.e. type 2 or type 3 AV blocks), junctional rhythms (lack of P waves with slow SA nodal conduction), idioventricular rhythms (wide QRS complex rhythms that originate from the ventricles, not atria), or low atrial fibrillation or atrial flutter. About 80% of all bradycardias are caused by factors external to the cardiac conduction system, such as hypoxia, drug effects (i.e., beta block or calcium channel blocker use or overdose), or acute coronary syndromes.

ecg qod25Sinus bradycardia (Choice A) occurs when the electrical impulse originates from the SA node in the atria. Signs of sinus bradycardia on EKG are the presence of a P wave prior to every QRS complex. This EKG shows P waves prior to each QRS complex, but there are extra P waves that are not followed by QRS complexes. Some P waves are “buried” within QRS complexes or within T waves. The EKG below marks each P wave with a red line and each QRS complex with a blue line.

 

First-degree AV Block (Choice B) is a benign arrhythmia characterized by a prolonged PR interval. This patient’s EKG has variable PR intervals (some prolonged, some normal). This is a result of a more severe AV conduction block. Second-Degree AV Blocks are divided into Mobitz type I and Mobitz Type II. Mobitz type I, also known as Wenckebach, is characterized by a progressive lengthening PR interval followed by a dropped QRS complex. This can be remembered by the phrase, “longer, longer, longer, drop.” Wenckebach is a benign arrhythmia that does not typically require any treatment. Mobitz type II (Choice C) is characterized by a normal PR interval with random intermittent dropping of QRS complexes. This patient’s EKG has consistent spacing between each QRS complex (blue lines) and consistent spacing between each P wave (red lines). However, the P waves and QRS complexes are not associated with each other. This phenomenon is known as AV dissociation. These EKG changes are signs of a complete heart block, also known as Third-Degree AV Block (Choice D). Both Second-Degree AV block- Mobitz type II (Choice C) and Third-Degree AV Block (Choice D) are more serious conduction blocks that require cardiac pacemakers. Correct Answer: D

References

  • Brady W.J., & Glass III G.F. (2020). Cardiac rhythm disturbances. Tintinalli J.E., Ma O, Yealy D.M., Meckler G.D., Stapczynski J, Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=218687685
  • Nickson, C. (2020). Heart Block and Conduction Abnormalities. Life in the Fast Lane. Retrieved from https://litfl.com/heart-block-and-conduction-abnormalities/

 

Cite this article as: Joseph Ciano, USA, "Question Of The Day #25," in International Emergency Medicine Education Project, February 5, 2021, https://iem-student.org/2021/02/05/question-of-the-day-25/, date accessed: April 18, 2021

Erythema Types in Medicine – Rapid Review For Medical Students

Our skin, the largest organ in the human body, is crucial for maintaining life and overall health. It serves as an airtight, watertight and flexible barrier with the outside world and helps with temperature regulation, immune defense, vitamin production and sensation.

However, the skin is unique in that no other organ demands as much attention in states of disease and health. Our skin’s quality and condition significantly contribute to health, wellness, youth, and beauty perceptions. Such a focus even causes self-esteem and mental health problems stemming from scars, acne, and inflammation to abnormal redness of the skin known as erythema.

Erythema stems from the dilation and irritation of the superficial capillaries and the augmented blood flow that imparts a reddish hue to the skin. Often presenting as a rash, erythema can be caused by environmental factors, infection, or overexposure to the sun.

Since exam season is here, this serves as a rapid review to recall the most common types of Erythema!

Erythema Ab Igne (EAI)

  • The skin reaction stems from chronic exposure to infrared radiation in the form of heat. Once considered a common condition of the elderly who stood or sat closely to open fires or electric space heaters. EAI has reduced significantly with the advent of central heating, although it is still found in individuals exposed to heat from other sources. In EAI, the skin and underlying tissue begin to atrophy, causing patients to complain of mild itchiness and a burning sensation.
  • To prevent the progression of EAI, discontinuing contact with the heat source is necessary.
  •  

Hotbottlerash.JPG
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Chronicum Migrans

  • The primary manifestation of Lyme Disease, erythema chronicum migrans appears 7 to 14 days after the infected tick bite. As an expanding red patch of skin, the size of the rash can reach several centimetres in diameter. The central spot surrounded by clear skin ringed by an expanding red rash known as a bull’s-eye is the most typical appearance.
  • Successful treatment of erythema migrans may be accomplished with 20 days of oral doxycyclineamoxicillin, or cefuroxime axetil.
  •  

Bullseye Lyme Disease Rash.jpg
By Hannah Garrison – <a href=”https://en.wikipedia.org/wiki/User:Jongarrison&#8221; class=”extiw” title=”en:User:Jongarrison”>en:User:Jongarrison</a>, CC BY-SA 2.5, Link

Erythema Induratum

  • Erythema induratum from Bazin disease presents as recurring nodules or lumps on the back of the legs in mostly women that ulcerate and scar.
  • Drugs for treatment include isoniazid, rifampicin, and pyrazinamide, that may be administered orally or intravenously in combination.

An introduction to dermatology (1905) erythema induratum 2.jpg
By Norman Purvis Walker – Walker, Norman Purvis (<span style=”white-space:nowrap”>1905</span>) <a rel=”nofollow” class=”external text” href=”https://books.google.com/books?id=fnYoAAAAYAAJ”>An introduction to dermatology</a> (3rd ed.), William Wood and company Retrieved on 26 September 2010., Public Domain, Link

Erythema Infectiosum or Fifth Disease

  • Erythema infectiosum is also known as the Fifth disease. It is caused by Parvovirus B19 that affects mostly children. The main clinical feature is the “slapped face” appearance along with a sore throat, mild fever and malaise, and signs of Fifth Disease’s prodrome period. The confluent netlike rash begins on the cheeks and spreads to the trunk and extremities.
  • Children may be given NSAIDs to alleviate and relieve fever, headache and achiness.

Fifth disease.jpg
By Andrew Kerr – <span class=”int-own-work” lang=”en”>Own work</span>, Public Domain, Link

Erythema Marginatum

  • Erythema marginatum rheumaticum occurs in about 10% of first attacks of Acute Rheumatic Fever (ARF) in children appearing on their trunk, upper arms and legs as pink or red macules or papules spreading in a circular shape. As the lesions advance, the edges become raised, red, and persist intermittently for weeks to months, even after successful ARF treatment.
  • There is no treatment for erythema marginatum specifically as the rash fades on its own.

Erythema Multiforme

  • Erythema multiforme is a cell-mediated cytotoxic reaction in the skin and mucous membranes triggered by Mycoplasma Pneumoniae or Herpes Simplex Virus or even drugs as sulfonamides, penicillin, barbiturates, NSAIDs, & phenytoin. Vesicles and bullae on the soles, palms, and extensor surfaces with a “targetoid” appearance are characteristic of the rash. Without treatment and care by dermatologists, Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) occur as they are severe forms of erythema multiforme.
  • Treatment includes oral antihistamines, analgesics, local skincare, and soothing mouthwashes.

Erythema multiforme minor of the hand.jpg
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Nodosum

  • Erythema nodosum is an acute inflammatory reaction involving the subcutaneous fat where the skin becomes red, raised and painful on the anterior portions of the shins and wrist. It is more common in women than men, and although the most identifiable cause is streptococcal pharyngitis, it is associated with coccidioidomycosis, histoplasmosis, tuberculosis, leprosy, sarcoidosis, ulcerative colitis, and pregnancy.
  • Anti-inflammatory drugs and corticosteroids by mouth or local injection may serve as treatment options. Colchicine is also administered to reduce inflammation.

ENlegs.JPG
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Toxicum Neonatorum

  • Erythema toxicum neonatorum is a self-limited skin eruption occurring in newborns due to an unknown cause. Erythematous papules, macules and plaques present in all sites except the soles and palms and may last approximately 2-3 weeks.
  • No treatment is necessary for erythema toxicum neonatorum as the lesions regress after 5 days to 2 weeks.

Erythema Elevatum Diutinum (EED)

  • Erythema elevatum diutinum (EED) is a type of necrotising vasculitis characterised by red, purple, or brown papules, plaques, or nodules. It is a rare form of erythema usually found on extensor surfaces overlying the joints, and the buttocks. It is a chronic and progressive skin disease that may last as long as 25 years.
  • The drug of choice for EED is Dapsone because of its rapid onset of action; however, it is possible for lesions to recur the following withdrawal promptly.

Erythema elevatum diutinum on hand.jpg
By <a href=”//commons.wikimedia.org/w/index.php?title=User:Dswierc&amp;action=edit&amp;redlink=1″ class=”new” title=”User:Dswierc (page does not exist)”>D Swierczek</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 4.0, Link

Erythema Gyratum Repens

  • Erythema gyratum repens is a rare paraneoplastic type of annular erythema with a ‘wood-grain’ appearance associated with malignancy. Furthermore, almost half of the patients with erythema gyratum repens have lung cancer and less commonly, oesophageal, breast, and stomach cancer.
  • The rash usually resolves once the malignancy has been removed with surgical resection.

References and Further Reading

Cite this article as: Leah Sarah Peer, Canada, "Erythema Types in Medicine – Rapid Review For Medical Students," in International Emergency Medicine Education Project, January 4, 2021, https://iem-student.org/2021/01/04/erythema-review-for-medical-students/, date accessed: April 18, 2021