Question Of The Day #48

question of the day

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

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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #48," in International Emergency Medicine Education Project, July 30, 2021, https://iem-student.org/2021/07/30/question-of-the-day-48/, date accessed: August 5, 2021

Question Of The Day #47

question of the day

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 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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #47," in International Emergency Medicine Education Project, July 23, 2021, https://iem-student.org/2021/07/23/question-of-the-day-47/, date accessed: August 5, 2021

Question Of The Day #46

question of the day

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 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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #46," in International Emergency Medicine Education Project, July 16, 2021, https://iem-student.org/2021/07/16/question-of-the-day-46/, date accessed: August 5, 2021

Question Of The Day #45

question of the day

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 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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #45," in International Emergency Medicine Education Project, July 9, 2021, https://iem-student.org/2021/07/09/question-of-the-day-45/, date accessed: August 5, 2021

Question Of The Day #44

question of the day

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

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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #44," in International Emergency Medicine Education Project, July 2, 2021, https://iem-student.org/2021/07/02/question-of-the-day-44/, date accessed: August 5, 2021

Question Of The Day #43

question of the day

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

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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #43," in International Emergency Medicine Education Project, June 25, 2021, https://iem-student.org/2021/06/25/question-of-the-day-43/, date accessed: August 5, 2021

Question Of The Day #42

question of the day

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 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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #42," in International Emergency Medicine Education Project, June 18, 2021, https://iem-student.org/2021/06/18/question-of-the-day-42/, date accessed: August 5, 2021

Question Of The Day #41

question of the day

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

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 depend 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 infographic below outlines this mnemonic.

ALTERED MENTAL STATUS

This patient is awake and moving all extremities, but with obvious confusion and dysarthria. Ordering a CT scan of the head without contrast (Choice A) may be helpful in this patient to evaluate for intracerebral hemorrhage, stroke, or a brain mass. However, the question stem indicates that this patient has a low glucose level. Glucose is considered low at levels below 70mg/dL (3.9 mmol/L); however, the absence of any symptoms can be reassuring. Glucose levels that are more severely low (less than 40mg/dL (2.2 mmol/L)) are more concerning than levels that are only moderately low (less than 70mg/dL (3.9mmol/L)). All patients with altered mental status should have a point of care glucose test. Both hypoglycemia and severe hyperglycemia can cause altered mental status. Hypoglycemia, if left untreated, can cause permanent brain damage. For this reason, the prompt identification of low blood glucose is critical so it can be treated rapidly.

Administration of IV hypertonic 3% NaCl (Choice B) would be helpful in a patient with severe hyponatremia with altered mental status or seizure. However, the question stem provides a cause for the patient’s symptoms (low glucose). IV potassium chloride (Choice D) would be helpful in the case of hyperkalemia to stabilize the cardiac membrane. Severe hyperkalemia can cause weakness and arrythmias, but does not cause dysarthria. This patient is at higher risk for hyperkalemia as he is a hemodialysis patient, but no evidence is given that he has hyperkalemia (i.e., peaked T waves on EKG or widened QRS interval). Again, a low glucose level is given in the question stem, which should be treated first.

IV dextrose (Choice C) is the best next step in management for this patient’s hypoglycemia. This patient has had poor oral intake and has end-stage renal disease. Insulin is excreted by the kidneys, so patients with end-stage renal disease are more prone to insulin “buildup” and hypoglycemia. In addition to administering IV dextrose (i.e., D50 bolus), providing food with complex carbohydrates is important to prevent recurring hypoglycemic episodes. If the patient continues to have persistent hypoglycemia despite an IV dextrose bolus and food, a continuous IV dextrose infusion (i.e., D10W at 100cc/hour) and admission for further evaluation should be considered. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #41," in International Emergency Medicine Education Project, May 28, 2021, https://iem-student.org/2021/05/28/question-of-the-day-41/, date accessed: August 5, 2021

Question Of The Day #40

question of the day

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

This elderly patient presents to the emergency department with left lower abdominal pain, constipation, and anorexia. The exam shows fever, tachycardia, and marked left lower quadrant tenderness. 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 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 most likely diagnosis for this patient is diverticulitis based on the location of the pain. Features of diverticulitis include left lower quadrant pain, nausea, vomiting, change in bowel habits (diarrhea or constipation), anorexia, fever, and leukocytosis. Right-sided diverticulitis is more common in patients of Asian descent, so these patients may alternatively present with right lower quadrant pain. Treatment for acute diverticulitis includes antibiotics, bowel rest, hydration, increased dietary fiber, and pain management.

Other potential diagnoses to consider for this patient include perforated diverticulitis, abdominal abscess, colitis, bowel obstruction, malignancy, AAA, urinary tract infection, ureterolithiasis, and soft tissue infections. The best next step in the management of this patient is to treat empirically for an abdominal infection with IV hydration, antipyretics, and antibiotics. Sepsis from a gastrointestinal source requires antibiotics that cover both gram-negative and anaerobic bacteria. IV Vancomycin (Choice A) is helpful for skin infections, soft tissue infections, MRSA (Methicillin-resistant Staph aureus) infections, or other infections from gram-positive organisms. Vancomycin would not include coverage for a gastrointestinal source. IV Metronidazole covers anaerobic bacteria, and Ciprofloxacin covers gram-negative bacteria. This makes Choice D the best antibiotic choice for this patient. Other options include IV ampicillin-sulbactam, ampicillin and metronidazole, piperacillin-tazobactam, ticarcillin-clavulanate, or imipenem. A CT scan on the abdomen and pelvis (Choice B) should be performed on this patient (ideally with PO and IV contrast). However, IV hydration and antibiotics are a more important initial step to address the patient’s sepsis. CT scanning is recommended for first-time diverticulitis episodes or if there are alternative diagnoses on the differential. Patients with a history of recurrent diverticulitis who present to the Emergency department with uncomplicated acute diverticulitis are able to be treated empirically with oral antibiotics in the outpatient setting. Ill-appearing patients, have no prior history of diverticulitis or have possible alternative diagnoses should get CT imaging. Emergent colonoscopy (Choice C) is not indicated as part of the Emergency department management of acute diverticulitis. In fact, colonic inflammation or inflamed diverticuli are contraindications to colonoscopy (increased risk of bowel rupture). Correct answer: D

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #40," in International Emergency Medicine Education Project, May 21, 2021, https://iem-student.org/2021/05/21/question-of-the-day-40/, date accessed: August 5, 2021

Question Of The Day #39

question of the day
Abnormal Right Upper Quadrant

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

This female patient presents to the Emergency department with atraumatic right shoulder pain, generalized abdominal discomfort, and vaginal bleeding.  She is found to have a positive urine pregnancy test and signs of shock on physical exam (hypotension and tachycardia).  The FAST exam (Focused Assessment with Sonography for Trauma) demonstrates free fluid around the liver.  This quick bedside sonographic exam evaluates the right upper quadrant (liver, right kidney, right lung base), left upper quadrant (spleen, left kidney, left lung base), suprapubic area (bladder), and subxiphoid area (view of heart).  The FAST exam is typically used in the setting of trauma to assess for intra-abdominal bleeding, or “free fluid”.  Fluid on ultrasound appears black, or anechoic.  In the setting of trauma or presumed hemorrhagic shock, free fluid is assumed to be blood.  The hepato-renal recess, also known as Morrison’s pouch, is the most common site for fluid to be seen on a FAST exam.  For this reason, the right upper quadrant should always be viewed first during a FAST exam if there is concern for hemorrhagic shock.  The patient’s right upper quadrant FAST view is annotated below.

This patient is in shock with free fluid in her right upper quadrant FAST view.  In the setting of a pregnancy of unknown origin, shock, and abdominal free fluid, a ruptured ectopic pregnancy is assumed to be the diagnosis.  A cystic adnexal structure and a uterus without a gestational sac can also be noted on ultrasound.  Ectopic pregnancy can present with mild symptoms ranging from abdominal pain and vaginal bleeding to signs of shock with hemoperitoneum as in this patient.  Risk factors for ectopic pregnancy include prior ectopic pregnancies, prior tubal surgeries, prior sexually transmitted infections, tobacco smoking, and use of an intrauterine device (IUD).  Initial Emergency department treatment should include volume resuscitation with blood products, pre-operative laboratory testing, and prompt OB/GYN consultation (Choice C).  Patients who are unstable, show signs of shock, or have large ectopic pregnancies are treated operatively.  Patients with stable vital signs, small ectopic pregnancies, and minimal symptoms are treated medically with Methotrexate (Choice A).   This patient’s hemodynamic instability makes Methotrexate contraindicated in her treatment course.  The patient’s atraumatic shoulder pain is likely from free fluid in the right upper quadrant, causing referred pain to the shoulder from diaphragmatic irritation.  A shoulder X-ray (Choice B) is not indicated in this patient.  Rho(D) immune globulin (RhoGAM) (Choice D) is an important treatment to provide in Rh-negative mothers with ectopic pregnancy.  RhoGAM is indicated in maternal-fetal hemorrhage in order to prevent the maternal immune system from attacking fetal Rh-positive cells in future pregnancies.  RhoGAM is indicated in Rh-negative mothers, not Rh-positive mothers.  The question does not indicate the mother’s blood type or Rh status, however, RhoGAM is not the best initial treatment.  Treatment of the hemorrhagic shock and OB/GYN consultation are the best next steps.  Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #39," in International Emergency Medicine Education Project, May 14, 2021, https://iem-student.org/2021/05/14/question-of-the-day-39/, date accessed: August 5, 2021

Question Of The Day #38

question of the day
251 - Gallbladder stone with thickened wall
Which of the following is the most likely cause for this patient’s condition?

This patient presents to the emergency department with upper abdominal pain, nausea, and vomiting. The physical exam demonstrates fever, tachycardia, and focal right upper quadrant abdominal tenderness. Differential diagnoses to consider include cholecystitis, choledocholithiasis, cholangitis, hepatitis, pancreatitis, and ruptured peptic ulcer. The ultrasound image provided shows a thickened gallbladder wall (>4mm) and a gallstone present. See the labeled image below.

Signs of acute cholecystitis on ultrasound include a thickened gallbladder wall, pericholecystic fluid (anechoic (black) fluid around gallbladder), the presence of a gallstone (hyperechoic (white) with posterior shadowing), sonographic Murphy sign (tenderness when the transducer is pressed into gallbladder), and a dilated gallbladder. This patient has some but not all sonographic signs of cholecystitis. However, the age, obese body habitus, fever, and location of the pain support a diagnosis of acute cholecystitis (Choice B). Treatment of acute cholecystitis involves IV hydration, parenteral pain management and antiemetics, IV antibiotics, and surgical consultation for cholecystectomy. Biliary colic (Choice A) is less likely given the ultrasound findings and fever on exam. If the patient’s vital signs were normal and the ultrasound showed gallstones with no other sonographic signs of cholecystitis, biliary colic would be more likely. Gastritis (Choice C) does not cause fever or the sonographic signs illustrated above. Gallstones are the most common cause of pancreatitis (Choice D), but there is focal tenderness over the gallbladder in the right upper quadrant. Additional findings, such as an elevated lipase level, pain that radiates to the back, or a history of alcohol abuse would make pancreatitis a more likely diagnosis. Correct Answer: B

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #38," in International Emergency Medicine Education Project, May 7, 2021, https://iem-student.org/2021/05/07/question-of-the-day-38/, date accessed: August 5, 2021

Question Of The Day #37

question of the day
25.1 - obstruction volvulus coffee bean 1

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

This elderly male patient presents to the emergency department with generalized abdominal pain and distension. 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 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 abdominal X-ray demonstrates a “coffee bean sign” and dilated loops of the large bowel (note haustra of the large bowel). The image supports the diagnosis of sigmoid volvulus, a type of large bowel obstruction that necessitates prompt surgical consultation in the Emergency department. Risk factors for sigmoid volvulus are elderly age, constipation, poor mobility, and residence in a long-term care facility. If left untreated, volvulus can result in intestinal ischemia, necrosis, perforation, and peritonitis. Sigmoid volvulus is most often treated with manual intestinal detorsion through flexible sigmoidoscopy or rectal tube. Cecal volvulus is more common in younger patients, and requires surgical bowel resection or cecopexy (fixing the cecum to the abdominal wall).

The abdominal X-ray provided is sufficient to make the diagnosis of volvulus. A CT scan of the abdomen and pelvis (Choice A) is not necessary for this patient. Surgical consultation is the next best step. IV antibiotics (Choice D) are indicated in volvulus if there are signs of intestinal perforation, necrosis, or peritonitis. The question stem indicates that although the abdomen is tender and distended, the abdomen is soft. This makes peritonitis and the need for antibiotics less likely. Surgical consultation for colectomy (Choice B) would be correct if the patient had cecal volvulus or if there were signs of bowel necrosis. Surgical consultation for bowel detorsion (Choice C) is the best next step for this patient with sigmoid volvulus. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #37," in International Emergency Medicine Education Project, April 30, 2021, https://iem-student.org/2021/04/30/question-of-the-day-37/, date accessed: August 5, 2021