Question Of The Day #14

question of the day
question of the day 14
40.1 - Pneumothorax 1

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

Anticoagulation (Choice A) would be the proper treatment for pulmonary embolism, NSTEMI/STEMI, and other conditions. This patient is dyspneic and hypoxemic on the exam, but his chest X-ray offers an alternative explanation for his symptoms. IV antibiotics (Choice D) would be helpful for pneumonia and COPD exacerbation, both of which are possible in this patient, but his chest X-ray offers an alternative explanation for his symptoms. Needle decompression of the left chest (Choice B) would be the appropriate initial treatment for a left-sided “tension” pneumothorax. This patient does have a large left-sided pneumothorax, but the X-ray lacks tracheal deviation, mediastinal shift, and left hemidiaphragm flattening, which can be attributed to tension pneumothorax. Most importantly, the patient lacks the hemodynamic instability that defines tension physiology (i.e. hypotension and tachycardia). In addition, the diagnosis and treatment of tension pneumothorax should be made clinically prior to chest radiography. Signs of hemodynamic instability along with tracheal deviation, absent unilateral lung sounds, and a history of trauma all support a diagnosis of tension pneumothorax. The treatment of a tension pneumothorax requires prompt recognition, needle decompression at the 3rd intercostal space at the midclavicular line, and a tube thoracostomy at the 4-5th intercostal space the anterior axillary line. The recommended needle decompression location is recently shifted to 4-5th intercostal space at the mid-anterior axillary line because the studies showed lower success rates in anterior – mid clavicular approach in adults. This patient has a spontaneous left-sided pneumothorax, not a tension pneumothorax. This is likely secondary to his coughing episodes and severe COPD. The treatment for this would be supplemental oxygen and the placement of a small-bore chest tube (i.e. “pig tail) in the left chest. Correct Answer: C. 

References

Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219641169

Nickson, C. (2019) Pneumothorax CCC. Life in the Fastlane. Accessed August 17, 2020. https://litfl.com/pneumothorax-ccc/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #14," in International Emergency Medicine Education Project, September 25, 2020, https://iem-student.org/2020/09/25/question-of-the-day-14/, date accessed: October 6, 2022

Question Of The Day #13

question of the day
qod13

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

This patient presents to the emergency department after an atypical, brief episode of chest pain. The list of potential diagnoses that may have caused the pain episodes is extensive. The focus of the Emergency Medicine practitioner should not be to determine the diagnosis per say, but rather to be to identify the presence of any life-threatening conditions (i.e. Myocardial infarction, Aortic dissection, Esophageal Rupture, Pulmonary embolism, Tension pneumothorax, Cardiac tamponade, etc.). Many of these serious diagnoses can be evaluated with a detailed history, physical exam, and basic imaging and lab work if needed. Many risk stratification tools have been developed to evaluate the likelihood a patient has chest pain due to Acute Coronary Syndrome. One well-supported tool with international validation is the HEART score tool. The HEART score categorizes a patient as low (0-3), moderate (4-6), or high risk (7-10) for a Major Adverse Cardiac Event (MACE) based on the patient’s history, EKG, age, risk factors, and troponin level. The below chart from Wieters et al. (2020) outlines the HEART score categories and how to make clinical decisions based on a patient’s score.

HEART score for cardiac risk assessment of major adverse cardiac event (MACE).

CategoryScoreExplanationRisk Features
HistoryHigh-risk features
• Middle- or left-sided chest pain
• Heavy chest pain
• Diaphoresis
• Radiation
• Nausea and vomiting
• Exertional
• Relief of symptoms by sublingual nitrates

Low-risk features
• Well localized
• Sharp pain
• Non-exertional
• No diaphoresis
• No nausea and vomiting
Slightly Suspicious 0Mostly low-risk features
Moderately Suspicious+1Mixture of high-risk and low-risk features
Highly Suspicious+2Mostly high-risk features
ECG
Normal0Completely Normal
Non-specific Repolarization Disturbance+1Non-specific repolarization disturbance• Repolarization abnormalities
• Non-specific T wave changes
• Non-specific ST wave depression or elevation
• Bundle branch blocks
• Pacemaker rhythms
• Left ventricular hypertrophy
• Early repolarization
• Digoxin effect
Significant ST Depression+2Significant ST depression• Ischemic ST-segment depression
• New ischemic T wave inversions
Age
<450
45-64+1
≥ 65+2
Risk Factors• Obesity (Body-Mass Index ≥ 30)
• Current or recent (≤ 90 days)smoker
• Currently treated diabetes mellitus
• Family history of coroner artery disease (1st degree relative < 55 year old)
• Hypercholesterolemia

OR

Any history of atherosclerotic disease earn 2 points:
• Know Coroner artery Disease: Prior myocardial infarctions, percutan coronary intervention (PCI) or coronary artery bypass graft
• Prior stroke or transient ischemic attack
• Peripheral arterial disease
No known risk factors0
1-2 risk factors+1
≥ 3 risk factors or history of atherosclerotic disease+2
Initial Troponin
≤ normal limit0
1-3 x normal limit+1
> 3x normal limit+2

Score 0–3 = 2.5 % MACE over next 6 wk: Discharge home
Score 4–6 = 22.3% MACE over next 6 wk: Admit for observation
Score 7–10 = 72.7% MACE over next 6 wk: Admit with early invasive strategies

The patient’s HEART score in this question would be 2 (1 point for age and 1 point for hypertension as a risk factor). This categorizes the patient as low risk for a MACE over the next six weeks. The appropriate course of action for this patient would be discharge home with prompt outpatient follow-up (Choice B). Admission for cardiac testing (Choice D) would be warranted for a moderate-high risk HEART score. Prescribing a benzodiazepine (Choice C) would not be warranted as this patient is asymptomatic and the pain episode is vague and atypical. Benzodiazepines are sometimes useful in patients with chest pain due to anxiety. Cardiology consultation (Choice A) would not be warranted as the patient has a low HEART score, is currently asymptomatic with normal imaging, blood work and troponin, and a normal EKG. Correct Answer: B 

References

Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219641169

Wieters J, McDonough J, Catral J. Chest Pain. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165059275

Cite this article as: Joseph Ciano, USA, "Question Of The Day #13," in International Emergency Medicine Education Project, September 18, 2020, https://iem-student.org/2020/09/18/question-of-the-day-13/, date accessed: October 6, 2022

Question Of The Day #12

question of the day

Which of the following medications should be avoided to prevent worsening of this patient’s condition?

This elderly female patient presents with chest pain described as post-prandial burning, radiating to the shoulders, and with associated nausea and diaphoresis. Burning chest pain after eating supports diagnoses, such as peptic ulcer disease, gastritis, gastroesophageal reflux, or biliary disease. However, chest pain that radiates to both shoulders (2.58 likelihood ratio) or has associated diaphoresis (1.50 likelihood ratio) should be very concerning for acute myocardial infarction (Smith & Mahler, 2020). Associated symptoms that should raise concern for acute coronary syndrome are any radiation of the chest pain, pain worsened with exertion, associated nausea or vomiting, pain described as pressure or squeezing, pain with associated diaphoresis, and pain described as feeling similar to prior ischemic events. This patient’s EKG demonstrates an inferior ST-segment elevation myocardial infarction (STEMI). This is indicated by two or more inferior EKG leads (II, III, and aVF) showing ST-segment elevation greater than 1 mm and reciprocal ischemic changes indicated in lateral leads (I, aVL). Aspirin (Choice A) should be given to all patients with high suspicion for ACS, assuming there are no contraindications. This patient has a confirmed STEMI on her EKG and should receive Aspirin for its antiplatelet effects. Ibuprofen (Choice B) may help the patient’s pain, but likely would not acutely worsen the patient’s clinical condition. Antacids (Choice C) are relatively benign medications, and they would be unlikely to worsen the patient’s clinical condition. Nitroglycerin (Choice D) is often given in patients with anginal chest pain for pain relief. In many inferior STEMIs, nitroglycerin can cause a dangerous drop in blood pressure and should be avoided. These patients may have infarction of the right ventricle, which makes these patients sensitive to nitrates and prone to precipitous drops in blood pressure. IV fluids are the preferred initial therapy in the setting of hypotension. About 40% of patients with an inferior STEMI have concurrent right ventricular infarction. About 80% of inferior STEMIs are caused by occlusions in the right coronary artery (RCA) and about 18% are from an occlusion in the left circumflex artery (LCx). Occluded vessels in both territories can cause right ventricular infarction. Correct Answer: D  

References

Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219641169

Burns, E. (2019) Inferior STEMI. Life in the Fast Lane. Accessed August 17, 2020. https://litfl.com/inferior-stemi-ecg-library/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #12," in International Emergency Medicine Education Project, September 11, 2020, https://iem-student.org/2020/09/11/question-of-the-day-12/, date accessed: October 6, 2022