Question Of The Day #60

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

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

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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #60," in International Emergency Medicine Education Project, October 22, 2021, https://iem-student.org/2021/10/22/question-of-the-day-60/, date accessed: December 3, 2022

Question Of The Day #59

question of the day
38 - atrial fibrillation

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

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

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

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

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #59," in International Emergency Medicine Education Project, October 15, 2021, https://iem-student.org/2021/10/15/question-of-the-day-59/, date accessed: December 3, 2022

Cryptic Shock – Identifying the Unseen (PART 1)

Case Presentation

A 68-year-old man presented to the Emergency Department with complaints of breathing difficulty and fever for three days. The patient is a known diabetic and hypertensive.

After detailed history taking, clinical examination, and radiological workup, the patient was diagnosed with right-sided lobar pneumonia (Community-acquired) and immediately started on intravenous antibiotics. In addition, necessary cultures and blood samples were taken for evaluation.

At the time of presentation, his vitals were HR – 92/min, BP – 130/70mmHg, RR – 30/min, SpO2 – 90% with RA à 96% with 2L O2. He underwent bladder catheterization.

During the 1st hour in the ER, the patient had a very low urine output, which continued for the next few hours. Lactate levels were more than 4mmol/L.

Based on the symptoms, oliguria, and hyperlactatemia, the patient was diagnosed to have sepsis and was initiated on fluid resuscitation. After 2 hours, the patient remained oliguric still, and his BP declined to 120/70mmHg.

After 6 hours, the patient’s BP became 110/60mmHg (MAP – 77). He became anuric and developed altered sensorium. Since he did not meet the criteria of septic shock, he was continued on IV fluids and antibiotics.

After 12 hours, the BP became 80/40mmHg (MAP – 63mmHg) à developed Multiorgan Dysfunction Syndrome. He was then started on vasopressors and mechanical ventilation.

By day 3, the patient further deteriorated and went into cardiac arrest. ROSC was not achieved.

Case Analysis

The treatment initiated was based on protocols like Surviving Sepsis Guidelines and Septic Shock management. So how did the process fail in order to adequately resuscitate this patient? Could something have been done more differently?

The case you read above is a very common scenario. Approximately 30% of the people coming to the ER are hypertensive, and around 10% have diabetes mellitus. They form a huge population, among whom the incidence of any other disease increases their morbidity and early mortality.

Before we delve into the pathology in these patients, let us look at the basic definitions of shock/hypotension.

  • SBP < 90mmHg
  • MAP < 65 mmHg
  • Decrease in SBP > 40mmHg
  • Organ Dysfunction
  • Hyperlactatemia
  • Shock: A state of circulatory insufficiency that creates an imbalance between tissue oxygen supply (delivery) and demand (consumption), resulting in end-organ dysfunction.
  • Septic Shock: Adult patients can be identified using the clinical criteria of hypotension requiring the use of vasopressors to maintain MAP of 65mmHg or greater and having a serum lactate level greater than 2 mmol/L persisting after adequate fluids resuscitation.
  • Cryptic Shock: Presence of hyperlactatemia (or systemic hypoperfusion) in a case of sepsis with normotension.

Based on all the information given above;

  1. what do you think was wrong with our patient?
  2. What kind of shock did he have?
  3. Could we have managed him any other way?
  4. When should we have started inotropes?
  5. Did the fact that he was hypertensive and diabetic have to do with his early deterioration? If so, how?
  6. When did the patient-first develop signs of shock?
  7. What are the different signs and symptoms of shock, and how are they recognized in the ER?

Keep your answers ready… 

Part 2 of Cryptic Shock Series – Vascular Pathology and What is considered ‘Shock’ in Hypertensive patients

Part 3 of Cryptic Shock Series – Individualised BP management

Part 4 of Cryptic Shock Series – Latest Trends

References and Further Reading

  1. Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Machado FR, Noritomi DT; Grupo de Cuidados Críticos Amil. Reclassifying the spectrum of septic patients using lactate: severe sepsis, cryptic shock, vasoplegic shock and dysoxic shock. Rev Bras Ter Intensiva. 2013 Oct-Dec;25(4):270-8. doi: 10.5935/0103-507X.20130047.
  2. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287.
  3. Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu VX, Deutschman CS, Angus DC, Rubenfeld GD, Singer M; Sepsis Definitions Task Force. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):775-87. doi: 10.1001/jama.2016.0289.
  4. Education Resources – Sepsis Trust
  5. The Research of Predicting Septic Shock – International Emergency Medicine Education Project (iem-student.org)
  6. Sepsis – International Emergency Medicine Education Project (iem-student.org)
  7. Empiric Antibiotics for Sepsis in the ED Infographics – International Emergency Medicine Education Project (iem-student.org)
  8. Sepsis – An Overview and Update – International Emergency Medicine Education Project (iem-student.org)
Cite this article as: Gayatri Lekshmi Madhavan, India, "Cryptic Shock – Identifying the Unseen (PART 1)," in International Emergency Medicine Education Project, October 4, 2021, https://iem-student.org/2021/10/04/cryptic-shock/, date accessed: December 3, 2022

Question Of The Day #57

question of the day

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

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

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

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

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #57," in International Emergency Medicine Education Project, October 1, 2021, https://iem-student.org/2021/10/01/question-of-the-day-57/, date accessed: December 3, 2022

Question Of The Day #52

question of the day

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

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

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #52," in International Emergency Medicine Education Project, August 27, 2021, https://iem-student.org/2021/08/27/question-of-the-day-52/, date accessed: December 3, 2022

Question Of The Day #7

question of the day
qod7 - sepsis

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

This patient has a diagnosis of septic shock due to pneumonia. In all patients presenting to the Emergency Department, the initial assessment should involve the “ABCs” (assessment of Airway, Breathing, and Circulation). The patient is given supplemental oxygen for her hypoxemia with an improved oxygen saturation from 89% to 95%. Performing endotracheal intubation (Choice A) is too aggressive at this time as the patient is improving with non-invasive oxygenation techniques. The Centers for Medicare and Medicaid sepsis guidelines recommend a 30 mL/kg of isotonic crystalloid fluid bolus in patients with sepsis. However, there is limited data to support this recommendation, as some patients may benefit from less or more fluids than 30 mL/kg. The question stem indicates that an appropriate bolus of fluids has been given, so providing more IV fluids (Choice B) is not the best course of action. The use of passive leg raising or bedside ultrasonography to assess for Inferior Vena Cava (IVC) size may help a clinician discern if more or less fluids are required. For example, visualizing a flat, collapsible IVC on ultrasound indicates additional fluids may be helpful. An increase in blood pressure after a patient’s legs are raised above the level of the heart (“passive leg raise”) also supports the use of additional IV fluids. Giving acetaminophen (Choice D) will help reduce the patient’s fever and improve patient comfort. However, initiating vasopressor therapy (Choice C) is the more appropriate next course of action. Vasopressors (i.e. norepinephrine, epinephrine) are generally recommended after IV fluid boluses if a patient is persistently hypotensive with a MAP less than 65mmHg. Vasopressors help to maintain cerebral and organ perfusion in states of shock. They should be titrated to a dose that maintains a MAP of 65mmHg or above.  Correct Answer: 

References

Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. “Chapter 12: Approach to Nontraumatic Shock”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

Cite this article as: Joseph Ciano, USA, "Question Of The Day #7," in International Emergency Medicine Education Project, August 7, 2020, https://iem-student.org/2020/08/07/question-of-the-day-7/, date accessed: December 3, 2022

Question Of The Day #6

question of the day
sepsis abdominal pain

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

This patient is in septic shock due to ascending cholangitis. Shock is a condition where the body is unable to deliver adequate perfusion to meet metabolic demands. Shock is often characterized by multiorgan dysfunction and hemodynamic changes (i.e. tachycardia, hypotension). Ascending cholangitis is a serious diagnosis that carries high mortality without prompt treatment and recognition. Causes of ascending cholangitis include choledocholithiasis, a biliary tract stricture, or compression by malignant disease. Some cases demonstrate Charcot’s Triad (fever, jaundice, right upper quadrant pain) or Reynolds’ Pentad (Charcot’s triad plus shock and altered mental status). This patient meets all 5 criteria of Reynolds’ Pentad. Rather than a gallstone obstructing the biliary tree, this patient has an underlying malignancy that is obstructing biliary outflow (hinted by weight loss and progressive jaundice over 3 months). Treatment includes antibiotics, IV fluids, and surgical management. The elevated white blood cell count, fever, history, and physical exam support the diagnosis of septic shock. Cardiogenic shock (Choice A) would be more likely in a patient with known baseline cardiac disease, a patient complaining of chest pain or shortness of breath, low ejection fraction seen on echocardiogram, and cold distal extremities. Conditions that can cause cardiogenic shock include STEMI, CHF, and myocarditis. Obstructive shock (Choice B) is seen in conditions, such as pulmonary embolism, tension pneumothorax, or cardiac tamponade. The patient’s history and physical do not support this diagnosis. Hypovolemic shock (Choice D) can be caused by severe dehydration or hemorrhagic shock (a type of hypovolemic shock). This patient likely has some component of dehydration, but septic shock is the primary condition in this patient. Septic shock is a form of Distributive shock (Choice C). Anaphylactic shock also is a type of Distributive shock. Correct Answer: C

References

Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. “Chapter 12: Approach to Nontraumatic Shock”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

Donaldson, R. (2020, May 2). Ascending cholangitis. WikEm. https://www.wikem.org/wiki/Ascending_cholangitis

Cite this article as: Joseph Ciano, USA, "Question Of The Day #6," in International Emergency Medicine Education Project, July 31, 2020, https://iem-student.org/2020/07/31/question-of-the-day-6/, date accessed: December 3, 2022

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: December 3, 2022

RUSH Course for Medical Students

Dear students,

We are pleased to open our third course for you; Rapid Ultrasound in Shock and Hypotension (RUSH).

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Hypotension is a high-risk sign which is associated with increased morbidity and mortality rate. The differential diagnosis for hypotension is broad and the treatment depends on the underlying etiology. In most cases of hypotension, patients present with limited history and physical examination may be inaccurate making the management of the condition a great challenge for emergency physicians.

The use of POCUS in undifferentiated hypotension has been shown to help correctly and rapidly identify the etiology and therefore initiate the appropriate management. Since 2001, there are many protocols published describing a systematic approach to the use of POCUS in undifferentiated hypotension. 

In this course, we will focus on the Rapid Ultrasound in Shock and Hypotension (RUSH) protocol.

This course aims to provide the necessary information on ultrasonography, its use in a hypotensive patient, and to prepare you for a RUSH practice session.

The course content is prepared and curated from iEM Education chapters, iEM image and video archives, and various FOAMed resources.

At the end of this course, you will be able to;

  • Describe the basics of ultrasound (terminology, knobology, image acquisition, artifacts, etc.)
  • Describe indications of RUSH protocol
  • Describe patient and machine preparations
  • Describe ultrasound examination views
  • Recognize normal anatomical structures
  • Recognize abnormal findings
  • Feel confident to take a practical session for RUSH protocol

Who can get benefit from this course?

  • Junior and senior medical students (course specifically designed for these groups)
  • Interns/Junior emergency medicine residents/registrars

Other Free Online Courses

Cite this article as: Arif Alper Cevik, "RUSH Course for Medical Students," in International Emergency Medicine Education Project, May 27, 2020, https://iem-student.org/2020/05/27/rush-course-for-medical-students/, date accessed: December 3, 2022

Shock Index

A 57-year-old male presented to the ED with severe abdominal pain for 1 day. No allergies or significant past medical history. His vitals are: Temp 37.6 Celsius, BP 100/55, HR 110/min, RR 20/min and O2 Saturation is 99% on room air. 

What level of care does this patient require?

To learn more about it, read chapters below.

Read "Shock" Chapter

Read "Scores" Chapter

Quick Read

Shock Index

SHOCK INDEX (SI) = Heart Rate / Systolic Blood Pressure

Application

SI can be used to identify patients needing a higher level of care despite vital signs that may not appear strikingly abnormal. This index is a sensitive indicator of left ventricular dysfunction and can become elevated following a reduction in left ventricular stroke work.

Interpretation

The answer to the above clinical scenario: By applying the above equation, (110/100 = 1.1), this patient has a high shock index and requires a high level of care.

To learn more about it, read chapters below.

Read "Shock" Chapter

Read "Scores" Chapter

Is this AAA going to be ruptured?

AAA rupture

Abdominal Aortic Aneurysm (AAA)

Lit Sin Quek

A 75-year-old obese man comes to the emergency department. He has history COPD, hypertension. He is a smoker and on regular follow-up with primary care. He describes sudden onset severe flank and back pain for past 2 hours. He denies any chest pain or dyspnea. He informs the physician about his chronic abdominal pain. His initial vital signs are HR 98 bpm, RR 24/min, BP 190/105 mmHg, T 36.9C. His examination revealed mild abdominal pain without rigidity or rebound tenderness. Bedside ultrasonography performed and the result is shown on the side.

What is the risk of rupture?

Touch Me

Risk of Rupture

increases with emphysema, smoking, hypertension. Regarding Powell’s (2003, 2007) study aneurisms above 5.5 cm have 9.4% to 32.4% rupture risk in one year.
Answer