We had a thick conference the past two weeks. If you had a desire to follow up on some of the topics we covered, below we have continued content on vent management, awake intubations, and the pharm. lecture on abx. There’s a lot to learn out there people, enjoy!
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Question 1 of 10
1. Question
A 45-year-old man, with a long history of alcohol abuse, presents to the ED complaining of fever and cough for 3 days. Which of the following organisms is the most common cause of pneumonia in this population?
Correct
The most common infection seen in alcoholism is pneumonia. Associated risk factors for pneumonia include smoking, decreased ciliary function, decreased surfactant production, decreased cough reflex, malnutrition, and poor oral hygiene. Although alcoholic patients may contract a variety of bacterial pneumonias, Streptococcuspneumoniaeis still the most common organism.
Incorrect
The most common infection seen in alcoholism is pneumonia. Associated risk factors for pneumonia include smoking, decreased ciliary function, decreased surfactant production, decreased cough reflex, malnutrition, and poor oral hygiene. Although alcoholic patients may contract a variety of bacterial pneumonias, Streptococcuspneumoniaeis still the most common organism.
Question 2 of 10
2. Question
A 42-year-old woman who spent two days hospitalized after she underwent an appendectomy three weeks ago presents with cough, green sputum and fever. Her vitals are T 100.7°F, HR 94, BP 123/76, RR 18, and oxygen saturation 97%. She is well appearing and her blood work (CBC and BMP) is unremarkable. A chest X-ray shows a left lower lobe infiltrate. Which of the following represents the best management for this patient?
Correct
This patient has a health-care associated pneumonia (HCAP) requiring IV antibiotics and admission. HCAP is defined as infection occurring within 90 days of a 2-day or longer hospitalization; in a nursing home or long-term care residence; within 30 days of receiving intravenous antibacterial therapy, chemotherapy, or wound care or after a hospital or hemodialysis clinic visit. HCAP requires IV broad spectrum antibiotics because it may involve both the typical pathogens involved in community-acquired pneumonia (CAP) (Mycoplasma pneumonia, Haemophilus influenzae,Streptococcus pneumoniae and Chlamydiapneumoniae) as well as more resistant organisms (Acinetobacter species, Pseudomonas species, Staphylococcus aureus (including MRSA) Enterobacter species, Escherichia coli, Proteus species, Klebsiella species etc.). Treatment should be as follows (one antibiotic from each category):
Incorrect
This patient has a health-care associated pneumonia (HCAP) requiring IV antibiotics and admission. HCAP is defined as infection occurring within 90 days of a 2-day or longer hospitalization; in a nursing home or long-term care residence; within 30 days of receiving intravenous antibacterial therapy, chemotherapy, or wound care or after a hospital or hemodialysis clinic visit. HCAP requires IV broad spectrum antibiotics because it may involve both the typical pathogens involved in community-acquired pneumonia (CAP) (Mycoplasma pneumonia, Haemophilus influenzae,Streptococcus pneumoniae and Chlamydiapneumoniae) as well as more resistant organisms (Acinetobacter species, Pseudomonas species, Staphylococcus aureus (including MRSA) Enterobacter species, Escherichia coli, Proteus species, Klebsiella species etc.). Treatment should be as follows (one antibiotic from each category):
Question 3 of 10
3. Question
Which of the following is true regarding active tuberculosis?
Correct
Most patients evaluated for tuberculosis present with reactivation of an old infection. When an immunocompetent person is exposed to tuberculosis, the immune system effectively gains control over the infection in the lung. It remains quiet and often never re-activates during a person’s lifetime. Most patients are asymptomatic during primary infection and only develop symptoms during a re-activation. Approximately 8-10% of persons who do not take chemoprophylaxis after a primary infection (typically identified through a positive skin PPD test) will develop active tuberculosis. Cough is the most common symptom of pulmonary tuberculosis. Additionally, patients may develop fever (more common in the afternoon or evening), night sweats and hemoptysis. Due to the effects of cytokines (particularly tumor necrosis factor alpha), patient often lose weight. The classic X-ray finding on chest radiograph is a cavitary lesion in the upper lobe of the lung. However, tuberculosis can cause any abnormality on the X-ray including infiltrate in any portion of the lung. Lymphadenopathy is commonly seen in the hilum on X-ray.
Incorrect
Most patients evaluated for tuberculosis present with reactivation of an old infection. When an immunocompetent person is exposed to tuberculosis, the immune system effectively gains control over the infection in the lung. It remains quiet and often never re-activates during a person’s lifetime. Most patients are asymptomatic during primary infection and only develop symptoms during a re-activation. Approximately 8-10% of persons who do not take chemoprophylaxis after a primary infection (typically identified through a positive skin PPD test) will develop active tuberculosis. Cough is the most common symptom of pulmonary tuberculosis. Additionally, patients may develop fever (more common in the afternoon or evening), night sweats and hemoptysis. Due to the effects of cytokines (particularly tumor necrosis factor alpha), patient often lose weight. The classic X-ray finding on chest radiograph is a cavitary lesion in the upper lobe of the lung. However, tuberculosis can cause any abnormality on the X-ray including infiltrate in any portion of the lung. Lymphadenopathy is commonly seen in the hilum on X-ray.
Question 4 of 10
4. Question
A 33-year-old man presents to the ED with several weeks of cough, pleuritic chest pain, weight loss, and night sweats. The patient drinks a 6-pack of beer daily. Vital signs are BP 145/75, HR 88, RR 18, and T 37.7°C. Pulmonary exam reveals crackles and decreased breath sounds on auscultation. You obtain the radiograph seen. Which of the following is the most likely diagnosis?
Correct
Patients with lung abscess classically present with several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats. There may be cough productive of putrid sputum. Because the progression of lung abscess is indolent, tachycardia, tachypnea, or fever may be absent. The chest radiograph often shows an area of dense consolidation with an air-fluid level inside a thick-walled cavitary lesion. Those who abuse alcohol or have other conditions associated with the potential for aspiration are at greatest risk for lung abscess development.
Incorrect
Patients with lung abscess classically present with several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats. There may be cough productive of putrid sputum. Because the progression of lung abscess is indolent, tachycardia, tachypnea, or fever may be absent. The chest radiograph often shows an area of dense consolidation with an air-fluid level inside a thick-walled cavitary lesion. Those who abuse alcohol or have other conditions associated with the potential for aspiration are at greatest risk for lung abscess development.
Question 5 of 10
5. Question
Which of the following HIV-positive patients suspected of having Pneumocystis pneumonia (PCP) should receive prednisone before treatment with trimethoprim/sulfamethoxazole?
Correct
Corticosteroids are used as adjunct therapy in HIV-positive patients with severe PCP (now known as Pneumocystis jiroveci pneumonia), defined by a room air arterial oxygen partial pressure (PaO2) of less than 70 mm Hg or analveolar-arterial oxygen gradient that exceeds 35 mm Hg. When administered, steroids should be given before trimethoprim/sulfamethoxazole or pentamidine because microbial degradation and clearance caused by antibiotics may trigger a severe inflammatory response. Corticosteroid therapy can blunt this inflammatory response, improve oxygenation, and reduce the incidence of respiratory failure.
Incorrect
Corticosteroids are used as adjunct therapy in HIV-positive patients with severe PCP (now known as Pneumocystis jiroveci pneumonia), defined by a room air arterial oxygen partial pressure (PaO2) of less than 70 mm Hg or analveolar-arterial oxygen gradient that exceeds 35 mm Hg. When administered, steroids should be given before trimethoprim/sulfamethoxazole or pentamidine because microbial degradation and clearance caused by antibiotics may trigger a severe inflammatory response. Corticosteroid therapy can blunt this inflammatory response, improve oxygenation, and reduce the incidence of respiratory failure.
Question 6 of 10
6. Question
A 68-year-old male with a history of esophageal cancer presents with progressive fever, chest pain, and shortness of breath over 24 hours. Chest radiography demonstrates a possible left lower lobe pneumonia and large left pleural effusion. Pleural fluid analysis reveals pH 6. 95, glucose 47 mg/dL, 11,500 white blood cells (WBCs)/mm3 (82% neutrophils), and a protein level 75% of plasma levels. What are the indicated maneuvers?
Correct
This is an exudative pleural effusion as defined by Light’s criteria (see Box 77-3). A pH less than 7. 0 suggests emphysema or esophageal rupture. This patient is at risk for both; hence the need to assess esophageal integrity. A pH less than 7. 0 with glucose less than 50 mg/dL are indications for tube thoracostomy. Normal pleural fluid has a WBC count of less than 1000/mm3.
Incorrect
This is an exudative pleural effusion as defined by Light’s criteria (see Box 77-3). A pH less than 7. 0 suggests emphysema or esophageal rupture. This patient is at risk for both; hence the need to assess esophageal integrity. A pH less than 7. 0 with glucose less than 50 mg/dL are indications for tube thoracostomy. Normal pleural fluid has a WBC count of less than 1000/mm3.
Question 7 of 10
7. Question
What is the sensitivity of venous duplex ultrasonography for detection of proximal deep vein thrombosis (DVT) in the leg?
Correct
The sensitivity of a single scan is 95%. Thus, 5% are missed.
Incorrect
The sensitivity of a single scan is 95%. Thus, 5% are missed.
Question 8 of 10
8. Question
A 29-year-old woman presents with onset of left calf pain and mild swelling during a 24-hour period. She is 26 weeks’ pregnant with no other medical problems and no other symptoms. Her D-dimer level is 845 ng/mL. Lower extremity duplex ultrasonography is negative. Which of the following would be the most appropriate course of action?
Correct
In moderate- to high-risk patients with an elevated D-dimer level, a single ultrasound examination may be insufficient. A repeated study in 2 to 7 days is often sufficient to confirm the diagnosis. The lack of pulmonary symptoms precludes the need for lung and embolus evaluation at this time. During pregnancy, there is a progressive rise in baseline D-dimer concentration; thus, a “normal” value is useful, but an elevated level is of no discriminatory value.
Incorrect
In moderate- to high-risk patients with an elevated D-dimer level, a single ultrasound examination may be insufficient. A repeated study in 2 to 7 days is often sufficient to confirm the diagnosis. The lack of pulmonary symptoms precludes the need for lung and embolus evaluation at this time. During pregnancy, there is a progressive rise in baseline D-dimer concentration; thus, a “normal” value is useful, but an elevated level is of no discriminatory value.
Question 9 of 10
9. Question
What percentage of patients diagnosed with pulmonary embolus have no apparent clinical risk factor for venous thromboembolism at the time of diagnosis?
Correct
Whereas risk factors increase the chance for a disease, many patients without known risk factors are also at risk, and being “healthy” does not rule out the possibility of venous thromboembolism. Risk factors are best applied to population analysis and are of limited use in evaluating a single patient.
Incorrect
Whereas risk factors increase the chance for a disease, many patients without known risk factors are also at risk, and being “healthy” does not rule out the possibility of venous thromboembolism. Risk factors are best applied to population analysis and are of limited use in evaluating a single patient.
Question 10 of 10
10. Question
55 year old with PMH significant for hypertension presents with shortness of breath and pleuritic chest pain. ECG shows sinus tachycardia. CT chest is shown below. Patient given 2L fluid bolus of Normal Saline and repeat vital signs are; BP 90/50, HR 110, RR 20 oxygenating 97% on 4L NC. What is the most appropriate next step in treatment?
Correct
The patient has a PE and hypotension even after a 2L fluid bolus. The CT shows a large mainstem thrombus. Thrombolytic therapy is indicated in a patient with a confirmed PE and systolic BP <100 systolic with no contraindications to thrombolytic therapy. Thrombolytic therapy has been shown to improve the hemodynamic profile in patients with hemodynamic instability. Heparin should be held when thrombolytics are being infused. Embolectomy can be life saving in patients with hemodynamic instability. Depending on where you work this may be done by thoracic surgery or interventional cardiology. Given the patient is already hypotensive further risk stratification with formal echo and troponin is unnecessary. Bedside ultrasound may be performed but should not hold up therapeutic interventions.
Incorrect
The patient has a PE and hypotension even after a 2L fluid bolus. The CT shows a large mainstem thrombus. Thrombolytic therapy is indicated in a patient with a confirmed PE and systolic BP <100 systolic with no contraindications to thrombolytic therapy. Thrombolytic therapy has been shown to improve the hemodynamic profile in patients with hemodynamic instability. Heparin should be held when thrombolytics are being infused. Embolectomy can be life saving in patients with hemodynamic instability. Depending on where you work this may be done by thoracic surgery or interventional cardiology. Given the patient is already hypotensive further risk stratification with formal echo and troponin is unnecessary. Bedside ultrasound may be performed but should not hold up therapeutic interventions.
We continue to FLIP this week with Drs. Bajkowski, Bedford, and Dikeman. We will be covering pneumonia, TB, pleural diseases, and PEs with a mix of stations and procedures! Be sure to watch or read about how to do a thoracentesis so that you can get the most out of Dr. Dikeman’s station.
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Question 1 of 10
1. Question
A 73-year-old man presents from a nursing home to the ED with respiratory failure. He has a history of a CVA 3 years ago, with left hemiplegia and is bed bound. His vital signs are T 37.5°C, HR 113, BP 173/96, RR 32, and oxygen saturation 91% on nonrebreather mask. You decide to perform rapid-sequence intubation. The patient’s weight is 70 kg. Which of the following represents the appropriate medications for this rapid-sequence induction?
Correct
This patient is suffering from respiratory distress and impending respiratory failure. Rocuronium is a nondepolarizing paralytic agent; succinylcholine is a depolarizing paralytic agent. One side effect of depolarizing agents is an increase in serum potassium. On average, succinylcholine raises the serum potassium by about 0.0–0.5 mEq. But in patients with certain underlying conditions, the rise in serum potassium can be more dramatic (1.0–2.0 mEq), leading to hyperkalemic dysrhythmias. These conditions include burns, denervation injuries, crush injuries, myopathies, and prolonged immobility. The more dramatic rise results from the upregulation of acetylcholine receptors at the neuromuscular junction, which takes 5 days to develop. Thus in patients with an acute burn, acute crush injury, or acute denervation, the risk of succinylcholine-induced hyperkalemia is minor. The dose of succinylcholine is 1.5 mg/kg and rocuronium is 1.0 mg/kg. Rocuronium and other nondepolarizing agents do not cause a rise in serum potassium.
In this patient, succinylcholine (C and D) would be contraindicated because the patient has suffered a denervation injury (CVA) and is bed bound. Rocuronium or another nondepolarizing agent would be a more appropriate drug. Etomidate, a short-acting hypnotic agent, should be dosed at 0.3 mg/kg during rapid-sequence intubation. A dose of 0.1 mg/kg of etomidate (B) can be used for procedural sedation.
Incorrect
This patient is suffering from respiratory distress and impending respiratory failure. Rocuronium is a nondepolarizing paralytic agent; succinylcholine is a depolarizing paralytic agent. One side effect of depolarizing agents is an increase in serum potassium. On average, succinylcholine raises the serum potassium by about 0.0–0.5 mEq. But in patients with certain underlying conditions, the rise in serum potassium can be more dramatic (1.0–2.0 mEq), leading to hyperkalemic dysrhythmias. These conditions include burns, denervation injuries, crush injuries, myopathies, and prolonged immobility. The more dramatic rise results from the upregulation of acetylcholine receptors at the neuromuscular junction, which takes 5 days to develop. Thus in patients with an acute burn, acute crush injury, or acute denervation, the risk of succinylcholine-induced hyperkalemia is minor. The dose of succinylcholine is 1.5 mg/kg and rocuronium is 1.0 mg/kg. Rocuronium and other nondepolarizing agents do not cause a rise in serum potassium.
In this patient, succinylcholine (C and D) would be contraindicated because the patient has suffered a denervation injury (CVA) and is bed bound. Rocuronium or another nondepolarizing agent would be a more appropriate drug. Etomidate, a short-acting hypnotic agent, should be dosed at 0.3 mg/kg during rapid-sequence intubation. A dose of 0.1 mg/kg of etomidate (B) can be used for procedural sedation.
Question 2 of 10
2. Question
A 65-year-old man is intubated in the ED for respiratory failure. Vital signs on the ventilator are BP 145/70 mm Hg, HR 90, RR 12, and pulse oximetry 98% on 100% FiO2. As part of his workup, the patient undergoes a CT scan of his thorax. Shortly after returning from the CT scanner, you hear the ventilator alarms sounding and the patient’s saturation declines to 85%. Which of the following is the most appropriate next step in management?
Correct
This intubated patient began to decompensate shortly after returning from the radiology suite. It is essential to establish a quick and logical approach to the unstable patient on mechanical ventilation when the ventilator alarms are sounding and the patient is hemodynamically compromised. The first critical action is to disconnect the patient from the ventilator. Removing the ventilator from the equation limits the number of variables in solving this life-threatening challenge and immediately eliminates it as a primary culprit.
The patient may be decompensating from a pulmonary embolism, but until more basic causes are ruled out, thrombolytics (A) should not be administered. A chest radiograph (C) can aid in determining why the patient is decompensating, but it should be obtained after the patient is disconnected from the ventilator. In the absence of clear signs of tension pneumothorax (decreased breath sounds, tracheal deviation, JVD), needle thoracostomy (D) should not be performed empirically.
Incorrect
This intubated patient began to decompensate shortly after returning from the radiology suite. It is essential to establish a quick and logical approach to the unstable patient on mechanical ventilation when the ventilator alarms are sounding and the patient is hemodynamically compromised. The first critical action is to disconnect the patient from the ventilator. Removing the ventilator from the equation limits the number of variables in solving this life-threatening challenge and immediately eliminates it as a primary culprit.
The patient may be decompensating from a pulmonary embolism, but until more basic causes are ruled out, thrombolytics (A) should not be administered. A chest radiograph (C) can aid in determining why the patient is decompensating, but it should be obtained after the patient is disconnected from the ventilator. In the absence of clear signs of tension pneumothorax (decreased breath sounds, tracheal deviation, JVD), needle thoracostomy (D) should not be performed empirically.
Question 3 of 10
3. Question
A 24-year-old woman presents by ambulance with an asthma exacerbation. The patient already received nebulized albuterol and ipratropium as well as intravenous methylprednisolone by EMS. Which of the following therapies is associated with decreased rates of intubation in severe asthma?
Correct
Endotracheal intubation occurs in approximately 2% of all asthma exacerbations and about 10-30% of patients requiring intensive care admissions. Management of patients with severe asthma who are mechanically ventilated is challenging and therapies aimed at avoiding intubation should be employed. Magnesium sulfate administered intravenously at doses of 2 to 3 g promotes bronchodilation and leads to decreased rates of intubation in the severe asthmatic. Noninvasive ventilation with BiPAP is another therapy shown to decrease rates of intubation in these patients.
Heliox (A) therapy has been employed as a means to improve the administration of medication into the distal branches of the airway. Heliox is a mixture of helium and oxygen, which in combination has a decreased density compared with air and allows for more laminar flow into the distal airway. Given the mixture of oxygen with helium, 100% oxygen cannot be delivered and this therapy is cautioned in severely hypoxemic patients. In theory, the use of heliox will improve the effectiveness of medication delivery and effect and potentially avoid intubation although no data has linked its use with decreased rates of hospitalization or intubation. Inhaled corticosteroids (B) have shown benefit when used either alone or in combination with systemic corticosteroids presumably through their anti-inflammatory effects locally within the airway tissue. Steroids typically begin to have effect within hours of their treatment. Inhaled corticosteroids are associated with decreased rates of hospital admission. Leukotriene inhibitors like montelukast (D) are useful in asthmatics due to overproduction of leukotrienes by these patients leading to increased airway inflammation. Patients who receive oral montelukast have more improvement of peak flow the morning after admission, but its use has not decreased rates of hospital admission or intubation.
Incorrect
Endotracheal intubation occurs in approximately 2% of all asthma exacerbations and about 10-30% of patients requiring intensive care admissions. Management of patients with severe asthma who are mechanically ventilated is challenging and therapies aimed at avoiding intubation should be employed. Magnesium sulfate administered intravenously at doses of 2 to 3 g promotes bronchodilation and leads to decreased rates of intubation in the severe asthmatic. Noninvasive ventilation with BiPAP is another therapy shown to decrease rates of intubation in these patients.
Heliox (A) therapy has been employed as a means to improve the administration of medication into the distal branches of the airway. Heliox is a mixture of helium and oxygen, which in combination has a decreased density compared with air and allows for more laminar flow into the distal airway. Given the mixture of oxygen with helium, 100% oxygen cannot be delivered and this therapy is cautioned in severely hypoxemic patients. In theory, the use of heliox will improve the effectiveness of medication delivery and effect and potentially avoid intubation although no data has linked its use with decreased rates of hospitalization or intubation. Inhaled corticosteroids (B) have shown benefit when used either alone or in combination with systemic corticosteroids presumably through their anti-inflammatory effects locally within the airway tissue. Steroids typically begin to have effect within hours of their treatment. Inhaled corticosteroids are associated with decreased rates of hospital admission. Leukotriene inhibitors like montelukast (D) are useful in asthmatics due to overproduction of leukotrienes by these patients leading to increased airway inflammation. Patients who receive oral montelukast have more improvement of peak flow the morning after admission, but its use has not decreased rates of hospital admission or intubation.
Question 4 of 10
4. Question
Which of the following procedural sedation agents is most likely to cause myoclonus?
Correct
Myoclonus is a common side effect after administration of etomidate in procedural sedation. Etomidate is a amnestic agent that is commonly used in rapid sequence intubation and for conscious sedation. The onset of action of an intravenous dose of etomidate is roughly 30 seconds and the drug has a short half-life leading to an awake and alert patient within 5-15 minutes of drug discontinuation. The primary adverse effects of the drug are myoclonus, nausea, vomiting and respiratory depression. The myoclonus is benign but can be mistaken for seizure activity and can make certain procedures more difficult (e.g. orthopedic reduction).
Fentanyl (B) is an opioid used for pain control in sedation and can cause respiratory depression. Midazolam (C), a benzodiazipine, and propofol (D) are both potent sedative agents that can cause respiratory depression and hypotension. Propofol very rarely can cause myoclonus, but is much less likely than etomidate to have this effect
Incorrect
Myoclonus is a common side effect after administration of etomidate in procedural sedation. Etomidate is a amnestic agent that is commonly used in rapid sequence intubation and for conscious sedation. The onset of action of an intravenous dose of etomidate is roughly 30 seconds and the drug has a short half-life leading to an awake and alert patient within 5-15 minutes of drug discontinuation. The primary adverse effects of the drug are myoclonus, nausea, vomiting and respiratory depression. The myoclonus is benign but can be mistaken for seizure activity and can make certain procedures more difficult (e.g. orthopedic reduction).
Fentanyl (B) is an opioid used for pain control in sedation and can cause respiratory depression. Midazolam (C), a benzodiazipine, and propofol (D) are both potent sedative agents that can cause respiratory depression and hypotension. Propofol very rarely can cause myoclonus, but is much less likely than etomidate to have this effect
Question 5 of 10
5. Question
A 37-year-old obese man requires procedural sedation for a shoulder dislocation reduction. On examination of his airway, you see the following as noted above. Which of the following is his Mallampati score?
Correct
The Mallampati score was developed in order to predict difficulty of orotracheal intubation based on the structures visualized upon inspection of the oropharynx. In order to perform the Mallampati evaluation, the patient is seated with the neck extended. The patient is asked to open the mouth and protrude the tongue, with or without phonating. Complete visualization of the oropharynx including the tonsillar pillars is a Class I view. Class I and II predict adequate oral access for laryngoscopy. Class III predicts only moderate access and Class IV predicts a significant difficulty. Research has shown that the Mallampati score is a valid predictor of difficult laryngoscopy. In a Class III view demonstrated above, the soft palate and base of the uvula is visible.
A Class I (A) view allows full visualization of the soft palate, uvula, fauces and tonsillar pillars. A Class II (B) view shows the soft palate, uvula and fauces but no tonsillar pillars. A Class IV (D) view only shows the hard palate and is most predictive of a difficult intubation.
Incorrect
The Mallampati score was developed in order to predict difficulty of orotracheal intubation based on the structures visualized upon inspection of the oropharynx. In order to perform the Mallampati evaluation, the patient is seated with the neck extended. The patient is asked to open the mouth and protrude the tongue, with or without phonating. Complete visualization of the oropharynx including the tonsillar pillars is a Class I view. Class I and II predict adequate oral access for laryngoscopy. Class III predicts only moderate access and Class IV predicts a significant difficulty. Research has shown that the Mallampati score is a valid predictor of difficult laryngoscopy. In a Class III view demonstrated above, the soft palate and base of the uvula is visible.
A Class I (A) view allows full visualization of the soft palate, uvula, fauces and tonsillar pillars. A Class II (B) view shows the soft palate, uvula and fauces but no tonsillar pillars. A Class IV (D) view only shows the hard palate and is most predictive of a difficult intubation.
Question 6 of 10
6. Question
A 7-year-old boy presents with a severe allergic reaction. He is lethargic and hypoxic. On physical examination, his airway is completely occluded with soft tissue swelling and you are unable to bag mask ventilate. You determine you need to perform a needle cricothyrotomy. Which of the following three pieces of equipment would be best suited for performing this?
Correct
A needle cricothyrotomy is a recommended last resort emergency department procedure for complete upper airway obstruction. Very little literature supports its use or safety due to the exceedingly rare circumstances in which it should be used. To perform a needle cricothyrotomy place a towel under the shoulders extending the neck and forcing the trachea anteriorly and palpate for the cricothyroid membrane. This may be difficult to find in small children and you may need to cannulate the proximal trachea instead. Place a finger and thumb on either side to stabilize the trachea and cannulate it at a 30° angle directed caudally with a 14G over-the-needle catheter. Aspirate air into a 3- or 5-mL syringe to ensure entry into the trachea. Without firm cartilaginous rings the trachea collapses easily making it difficult not to penetrate the back wall of the trachea. Once you aspirate air, gently slide the catheter off the needle and attach the 3.0 mm ETT adapter to which you can attach a bag-valve mask. You will need significant pressure to overcome the resistance of the small diameter catheter, well above the limits of a regular pop-off valve that must be disabled. Watch and wait for chest fall between each breath which may be significantly delayed due to the small diameter catheter. Hold the catheter at all times even after it has been secured. Remember this is a temporizing measure only to provide oxygenation for a brief period while additional resources are summoned. Jet ventilation has also been defended but has been shown to cause barotrauma.
With a 5 mL syringe, 3.0 mm ETT adapter, and 20G over-the-needle catheter (B) you may not be able to provide sufficient oxygen; use the largest bore needle available. A 5 mL syringe, 5.0 mm ETT adapter, and 14G over-the-needle catheter (C) or a 5 mL syringe, 5.0 mm ETT adapter, and 20G over-the-needle catheter (D) do not have the correct adapter size that will fit your catheter.
*Alternatively, a 3 mL luer-lock syringe is compatible with a 7.0 mm ET tube, which you can connect together and attach to your angiocath
Incorrect
A needle cricothyrotomy is a recommended last resort emergency department procedure for complete upper airway obstruction. Very little literature supports its use or safety due to the exceedingly rare circumstances in which it should be used. To perform a needle cricothyrotomy place a towel under the shoulders extending the neck and forcing the trachea anteriorly and palpate for the cricothyroid membrane. This may be difficult to find in small children and you may need to cannulate the proximal trachea instead. Place a finger and thumb on either side to stabilize the trachea and cannulate it at a 30° angle directed caudally with a 14G over-the-needle catheter. Aspirate air into a 3- or 5-mL syringe to ensure entry into the trachea. Without firm cartilaginous rings the trachea collapses easily making it difficult not to penetrate the back wall of the trachea. Once you aspirate air, gently slide the catheter off the needle and attach the 3.0 mm ETT adapter to which you can attach a bag-valve mask. You will need significant pressure to overcome the resistance of the small diameter catheter, well above the limits of a regular pop-off valve that must be disabled. Watch and wait for chest fall between each breath which may be significantly delayed due to the small diameter catheter. Hold the catheter at all times even after it has been secured. Remember this is a temporizing measure only to provide oxygenation for a brief period while additional resources are summoned. Jet ventilation has also been defended but has been shown to cause barotrauma.
With a 5 mL syringe, 3.0 mm ETT adapter, and 20G over-the-needle catheter (B) you may not be able to provide sufficient oxygen; use the largest bore needle available. A 5 mL syringe, 5.0 mm ETT adapter, and 14G over-the-needle catheter (C) or a 5 mL syringe, 5.0 mm ETT adapter, and 20G over-the-needle catheter (D) do not have the correct adapter size that will fit your catheter.
*Alternatively, a 3 mL luer-lock syringe is compatible with a 7.0 mm ET tube, which you can connect together and attach to your angiocath
Question 7 of 10
7. Question
A 20-year-old man presents to the emergency department with wheezing and shortness of breath for one day. He has a history of asthma and reports using his albuterol inhaler all night at home without improvement. His girlfriend brought him to the hospital because his breathing has been declining and now he cannot speak full sentences. On exam, the patient appears diaphoretic and sleepy. Vital signs show HR 143, BP 115/68, RR 30, and oxygen saturation 89% on room air. While you are initiating treatment of this patient, you grow concerned that you may have to intubate him for respiratory support. What induction agent is preferred in this patient?
Correct
Asthma results in over 1.5 million emergency department visits yearly, and while the vast majority of these patients are treated and subsequently discharged home, a small percentage have severe symptoms that require endotracheal intubation and mechanical ventilation. Indications for intubation are based on clinical findings and include depressed mental status, declining respiratory rate, worsening hypercapnia and progressive hypoxia despite adequate treatment. Rapid sequence intubation (RSI) is the preferred method of intubation. Ketamine is the induction agent of choice when intubating severe asthmatics. A dissociative anesthetic, ketamine has potent bronchodilator effects, making it an ideal choice. It acts as a smooth muscle dilator, increases circulating catecholamines and does not cause histamine release. Ketamine (1-2 mg/kg IV) should be given followed by succinylcholine (1.5 mg/kg) or a competitive neuromuscular blocking agent such as rocuronium.
Etomidate (A) is a sedative-hypnotic frequently used for RSI and is a good choice in hypotensive patients as it the most hemodynamically neutral of the sedative agents used. However, it does not have any bronchodilator effects making ketamine the better choice. Midazolam (C) is a rapidly acting benzodiazepine that can be used for RSI but it can cause moderate hypotension so it would not be a good choice in this case. Propofol (D) is a lipid-soluble alkylphenol derivative that acts at the GABA receptor to cause sedation and amnesia. It also has some bronchodilator effects making it a good choice in asthmatic patients. However, it can also cause hypotension and, therefore, would not be the best choice in this case.
Incorrect
Asthma results in over 1.5 million emergency department visits yearly, and while the vast majority of these patients are treated and subsequently discharged home, a small percentage have severe symptoms that require endotracheal intubation and mechanical ventilation. Indications for intubation are based on clinical findings and include depressed mental status, declining respiratory rate, worsening hypercapnia and progressive hypoxia despite adequate treatment. Rapid sequence intubation (RSI) is the preferred method of intubation. Ketamine is the induction agent of choice when intubating severe asthmatics. A dissociative anesthetic, ketamine has potent bronchodilator effects, making it an ideal choice. It acts as a smooth muscle dilator, increases circulating catecholamines and does not cause histamine release. Ketamine (1-2 mg/kg IV) should be given followed by succinylcholine (1.5 mg/kg) or a competitive neuromuscular blocking agent such as rocuronium.
Etomidate (A) is a sedative-hypnotic frequently used for RSI and is a good choice in hypotensive patients as it the most hemodynamically neutral of the sedative agents used. However, it does not have any bronchodilator effects making ketamine the better choice. Midazolam (C) is a rapidly acting benzodiazepine that can be used for RSI but it can cause moderate hypotension so it would not be a good choice in this case. Propofol (D) is a lipid-soluble alkylphenol derivative that acts at the GABA receptor to cause sedation and amnesia. It also has some bronchodilator effects making it a good choice in asthmatic patients. However, it can also cause hypotension and, therefore, would not be the best choice in this case.
Question 8 of 10
8. Question
A patient presents to the ED with acute cardiogenic pulmonary edema. Which of the following airway management techniques is most likely to help avoid the need for endotracheal intubation?
Correct
Bilevel positive airway pressure (BiPAP) is a method of noninvasive positive-pressure ventilation that uses two different pressure settings, one during inspiration and one during expiration. The inspiratory pressure is triggered when the patient takes a breath. Both continuous positive airway pressure (CPAP) and BiPAP can be used in patients with acute cardiogenic pulmonary edema and help avoid the need for endotracheal intubation. CPAP and BiPAP reduce the work of breathing, increase inflation of alveoli, and improve compliance. They also decrease preload, thus offsetting ventricular filling pressures.
Albuterol/ipratropium (B) is used in the treatment of asthma. It has not been shown to reduce rates of intubation in pulmonary edema. High-flow nasal cannula oxygen (C) is an emerging method of respiratory support for patients with severe dyspnea. In the pediatric patient with bronchiolitis, it has been shown to improve oxygenation and reduce the need for intensive care unit admission. But it has not been specifically evaluated in the management of adults with acute cardiogenic pulmonary edema. A non-rebreather mask (D) delivers oxygen but does not provide significant positive pressure. Therefore, it does not have the same beneficial effects that BiPAP or CPAP has in patients with pulmonary edema.
Incorrect
Bilevel positive airway pressure (BiPAP) is a method of noninvasive positive-pressure ventilation that uses two different pressure settings, one during inspiration and one during expiration. The inspiratory pressure is triggered when the patient takes a breath. Both continuous positive airway pressure (CPAP) and BiPAP can be used in patients with acute cardiogenic pulmonary edema and help avoid the need for endotracheal intubation. CPAP and BiPAP reduce the work of breathing, increase inflation of alveoli, and improve compliance. They also decrease preload, thus offsetting ventricular filling pressures.
Albuterol/ipratropium (B) is used in the treatment of asthma. It has not been shown to reduce rates of intubation in pulmonary edema. High-flow nasal cannula oxygen (C) is an emerging method of respiratory support for patients with severe dyspnea. In the pediatric patient with bronchiolitis, it has been shown to improve oxygenation and reduce the need for intensive care unit admission. But it has not been specifically evaluated in the management of adults with acute cardiogenic pulmonary edema. A non-rebreather mask (D) delivers oxygen but does not provide significant positive pressure. Therefore, it does not have the same beneficial effects that BiPAP or CPAP has in patients with pulmonary edema.
Question 9 of 10
9. Question
How should ventilator settings be adjusted to address air trapping (auto-PEEP) in intubated patients with COPD?
Correct
The term permissive hypercapnia defines a ventilatory strategy for acute respiratory failure in which the lungs are ventilated with a low inspiratory volume and pressure. The aim of permissive hypercapnia is to minimize lung damage during mechanical ventilation; its limitation is the resulting hypoventilation and carbon dioxide (CO2) retention.
The major concern for mechanically ventilated patients with obstructive airway disease is dynamic hyperinflation (also known as auto-PEEP, intrinsic PEEP, breath stacking, or air trapping). This condition occurs when gas becomes trapped in the lungs during mechanical ventilation. The air trapping is caused by inadequate time for exhalation allowing for delivery of the next breath before the patient has time to completely exhale. This leads to increased alveolar pressures, decreased venous return, and decreased cardiac output ultimately leading to hemodynamic instability. Auto-PEEP can be detected on the ventilator waveform because the flow will not return to zero before the next breath.
Strategies to avoid auto-PEEP would be any factor that decreases the I:E ratio which include decreasing the minute-ventilation (respiratory rate and/or tidal volume), or increasing the inspiratory flow rate (the standard flow rate is 60 L/min, this can be increased up to 80-100 L/min). These factors allow more time for the patient to complete exhalation minimizing the risk of hyperinflation. In severe cases, deep sedation and paralysis may be necessary to improve ventilator synchrony and avoid auto-PEEP.
Incorrect
The term permissive hypercapnia defines a ventilatory strategy for acute respiratory failure in which the lungs are ventilated with a low inspiratory volume and pressure. The aim of permissive hypercapnia is to minimize lung damage during mechanical ventilation; its limitation is the resulting hypoventilation and carbon dioxide (CO2) retention.
The major concern for mechanically ventilated patients with obstructive airway disease is dynamic hyperinflation (also known as auto-PEEP, intrinsic PEEP, breath stacking, or air trapping). This condition occurs when gas becomes trapped in the lungs during mechanical ventilation. The air trapping is caused by inadequate time for exhalation allowing for delivery of the next breath before the patient has time to completely exhale. This leads to increased alveolar pressures, decreased venous return, and decreased cardiac output ultimately leading to hemodynamic instability. Auto-PEEP can be detected on the ventilator waveform because the flow will not return to zero before the next breath.
Strategies to avoid auto-PEEP would be any factor that decreases the I:E ratio which include decreasing the minute-ventilation (respiratory rate and/or tidal volume), or increasing the inspiratory flow rate (the standard flow rate is 60 L/min, this can be increased up to 80-100 L/min). These factors allow more time for the patient to complete exhalation minimizing the risk of hyperinflation. In severe cases, deep sedation and paralysis may be necessary to improve ventilator synchrony and avoid auto-PEEP.
Question 10 of 10
10. Question
A 23-year-old woman presents with an asthma exacerbation. Which of the following increases her risk of mortality?
Correct
Rates of asthma mortality have decreased over time. Mortality rates are higher in women and African-Americans. Assessing risk factors related to increased rates of mortality are important to identify in the evaluation of a patient with an acute exacerbation. A history of prior intubationsis associated with increased mortality in patients with an acute asthma exacerbation. Other factors include:
History of hospitalization at age 18 (A), Recent use of nebulized albuterol (B), and peak flow 70%predicted (C) are not predictive of increased mortality as isolated risk factors. A history of hospitalization at age 18 does suggest that the patient has had an episode of severe asthma in the past, but hospitalizations are predictive within the last year or month. Recent use of corticosteroids not albuterol is associated with increased risk of mortality. During an acute exacerbation, there is impairment of expiratory flow. A peak flow 70% predicted suggests mild airway obstruction but is not an independent predictor of mortality. Some studies have linked an increasing severity score of asthma with mortality, however a severe asthma exacerbation is marked by a PEF <40%
Incorrect
This week we start up part 1 of our 2 part series on everything respiratory, focusing on obstructive/restrictive lung diseases, as well as the finer points of vent. management, RSI, airway adjuncts, and NPPV. We will be collaborating with both the MICU and our very own ED RTs, who will be joining us to share their wisdom, so come hungry for that knowledge as Drs. Melhem, Buscarino, and Wong get their FLIP on. Note that there will be hands-on practice with the vent and NPPV, we have REQUIRED content below to help you brush up on your skills. Otherwise, stick to your own study plan and enjoy the shmattering of readings below. Read up, come prepared, and as always…
*Required Material*
Please review the below EMcrit Vodcasts. While Dr. Weingart’s lectures are often controversial, this is an excellent review on vent. management. –dominating the vent pt 1 –dominating the vent pt 2
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Question 1 of 10
1. Question
28 year old woman reports to emergency room for sudden vision loss in her right eye that occurred while she was getting ready for her mother’s funeral. In the preceding months she was present for her mother’s arduous struggle against an aggressive cancer. On exam the patient has a normal pupillary reflex and a normal fundoscopic examination. The remainder of the physical exam is normal. B-scan ocular ultrasound, CT scan, and labs are unremarkable. An emergent evaluation by the ophthalmologist also is unremarkable. What is the most likely cause of this patient’s vision loss?
Correct
Conversion disorder is typically characterized by the sudden, and often dramatic, onset of a single nonpainful neurologic disorder. The symptom cannot be explained by any known organic etiology. Conversion disorder will often be associated with recent severe stressor or conflict. The most common presentations include pseudoseizures, paralysis, numbness, aphonia, coordination disturbance, blindness and tunnel vision. This disorder has a female predominance and typically appears in adolescence and early adulthood. Patients with conversion disorder have a nondeliberate symptom and will have a flatter affect than expected under the circumstances, termed la belle indifference. This is a diagnosis of exclusion and all organic etiologies must be ruled out. The treatment involves identifying the stressor and addressing the underlying issue.
Incorrect
Conversion disorder is typically characterized by the sudden, and often dramatic, onset of a single nonpainful neurologic disorder. The symptom cannot be explained by any known organic etiology. Conversion disorder will often be associated with recent severe stressor or conflict. The most common presentations include pseudoseizures, paralysis, numbness, aphonia, coordination disturbance, blindness and tunnel vision. This disorder has a female predominance and typically appears in adolescence and early adulthood. Patients with conversion disorder have a nondeliberate symptom and will have a flatter affect than expected under the circumstances, termed la belle indifference. This is a diagnosis of exclusion and all organic etiologies must be ruled out. The treatment involves identifying the stressor and addressing the underlying issue.
Question 2 of 10
2. Question
A 48-year old male presents to the Emergency Department for chronic abdominal pain. He has a history of multiple presentations for the same, with no underlying diagnosis found despite an extensive workup. He demands hydromorphone IV for his pain, stating that his last doctor was “the best doctor he’s ever had” and immediately treated his pain. He also requests a new nurse, stating, “My current nurse is terrible, where’s the last one I had? She was the best!” Which of the following is the most likely diagnosis in this patient?
Correct
This patient likely has borderline personality disorder, characterized by unstable relationships, self image issues, labile affect, poor impulse control, and polarizing interactions with others. Antisocial personality disorder is characterized by pervasive disregard for the rights of others and failure to conform to social/legal norms, often highlighted by a history of crime/legal problems/aggressive behavior. Histrionic personality disorder is characterized by a pattern of excessive emotions and attention-seeking behavior, characterized by inappropriately seductive behavior and excessive need for approval (e.g. dramatic, flirtatious, overly enthusiastic). Narcissistic personality disorder is characterized by an excessive preoccupation with personal adequacy, power, prestige and vanity.
Incorrect
This patient likely has borderline personality disorder, characterized by unstable relationships, self image issues, labile affect, poor impulse control, and polarizing interactions with others. Antisocial personality disorder is characterized by pervasive disregard for the rights of others and failure to conform to social/legal norms, often highlighted by a history of crime/legal problems/aggressive behavior. Histrionic personality disorder is characterized by a pattern of excessive emotions and attention-seeking behavior, characterized by inappropriately seductive behavior and excessive need for approval (e.g. dramatic, flirtatious, overly enthusiastic). Narcissistic personality disorder is characterized by an excessive preoccupation with personal adequacy, power, prestige and vanity.
Question 3 of 10
3. Question
A 45-year-old female presents with sudden onset of fear and intense apprehension. She says the symptoms started 30 minutes prior when she was doing her taxes. Her only other symptoms include tingling around her mouth and in both hands. She has never had symptoms like this before. Basic laboratory studies and electrocardiogram are within normal limits. Given the most likely diagnosis, what pharmacologic therapy would be most effective in the acute setting?
Correct
Panic attacks are defined as a discrete period of sudden onset of intense apprehension and fear. Panic disorder is defined as recurrent, unexpected panic attacks and at least one month of worry surrounding the attacks. Panic attacks may be treated with short-acting benzodiazepines, whereas panic disorder may be treated with SSRIs, short-acting benzos, beta blockers and/or CBT. Long-acting benzodiazepines are generally indicated for generalized anxiety disorder.
Incorrect
Panic attacks are defined as a discrete period of sudden onset of intense apprehension and fear. Panic disorder is defined as recurrent, unexpected panic attacks and at least one month of worry surrounding the attacks. Panic attacks may be treated with short-acting benzodiazepines, whereas panic disorder may be treated with SSRIs, short-acting benzos, beta blockers and/or CBT. Long-acting benzodiazepines are generally indicated for generalized anxiety disorder.
Question 4 of 10
4. Question
A 23-year old male is brought in to the Emergency Department by his family for “odd behavior.” They deny any acute change, however they state that the patient refuses to go outside or interact with people, preferring to stay in his room. They also state that the patient believes he can see the future and read minds. The patient has no past medical history and works as a computer programmer from home. Physical exam reveals a strangely dressed young man in bright clothes. He is alert, oriented, and denies any history of auditory or visual hallucinations. His affect is slightly blunted. What is the most likely diagnosis in this patient?
Correct
The correct answer is schizotypal personality disorder, characterized by social and relationship discomforts, decrease in close relationships, and magical thinking (eccentric). Paranoid schizophrenia is unlikely in the absence of hallucinations. Also this patient, while withdrawn from society, holds a job and is highly functional.
Incorrect
The correct answer is schizotypal personality disorder, characterized by social and relationship discomforts, decrease in close relationships, and magical thinking (eccentric). Paranoid schizophrenia is unlikely in the absence of hallucinations. Also this patient, while withdrawn from society, holds a job and is highly functional.
Question 5 of 10
5. Question
A 22-year-old female is brought to the ED by her roommate for evaluation. Per the roommate, the patient has stayed-up all night for two weeks shopping online. She has missed her classes saying that she is “too smart for college-level courses.” Her roommate reports also that last month the patient did not get out of bed for a week, and was continually crying and over-eating. On physical examination the patient has pressured speech and is having difficulty keeping still for the exam. She reports she is wokring on “grand projects to save the world.” Based on these features, what type of mood disorder is exhibited by this patient?
Correct
Bipolar disorder, depression and dysthmic disorder are all mood disorders. The patient in this question presents with Bipolar Type I. Type I is indicated by one or more manic episodes cycling with depressive episodes. Type II is characterized by one or more major depressive episodes with at least one hypomanic episode. Hypomania presents with similar symptoms as mania, but lacks psychotic features and impairment of function. Dysthmic disorder is chronic and fluctuating low-grade depression for at least two years. Major depression is diagnosed by specific symptoms that are present almost every day for at least 2 weeks that impair daily function. In diagnosing and differentiating mood disorders it is important to understand the time-frame associated with each disease.
Incorrect
Bipolar disorder, depression and dysthmic disorder are all mood disorders. The patient in this question presents with Bipolar Type I. Type I is indicated by one or more manic episodes cycling with depressive episodes. Type II is characterized by one or more major depressive episodes with at least one hypomanic episode. Hypomania presents with similar symptoms as mania, but lacks psychotic features and impairment of function. Dysthmic disorder is chronic and fluctuating low-grade depression for at least two years. Major depression is diagnosed by specific symptoms that are present almost every day for at least 2 weeks that impair daily function. In diagnosing and differentiating mood disorders it is important to understand the time-frame associated with each disease.
Question 6 of 10
6. Question
A 16-year old female presents to the Emergency Department with epigastric pain for several days. The pain is worse with foods. Vital signs are: BP 110/72, P 100, RR 18, O2Sat 100% room air. Physical exam is unremarkable, except you note discolored teeth, slightly dry oral mucous membranes and the image shown. Which of the following is the most likely associated diagnosis?
Correct
This image depicts scarring/callus on the dorsal metacarpophalangeal joints known as Russell’s sign, which in the appropriate clinical context, suggests self-induced purging behavior. Russell’s sign is due to pressure of the teeth against the skin while inducing a gag reflex to cause vomiting. Binge eating episodes is classically associated with bulimia nervosa, followed with inappropriate compensatory mechanisms such as self-purging via vomiting/laxatives/diuretics, excessive exercise, diets, etc. Other dermatologic manifestations of bulimia nervosa include xerosis, poor dentition (due to gastric acid eroding enamel), poor skin turgor, telogen effluvium, and acne.
Incorrect
This image depicts scarring/callus on the dorsal metacarpophalangeal joints known as Russell’s sign, which in the appropriate clinical context, suggests self-induced purging behavior. Russell’s sign is due to pressure of the teeth against the skin while inducing a gag reflex to cause vomiting. Binge eating episodes is classically associated with bulimia nervosa, followed with inappropriate compensatory mechanisms such as self-purging via vomiting/laxatives/diuretics, excessive exercise, diets, etc. Other dermatologic manifestations of bulimia nervosa include xerosis, poor dentition (due to gastric acid eroding enamel), poor skin turgor, telogen effluvium, and acne.
Question 7 of 10
7. Question
A 16-year-old girl presents to the ED via ambulance for general pain. She is a refugee from a conflict area who is known to have frequent nighttime visits to the ED over the past year for the same chief complaint. She’s undergone multiple medical workups that have all been negative. In the ED she appears angry, irritable, and demonstrates hypervigilance. After a brief conversation with the patient her pain resolves and she feels much better. Which of the following is the most likely diagnosis?
Correct
Posttraumatic stress disorder (PTSD) is a long-lasting anxiety response following a traumatic or catastrophic event. Although most people encounter trauma over a lifetime, about 20-30% develop PTSD but over half of these people will recover without treatment. Prediction models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD. Other risk factors include military experiences, war-zone exposure, domestic violence, and foster care. PTSD often leads to patients having difficulty falling or staying asleep, problems with concentration, hypervigilance, irritability, angry outbursts, and increased startle response. The patient in the above clinical scenario is a refugee from a conflict region and exhibits symptoms consistent with PTSD (anger, irritability, and hypervigilance). An important management principle when caring for a patient with PTSD is to ensure his or her safety and to validate his or her symptoms. Detailed questioning should be avoided as it may trigger severe symptoms.
Borderline personality disorder (B) is characterized by unstable personal relationships, unstable self-image, and inappropriate behaviors. Patients with BPD usually present to the ED after deliberate self-injury or suicidal attempts. Malingering (C) is fabricating or exaggerating the symptoms of mental or physical disorders for secondary gain. This may include financial compensation, avoiding school, work or military service, obtaining drugs, getting lighter criminal sentences or to attract attention or sympathy. An adjustment disorder (A) occurs when an individual is unable to adjust to or cope with a particular stressor, like a major life event. The condition is different from anxiety disorder, which lacks the presence of a stressor, or posttraumatic stress disorder that is associated with a more intense stressor.
Incorrect
Posttraumatic stress disorder (PTSD) is a long-lasting anxiety response following a traumatic or catastrophic event. Although most people encounter trauma over a lifetime, about 20-30% develop PTSD but over half of these people will recover without treatment. Prediction models have consistently found that childhood trauma, chronic adversity, and familial stressors increase risk for PTSD. Other risk factors include military experiences, war-zone exposure, domestic violence, and foster care. PTSD often leads to patients having difficulty falling or staying asleep, problems with concentration, hypervigilance, irritability, angry outbursts, and increased startle response. The patient in the above clinical scenario is a refugee from a conflict region and exhibits symptoms consistent with PTSD (anger, irritability, and hypervigilance). An important management principle when caring for a patient with PTSD is to ensure his or her safety and to validate his or her symptoms. Detailed questioning should be avoided as it may trigger severe symptoms.
Borderline personality disorder (B) is characterized by unstable personal relationships, unstable self-image, and inappropriate behaviors. Patients with BPD usually present to the ED after deliberate self-injury or suicidal attempts. Malingering (C) is fabricating or exaggerating the symptoms of mental or physical disorders for secondary gain. This may include financial compensation, avoiding school, work or military service, obtaining drugs, getting lighter criminal sentences or to attract attention or sympathy. An adjustment disorder (A) occurs when an individual is unable to adjust to or cope with a particular stressor, like a major life event. The condition is different from anxiety disorder, which lacks the presence of a stressor, or posttraumatic stress disorder that is associated with a more intense stressor.
Question 8 of 10
8. Question
Which of the following disorders best describes a patient with a wide variety of complaints, a long and complicated medical history with no apparent medical cause, and multiple ED visits?
Correct
Somatization disorder is most common in young to middle-aged women who have particular complaints or symptoms for which no medical explanation can be identified. These symptoms cause the patient significant distress or impairment in social, occupational, or other areas of functioning. Some patients have a wide variety of complaints and long, complicated histories of medical problems that have no apparent cause. This disorder often leads to many unnecessary diagnostic and surgical interventions.
Compulsive disorder (A) is a mental disorder in which someone engages in compulsive behavior or rituals such as excessive washing, repetitive checking, or counting. When these behaviors occupy a great deal of time, the patient may become significantly disabled and seek psychiatric attention. Hypochondriasis (B) is defined by preoccupation with fears of serious illness that persists despite appropriate medical evaluation and reassurance. Malingering (C) is the intentional invention or exaggeration of physical or psychological symptoms for external gain. The external gain may be to avoid work or to obtain drugs.
Incorrect
Somatization disorder is most common in young to middle-aged women who have particular complaints or symptoms for which no medical explanation can be identified. These symptoms cause the patient significant distress or impairment in social, occupational, or other areas of functioning. Some patients have a wide variety of complaints and long, complicated histories of medical problems that have no apparent cause. This disorder often leads to many unnecessary diagnostic and surgical interventions.
Compulsive disorder (A) is a mental disorder in which someone engages in compulsive behavior or rituals such as excessive washing, repetitive checking, or counting. When these behaviors occupy a great deal of time, the patient may become significantly disabled and seek psychiatric attention. Hypochondriasis (B) is defined by preoccupation with fears of serious illness that persists despite appropriate medical evaluation and reassurance. Malingering (C) is the intentional invention or exaggeration of physical or psychological symptoms for external gain. The external gain may be to avoid work or to obtain drugs.
Question 9 of 10
9. Question
Which of the following best defines delusions?
Correct
Delusions are erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Their content may include a variety of themes (persecutory, referential, somatic, religious, or grandiose). In persecutory delusions the person believes he or she is being tormented, followed, tricked, spied on, or ridiculed. In referential delusions the person believes that certain gestures, comments, passages from books, newspapers, song lyrics, or other environmental cues are specifically directed at him or her.
Psychosis (B) is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. Hallucinations (D) are sensory perceptions without external stimulation. Hallucinations may occur in any sensory modality (auditory, visual, olfactory, gustatory, and tactile). Auditory hallucinations are the most common. Delirium (C) is characterized by marked disorientation, confusion, and fluctuating consciousness.
Incorrect
Delusions are erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Their content may include a variety of themes (persecutory, referential, somatic, religious, or grandiose). In persecutory delusions the person believes he or she is being tormented, followed, tricked, spied on, or ridiculed. In referential delusions the person believes that certain gestures, comments, passages from books, newspapers, song lyrics, or other environmental cues are specifically directed at him or her.
Psychosis (B) is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. Hallucinations (D) are sensory perceptions without external stimulation. Hallucinations may occur in any sensory modality (auditory, visual, olfactory, gustatory, and tactile). Auditory hallucinations are the most common. Delirium (C) is characterized by marked disorientation, confusion, and fluctuating consciousness.
Question 10 of 10
10. Question
Which of the following predicts a higher risk of suicide completion?
Correct
Suicidal ideation is very common with up to one-third of the population experiencing it in their lifetime. Suicide rates vary with multiple factors including age, gender, race, and marital status. Females attempt suicide three to four times more often than men, but men are more successful in suicide completion. Up to one-quarter of suicides by men are successful as opposed to 5% in women because men tend to use more violent methods. Patients with active substance abuse, including alcohol, are among the highest risk for suicide completion. Other very high risk groups include those with underlying psychiatric disorders, adolescents, elders, and patients with some chronic illnesses. A history of prior suicide attempt raises the risk significantly although 60-70% of successful suicides occur in individuals without any previous attempt. Additionally, the presence of a firearm in the household is an independent risk factor.
Unemployment (D) appears to be a risk factor for suicide in 18 to 24 year old men as the highest risk. It does slightly increase the risk in other age groups. Females (A) attempt suicide more often than men but are less successful in completing the attempt. Pregnant women and mothers are at lower risk than others. Being married (B) is protective against suicide. Those at highest risk are single persons or those who are separated, widowed or divorced.
Incorrect
Suicidal ideation is very common with up to one-third of the population experiencing it in their lifetime. Suicide rates vary with multiple factors including age, gender, race, and marital status. Females attempt suicide three to four times more often than men, but men are more successful in suicide completion. Up to one-quarter of suicides by men are successful as opposed to 5% in women because men tend to use more violent methods. Patients with active substance abuse, including alcohol, are among the highest risk for suicide completion. Other very high risk groups include those with underlying psychiatric disorders, adolescents, elders, and patients with some chronic illnesses. A history of prior suicide attempt raises the risk significantly although 60-70% of successful suicides occur in individuals without any previous attempt. Additionally, the presence of a firearm in the household is an independent risk factor.
Unemployment (D) appears to be a risk factor for suicide in 18 to 24 year old men as the highest risk. It does slightly increase the risk in other age groups. Females (A) attempt suicide more often than men but are less successful in completing the attempt. Pregnant women and mothers are at lower risk than others. Being married (B) is protective against suicide. Those at highest risk are single persons or those who are separated, widowed or divorced.
Heading into the world of Crisis. We’ve got another round of psych FLIPs this week done by Drs. McElroy, Moore, and Praamsma. We will be covering personality disorders, mood disorders, violent patients, including how to properly put on restraints. This will be followed by a FUR by Dr. McRae.
Hey Everyone! As the new interns settle in, we don’t want new education falling behind. Some of you may have celebrated at Dubey’s pool party, but little did you know there was a club within the party…a JOURNAL CLUB. If you missed out on it, Dr. Maqbool discussed the benefits of high flow nasal cannula (something we see everyday at CHM but RARELY at DRH). See below for the recap!
Clinical Vignette: A 55 year old male with a history of Type II diabetes and hypertension presents to the emergency department with a chief complaint of “I’m having trouble breathing.” Patient states that for the past two days, he has felt increasingly short of breath. He denies any fever, cough, rhinorrhea, or chest pain. He is tachypneic and lungs are clear to auscultation. Initial vitals are blood pressure 180/76, HR 94, RR 24, SpO2 is 91% on room air. You are concerned about the patient’s respiratory distress but don’t think the patient warrants intubation because he is alert, has no accessory muscle use, and is able to speak to you in full sentences. However, you want to address the patient’s tachypnea and hypoxia. You wonder which intervention will help prevent your patient from being intubated in the ED today and also provide the greatest long term benefit for his respiratory status. What will you use for oxygen therapy? Standard O2 nasal cannula or high flow nasal cannula? What would you use if the patient had COPD? What if the patient had fevers or signs of pneumonia? What if the patient presented with signs of pulmonary edema or heart failure?
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Question 1 of 10
1. Question
Which of the following is most suggestive of measles infection?
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Measles (rubeola) is caused by a paramyxovirus and spread by respiratory contact. Measles begins with a prodrome of fever, coryza, cough, and conjunctivitis for several days followed by the development of a morbilliform rash. The rash starts with erythematous maculopapular lesions a few millimeters in diameter which become confluent. The rash typically starts on the face and spreads to the extremities. White spots on the buccal mucosa, known as Koplik spots, are pathognomonic for measles. Complications include otitis media, pneumonia, myocarditis, pericarditis, and encephalitis. Treatment is supportive. Choice A) is less specific than choice B). Choice C) is suggestive of roseola. Choice D) is more suggestive of hand foot & mouth disease
Incorrect
Measles (rubeola) is caused by a paramyxovirus and spread by respiratory contact. Measles begins with a prodrome of fever, coryza, cough, and conjunctivitis for several days followed by the development of a morbilliform rash. The rash starts with erythematous maculopapular lesions a few millimeters in diameter which become confluent. The rash typically starts on the face and spreads to the extremities. White spots on the buccal mucosa, known as Koplik spots, are pathognomonic for measles. Complications include otitis media, pneumonia, myocarditis, pericarditis, and encephalitis. Treatment is supportive. Choice A) is less specific than choice B). Choice C) is suggestive of roseola. Choice D) is more suggestive of hand foot & mouth disease
Question 2 of 10
2. Question
A 16-year-old man presents with a rash to the back for 1 week. He states that the rash started as a single patch and then spread to the rest of his back. The rash is itchy but otherwise, the patient is asymptomatic. What management is indicated?
Correct
This patient presents with pityriasis rosea and should be treated symptomatically withantihistamines as the condition is self-limiting. Pityriasis rosea presents as scaly, salmon colored, oval papules or plaques 1 – 2 cm in diameter on the trunk and proximal extremities. It usually presents in children and young adults. Classically, the diffuse rash is preceded by a herald patch 1 week prior. This lesion is larger (2-5 cm in diameter) than the others that form. Patients may also initially have fever, malaise or lymphadenopathy prior to the appearance of a rash but this is rare. The diffuse form of the rash has a Christmas tree-like distribution following the cleavage lines of the skin. Pityriasis rosea is a self-limiting disease but may take 8-12 weeks to completely resolve. The causative agent is unknown although a virus is suspected (HHV 7). There is no specific treatment for the disease and so care should be directed at relieving symptoms, most commonly itching, with antihistamines.
Incorrect
This patient presents with pityriasis rosea and should be treated symptomatically withantihistamines as the condition is self-limiting. Pityriasis rosea presents as scaly, salmon colored, oval papules or plaques 1 – 2 cm in diameter on the trunk and proximal extremities. It usually presents in children and young adults. Classically, the diffuse rash is preceded by a herald patch 1 week prior. This lesion is larger (2-5 cm in diameter) than the others that form. Patients may also initially have fever, malaise or lymphadenopathy prior to the appearance of a rash but this is rare. The diffuse form of the rash has a Christmas tree-like distribution following the cleavage lines of the skin. Pityriasis rosea is a self-limiting disease but may take 8-12 weeks to completely resolve. The causative agent is unknown although a virus is suspected (HHV 7). There is no specific treatment for the disease and so care should be directed at relieving symptoms, most commonly itching, with antihistamines.
Question 3 of 10
3. Question
A 27-year-old woman presents with a painful rash on both of her legs as seen below. What is the most common cause of this condition?
Correct
Erythema nodosum is a condition in which patients develop painful red/violet nodules deep under the skin. It develops as a result of an inflammatory reaction between the dermis and adjacent adipose tissue. It is thought to be a delayed hypersensitivity reaction to various infections, drugs or systemic disease. Most commonly the lesions develop over the anterior tibia but can appear anywhere on the body. Before the development of the rash, the patient often complains of fever and arthralgias, particularly of the ankles. There are multiple diseases or infections associated with erythema nodosum, the most common of which is Streptococcal infections. Others include: tuberculosis, sarcoidosis, cocciodiomycosis, histoplasmosis, ulcerative colitis, enteritis, pregnancy, Yersenia enterocolitica, and Chlamydia. The disease is treated symptomatically (NSAIDs, elevation, stockings) and is typically self-limited.
Incorrect
Erythema nodosum is a condition in which patients develop painful red/violet nodules deep under the skin. It develops as a result of an inflammatory reaction between the dermis and adjacent adipose tissue. It is thought to be a delayed hypersensitivity reaction to various infections, drugs or systemic disease. Most commonly the lesions develop over the anterior tibia but can appear anywhere on the body. Before the development of the rash, the patient often complains of fever and arthralgias, particularly of the ankles. There are multiple diseases or infections associated with erythema nodosum, the most common of which is Streptococcal infections. Others include: tuberculosis, sarcoidosis, cocciodiomycosis, histoplasmosis, ulcerative colitis, enteritis, pregnancy, Yersenia enterocolitica, and Chlamydia. The disease is treated symptomatically (NSAIDs, elevation, stockings) and is typically self-limited.
Question 4 of 10
4. Question
A 12-year-old boy presents with intermittent abdominal pain and a rash as seen in the image. There is no fever. Which of the following is a complication of this diagnosis?
Correct
Henoch-Schönlein purpura (HSP) is a small vessel vasculitis caused by the deposition of immune complexes in blood vessels. In approximately half of cases, it is preceded by an upper respiratory infection. It is also induced by vancomycin, cefuroxime and ACE inhibitors. HSP is characterized by palpable purpura as well as gastrointestinal and renal symptoms. The disease almost always occurs under the age of 20, and children under the age of 5 are more frequently affected. Classically symptoms appear 1-2 weeks after and upper respiratory infection. The triad of signs and symptoms is: purpura, arthralgias and abdominal pain. The purpura typically affect dependent regions of the body and therefore are seen on the legs and buttocks. Patients develop colicky abdominal pain and may even get hematochezia due to the gastrointestinal vasculitis. Rarely, enteroenteral intussusception occurs. Renal manifestations include glomerulonephritis presenting with hematuria, red cell casts and azotemia. Treatment is supportive.
Incorrect
Henoch-Schönlein purpura (HSP) is a small vessel vasculitis caused by the deposition of immune complexes in blood vessels. In approximately half of cases, it is preceded by an upper respiratory infection. It is also induced by vancomycin, cefuroxime and ACE inhibitors. HSP is characterized by palpable purpura as well as gastrointestinal and renal symptoms. The disease almost always occurs under the age of 20, and children under the age of 5 are more frequently affected. Classically symptoms appear 1-2 weeks after and upper respiratory infection. The triad of signs and symptoms is: purpura, arthralgias and abdominal pain. The purpura typically affect dependent regions of the body and therefore are seen on the legs and buttocks. Patients develop colicky abdominal pain and may even get hematochezia due to the gastrointestinal vasculitis. Rarely, enteroenteral intussusception occurs. Renal manifestations include glomerulonephritis presenting with hematuria, red cell casts and azotemia. Treatment is supportive.
Question 5 of 10
5. Question
A 23-year old male presents to the emergency department with a chief complaint of a rash to his arms and legs. He reports he had fever and chills approximately one week previous, followed by development of vesicles and erosions on his upper lip. Three days later, he developed dermal lesions on his arms and legs. On exam, the patient has lesions on his hands and feet (see image); he has no conjunctival injection or oral lesions. Which of the following is the most likely underlying cause of this patient’s presentation?
Correct
The patient in the question stem has erythema multiforme, characterized by target lesions on the extremities, usually the palms and soles. It is most common in the 20-40 age group, and most cases are due to HSV infections. While drugs/medications can cause EM, it is more rare, but consider it in patients on the “SHNAP” drugs (Sulfa, Hypoglycemics, NSAIDs, AEDs, Penicillins). Treatment is largely supportive, though systemic steroids can be considered if the rash is diffuse or involves oral mucosa.
Incorrect
The patient in the question stem has erythema multiforme, characterized by target lesions on the extremities, usually the palms and soles. It is most common in the 20-40 age group, and most cases are due to HSV infections. While drugs/medications can cause EM, it is more rare, but consider it in patients on the “SHNAP” drugs (Sulfa, Hypoglycemics, NSAIDs, AEDs, Penicillins). Treatment is largely supportive, though systemic steroids can be considered if the rash is diffuse or involves oral mucosa.
Question 6 of 10
6. Question
A 74-year-old man presents to the ED with blistering on his extremities. On physical exam, tense bullae are noted on the arms and legs. Nikolsky sign is negative. There is no oral involvement. Which of the following is part of the appropriate treatment for this disease process?
Correct
This patient is exhibiting symptoms and physical exam findings consistent with bullous pemphigoid. Bullous pemphigoid is a chronic bullous disease that involves IgG autoantibodies against the basement membrane (subepidermal). It is the most common bullous disease and is classically seen in adults over the age of 60 years. It may be caused by repeated skin trauma and presence of other inflammatory skin conditions such as psoriasis; however, it is often idiopathic. Signs and symptoms include a pruritic rash that evolves into tender, tense bullae occurring most often over the legs, forearms, and axilla. Mucosal involvement is uncommon. Nikolsky sign is negative. Diagnosis is made by needle biopsy to discriminate from pemphigus vulgaris; however, it may be differentiated clinically based on the differences between the two as pemphigus vulgaris includes oral involvement, flaccid bullae, and a positive Nikolsky sign while bullous pemphigoid does not. Management includes wound care, steroids, tetracycline, dapsone, and immunomodulators such as azathioprine, cyclosporine, and methotrexate. This disease process often improves and relapses spontaneously. Mortality, though rare, is most commonly caused by sepsis. Overall, bullous pemphigoid has a relatively good prognosis when compared to pemphigus vulgaris.
Burn center admission (A) would be appropriate if this patient were suffering from Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN); however, there is no evidence of recent infection or medication use and no description of sloughing skin. Additionally, Nikolsky sign is positive in SJS and TEN. Clindamycin (B) would be appropriate for necrotizing fasciitis, which may exhibit blistering but is also characterized by pain out of proportion to exam findings, crepitus, and gas in the tissues. These patients also tend to be febrile and have abnormal vital signs. Vancomycin (D) would be appropriate for inpatient treatment of cellulitis. This would be warranted if he had vital sign abnormalities or had failed outpatient treatment for cellulitis. Vancomycin should be reserved for instances for MRSA treatment.
Incorrect
This patient is exhibiting symptoms and physical exam findings consistent with bullous pemphigoid. Bullous pemphigoid is a chronic bullous disease that involves IgG autoantibodies against the basement membrane (subepidermal). It is the most common bullous disease and is classically seen in adults over the age of 60 years. It may be caused by repeated skin trauma and presence of other inflammatory skin conditions such as psoriasis; however, it is often idiopathic. Signs and symptoms include a pruritic rash that evolves into tender, tense bullae occurring most often over the legs, forearms, and axilla. Mucosal involvement is uncommon. Nikolsky sign is negative. Diagnosis is made by needle biopsy to discriminate from pemphigus vulgaris; however, it may be differentiated clinically based on the differences between the two as pemphigus vulgaris includes oral involvement, flaccid bullae, and a positive Nikolsky sign while bullous pemphigoid does not. Management includes wound care, steroids, tetracycline, dapsone, and immunomodulators such as azathioprine, cyclosporine, and methotrexate. This disease process often improves and relapses spontaneously. Mortality, though rare, is most commonly caused by sepsis. Overall, bullous pemphigoid has a relatively good prognosis when compared to pemphigus vulgaris.
Burn center admission (A) would be appropriate if this patient were suffering from Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN); however, there is no evidence of recent infection or medication use and no description of sloughing skin. Additionally, Nikolsky sign is positive in SJS and TEN. Clindamycin (B) would be appropriate for necrotizing fasciitis, which may exhibit blistering but is also characterized by pain out of proportion to exam findings, crepitus, and gas in the tissues. These patients also tend to be febrile and have abnormal vital signs. Vancomycin (D) would be appropriate for inpatient treatment of cellulitis. This would be warranted if he had vital sign abnormalities or had failed outpatient treatment for cellulitis. Vancomycin should be reserved for instances for MRSA treatment.
Question 7 of 10
7. Question
Which of the following is correct regarding the condition seen in the image above?
Correct
The well-demarcated erythematous plaques and papules with silvery white scales are characteristic of psoriasis. Removal of the scale typically reveals pinpoint-bleeding areas referred to as the Auspitz sign. There is a hereditary predilection for the condition and often begins in the 2nd or 3rd decade of life.
Lesions tend to be symmetric and most commonly found on the trunk, scalp, nails (A), and extensor surfaces (C). Systemic steroids (D) should be avoided due to the risk of developing rebound or induction of pustular psoriasis.
Incorrect
The well-demarcated erythematous plaques and papules with silvery white scales are characteristic of psoriasis. Removal of the scale typically reveals pinpoint-bleeding areas referred to as the Auspitz sign. There is a hereditary predilection for the condition and often begins in the 2nd or 3rd decade of life.
Lesions tend to be symmetric and most commonly found on the trunk, scalp, nails (A), and extensor surfaces (C). Systemic steroids (D) should be avoided due to the risk of developing rebound or induction of pustular psoriasis.
Question 8 of 10
8. Question
A 4-year old male with a history of asthma is brought to the Emergency Department for a pruritic rash. He has no other medical problems, is current on his vaccinations, and has otherwise been afebrile and well. Physical exam reveals an erythematous scaly rash made up of plaques present behind the knees as well as in the antecubital fossa, and volar surfaces of the wrists. The mother reports that the child has had similar symptoms in the past, but the pruritus has become particularly irritating for him. Which of the following is the most appropriate initial treatment of this child’s condition?
Correct
The correct answer is topical corticosteroid and moisturizer. This patient’s presentation is most suggestive of atopic dermatitis, particularly due to his history of asthma and the involvement of the flexor surfaces. Treatment is geared towards reducing inflammation using topical steroids, as well as hydration of the skin. Atopic dermatitis in general has three age groups: infantile from infancy to two years, childhood from two to 12 years old, and adult stage for those older than 12. The infantile stage typically presnts on the extensor surfaces and cheeks and scalp and occasionally can have serous exudates. The childhood and adult stage typically involves flexor areas. Lesions are more typically lichenified due to the intense pruritus.
Incorrect
The correct answer is topical corticosteroid and moisturizer. This patient’s presentation is most suggestive of atopic dermatitis, particularly due to his history of asthma and the involvement of the flexor surfaces. Treatment is geared towards reducing inflammation using topical steroids, as well as hydration of the skin. Atopic dermatitis in general has three age groups: infantile from infancy to two years, childhood from two to 12 years old, and adult stage for those older than 12. The infantile stage typically presnts on the extensor surfaces and cheeks and scalp and occasionally can have serous exudates. The childhood and adult stage typically involves flexor areas. Lesions are more typically lichenified due to the intense pruritus.
Question 9 of 10
9. Question
A 21-year-old man presents complaining of dysuria. He states that he noted dark-colored urine four days ago and was concerned he had developed a urinary tract infection. He attempted to treat himself at home by taking some old antibiotics he had lying around. Despite trying cephalexin, sulfamethoxazole, and amoxicillin, his symptoms have not improved. Yesterday, he started to note dysuria and complains of ulcers on his penis and mouth as well as rash to his abdomen. Physical exam reveals superficial ulcers to the urethral meatus and buccal mucosa and scrotum. There is no inguinal lymphadenopathy. An erythematous macular rash with purpuric center is present on the abdomen without vesicles or bullae. Urinalysis is negative. What is the next best step in clinical management?
Correct
Stevens-Johnson syndrome is an autoimmune type IV hypersensitivity reaction that affects the skin and mucous membranes. Stevens-Johnson syndrome exists on a continuum with toxic epidermal necrolysis where Stevens-Johnson syndrome is defined as less than 10% total body surface area (TBSA) affected, while toxic epidermal necrolysis involves greater than 30% TBSA. The rash occurs most often on the trunk and is classically described as macular and target-like with two zones of color: purpuric at the core with surrounding erythema. However, the rash can also be vesicular, bullous, and necrotic. Ruptured bullae and desquamation place the patient at risk for secondary infection, which is the leading cause of death. Stevens-Johnson syndrome can also affect the renal, hepatic, and pulmonary organ systems. Mucosal involvement is often present as well, affecting the genitals, mouth, and eyes. Up to half of all patients will have eye involvement and early ophthalmologic consultation is necessary for patients with ocular symptoms. Risk factors include antibiotics (e.g., penicillins and sulfonamides), anticonvulsants (e.g., carbamazepine and phenytoin), and infection (e.g. upper respiratory infections). Treatment consists of stopping the offending agent and supportive care. These patients are often best cared for at burn centers.
Incorrect
Stevens-Johnson syndrome is an autoimmune type IV hypersensitivity reaction that affects the skin and mucous membranes. Stevens-Johnson syndrome exists on a continuum with toxic epidermal necrolysis where Stevens-Johnson syndrome is defined as less than 10% total body surface area (TBSA) affected, while toxic epidermal necrolysis involves greater than 30% TBSA. The rash occurs most often on the trunk and is classically described as macular and target-like with two zones of color: purpuric at the core with surrounding erythema. However, the rash can also be vesicular, bullous, and necrotic. Ruptured bullae and desquamation place the patient at risk for secondary infection, which is the leading cause of death. Stevens-Johnson syndrome can also affect the renal, hepatic, and pulmonary organ systems. Mucosal involvement is often present as well, affecting the genitals, mouth, and eyes. Up to half of all patients will have eye involvement and early ophthalmologic consultation is necessary for patients with ocular symptoms. Risk factors include antibiotics (e.g., penicillins and sulfonamides), anticonvulsants (e.g., carbamazepine and phenytoin), and infection (e.g. upper respiratory infections). Treatment consists of stopping the offending agent and supportive care. These patients are often best cared for at burn centers.
Question 10 of 10
10. Question
A 21 year old female presents with 1 week of a pruritic rash of the abdomen. She denies any history of similar rashes. She has been afebrile, without any nausea/vomiting/diarrhea. She denies any recent travel or camping. The rash is located in the mid-line of the abdomen inferior to the umbilicus, there is no purulent drainage. On your physical exam it appears as an erythematous, indurated, scaly plaque, and approximately 3 cm in diameter. There is no tenderness or fluctuance to palpation. What is the best treatment for this patient?
Correct
This patient has classic contact dermatitis, and in this case the patient likely has an allergy to a metal contained in a belt-buckle or jean button. Patient’s will not always know they have an allergy to a particular substance, so be aware of anybody with a rash in areas of common contact with jewelry (e.g. ears/neck/wrist). It also commonly occurs on the hands of people who frequently wear gloves (healthcare workers/food service workers). Avoidance of the source agent, protection of involved skin, and treatment of inflammation is the treatment of choice for contact dermatitis. Because contact dermatitis is defined as patterns of skin reaction resulting from topical contact with external agents it is reasonable to begin management with measures that minimize continued or recurrent exposure to the known or suspected causative agent. The agent may be an irritant (such as solvents, caustics, and detergents) or an allergen (such as nickel in jewelry, soaps, cosmetics, rubber compounds, latex, and poison ivy, oak, or sumac). The cause may be readily identifiable via a detailed history and physical examination or may require eventual skin testing. Contact dermatitis may develop from brief but intense or repetitive low levels of exposure. Avoidance of continued or recurrent exposure may include measures such as substituting a different brand or type of a topical agent, avoiding the location of exposure, or even changing occupation. Protection of involved skin may include wearing gloves or clothing or use of a barrier cream when exposure is possible. The other initial component is treatment of inflammation. Oral antihistamines may be effective for control of itching, low to moderate potency topical steroids can be used on erythematous areas, and cool compresses with aluminum acetate solutions can be used on oozing or vesiculated skin to treat inflammation. Steroid use can sometimes be delayed until patient follow-up to ascertain whether avoidance and protective measures alone have been adequate.
Incorrect
This patient has classic contact dermatitis, and in this case the patient likely has an allergy to a metal contained in a belt-buckle or jean button. Patient’s will not always know they have an allergy to a particular substance, so be aware of anybody with a rash in areas of common contact with jewelry (e.g. ears/neck/wrist). It also commonly occurs on the hands of people who frequently wear gloves (healthcare workers/food service workers). Avoidance of the source agent, protection of involved skin, and treatment of inflammation is the treatment of choice for contact dermatitis. Because contact dermatitis is defined as patterns of skin reaction resulting from topical contact with external agents it is reasonable to begin management with measures that minimize continued or recurrent exposure to the known or suspected causative agent. The agent may be an irritant (such as solvents, caustics, and detergents) or an allergen (such as nickel in jewelry, soaps, cosmetics, rubber compounds, latex, and poison ivy, oak, or sumac). The cause may be readily identifiable via a detailed history and physical examination or may require eventual skin testing. Contact dermatitis may develop from brief but intense or repetitive low levels of exposure. Avoidance of continued or recurrent exposure may include measures such as substituting a different brand or type of a topical agent, avoiding the location of exposure, or even changing occupation. Protection of involved skin may include wearing gloves or clothing or use of a barrier cream when exposure is possible. The other initial component is treatment of inflammation. Oral antihistamines may be effective for control of itching, low to moderate potency topical steroids can be used on erythematous areas, and cool compresses with aluminum acetate solutions can be used on oozing or vesiculated skin to treat inflammation. Steroid use can sometimes be delayed until patient follow-up to ascertain whether avoidance and protective measures alone have been adequate.
This week we will conclude our dermatology block. These are all board relevant topics, and chief complaints we see almost daily! Not the most exciting topic, but it’s bread and butter baby. We will kick things off with FLIP hosted by Drs. Padgett and Darr. For this week focus on non-infectious dermatologic pathology and pediatric rashes. Also, if you didn’t know, we have online access to Rosen’s! If you prefer their exhaustively detailed approach to core content, then feel free to use it as your main source, but we still primarily advocate for Harwood & Nuss. See the link below, you will have to use your Wayne State login to access it (if you don’t have this e-mail Gloria).
If you missed Dr. Neha Mehta-Sykes’s JC on this topic, make sure to read the review posted below. Our choice of paralytics in these patients often causes a stur amongst our NICU colleagues, so educate yourself!
Clinical Vignette: 70 yo M with PMH of HTN, non-compliant with HCTZ and amlodipine, presenting with new-onset seizure x2 witnessed by family, followed by altered mentation. EMS was called by family. Presenting vital signs are: BP 225/135, HR 120, RR 12, pulse ox 95% on non-rebreather mask, temp 37.3. GCS 5, responsive to pain in all extremities except for right upper, with right eye gaze deviation. The decision is made to intubate the patient for airway protection. You suspect an intracranial hemorrhage as the cause of his seizures. Which medications would you like to use to intubate the patient?
We had our first ever Think Pair & Share FLIP this week! Big shout out to Drs. Messman, Kava, and Burkholder for paving the way for this. We hope to integrate more true FLIPs such as this into our conferences. These are discussion based small groups, so I’m sure every group had a slightly different experience. See the full literature review below if you wanted to revisit any of the topics.
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Question 1 of 10
1. Question
Which of the following risk factors has the strongest association for cellulitis?
Correct
Certain host factors predispose to cellulitis. The elderly and immunocompromised individuals are at risk for more severe disease. Patients with diabetes, immunodeficiency, cancer, venous stasis, chronic liver disease, peripheral arterial disease, and chronic kidney disease appear to be at a higher risk for recurrent infection, owing to an altered host immune response. While other factors that affect host immunity such as concurrent intravenous or subcutaneous “skin popping” drug use predispose to development of infection, the risk factor that is most strongly associated with cellulitis islymphedema (odds ratio [OR] = 71.2).
Incorrect
Certain host factors predispose to cellulitis. The elderly and immunocompromised individuals are at risk for more severe disease. Patients with diabetes, immunodeficiency, cancer, venous stasis, chronic liver disease, peripheral arterial disease, and chronic kidney disease appear to be at a higher risk for recurrent infection, owing to an altered host immune response. While other factors that affect host immunity such as concurrent intravenous or subcutaneous “skin popping” drug use predispose to development of infection, the risk factor that is most strongly associated with cellulitis islymphedema (odds ratio [OR] = 71.2).
Question 2 of 10
2. Question
A 27-year-old man with AIDS has the rash shown in the picture. What type of isolation is required if he is admitted?
Correct
Varicella zoster virus (human herpesvirus 3) is the causative agent in both chicken pox and shingles. Herpes zoster shown in this patient occurs from reactivation of the varicella zoster virus that has been dormant in a dorsal root nerve ganglion since an episode of chicken pox. Most reoccurrences occur in elderly and immunocompromised patients. Prior to the onset of rash, patients experience tingling or hyperesthesia in the dermatome. Painful, vesicular lesions then appear on the skin along the distribution of the dermatome. Patients are considered infectious from 5 days before the appearance of the rash until 5 days after the appearance of the vesicles. Until the vesicles are crusted over, patients required airborne isolation (negative pressure room) with contact precautions for anyone entering the room.
Incorrect
Varicella zoster virus (human herpesvirus 3) is the causative agent in both chicken pox and shingles. Herpes zoster shown in this patient occurs from reactivation of the varicella zoster virus that has been dormant in a dorsal root nerve ganglion since an episode of chicken pox. Most reoccurrences occur in elderly and immunocompromised patients. Prior to the onset of rash, patients experience tingling or hyperesthesia in the dermatome. Painful, vesicular lesions then appear on the skin along the distribution of the dermatome. Patients are considered infectious from 5 days before the appearance of the rash until 5 days after the appearance of the vesicles. Until the vesicles are crusted over, patients required airborne isolation (negative pressure room) with contact precautions for anyone entering the room.
Question 3 of 10
3. Question
A 5-year old male is brought in to the Emergency Department with a diffuse rash and fever. The patient has no past medical history and has previously been well. Physical exam is significant for diffuse errythroderma with bullae but no mucous membrane involvement. Nikolsky sign is positive. Which of the following is the most appropriate treatment for this patient?
Correct
The correct answer is anti-staphylococcal antibiotics. This patient’s presentation is concerning for Staph Scalded Skin Syndrome. Treatment is with anti-staph antibiotics as well as supportive measures, particularly fluid resuscitation since these patients are essentially treated like burn victims due to the skin sloughing.
Incorrect
The correct answer is anti-staphylococcal antibiotics. This patient’s presentation is concerning for Staph Scalded Skin Syndrome. Treatment is with anti-staph antibiotics as well as supportive measures, particularly fluid resuscitation since these patients are essentially treated like burn victims due to the skin sloughing.
Question 4 of 10
4. Question
A 23 yo professional photographer presents to the ED with complaints of fever, vomiting for 2 days and a rash. He is an avid traveler and outdoorsman. He travels out of the country often for work and recently returned from a camping trip. He has otherwise been in good health and reports good symptom relief with acetaminophen. Vital signs are BP 114/80, HR 106, RR 14, O2 100% on RA, and T 102.2F (39C). His exam is otherwise remarkable for a red to purple small macular rash on his wrists, palms, and ankles. What treatment is likely indicated?
Correct
Given his recent camping trip and rash around the distal extremities, this is concerning forRocky Mountain spotted fever (RMSF). The vast majority of patients with RMSF present with some type of rash which typically is noticed 2-5 days after the onset of fever and starts peripherally and spreads to the trunk. Frank petechiae do not develop until the 6th day or later and can be a sign of severe disease requiring more aggressive treatment. Treatment should be initiated as soon as possible and may be initiated based on clinical suspicion. Doxycycline is the most effective treatment.
Incorrect
Given his recent camping trip and rash around the distal extremities, this is concerning forRocky Mountain spotted fever (RMSF). The vast majority of patients with RMSF present with some type of rash which typically is noticed 2-5 days after the onset of fever and starts peripherally and spreads to the trunk. Frank petechiae do not develop until the 6th day or later and can be a sign of severe disease requiring more aggressive treatment. Treatment should be initiated as soon as possible and may be initiated based on clinical suspicion. Doxycycline is the most effective treatment.
Question 5 of 10
5. Question
A 29-year-old homosexual male presents to the Emergency Department with fever, weight loss, fatigue and the finding shown above. Which of the following is the most likely causative agent?
Correct
Kaposi sarcoma is an opportunistic cutaneous neoplasm linked to human herpesvirus (HHV)-8 infection. HHV-8 is also referred to as Kaposi sarcoma-associated herpesvirus (KSHV). It is an AIDS-defining illness in patients older than 13 years old infected with human immunodeficiency virus (HIV). It is the most common AIDS-associated tumor in homosexual patients, but other at-risk populations include intravenous drug users, blood-transfusion recipients, hemophiliacs and children born to HIV-positive mothers. Lesions are classically multifocal and are in different stages of development: papules, nodules, macules. Small violaceous macules may merge to form large plaques. Extracutaneous sites are frequently involved, including the oral mucosa, gastrointestinal tract, lungs and lymph nodes. Despite its viral oncogenesis, it responds well to chemotherapy and radiation.
Patients infected with Rubella (A) often have a self-limited disease course with morbilliform rash, whereas congenital rubella has a higher mortality and can cause the “blueberry muffin” rash with purpuric lesions. Meningococcemia from Neisseria meningitidis (C) most commonly causes a petechial or purpuric rash. Additionally, patients with this condition are systemically ill and often exhibiting altered mental status, hemodynamic instability and rapid clinical deterioration. Tinea versicolor (D) is caused by the Malassezia fungal genus and characteristically causes a hypopigmented papular rash that is more notable in darker-skinned individuals.
Incorrect
Kaposi sarcoma is an opportunistic cutaneous neoplasm linked to human herpesvirus (HHV)-8 infection. HHV-8 is also referred to as Kaposi sarcoma-associated herpesvirus (KSHV). It is an AIDS-defining illness in patients older than 13 years old infected with human immunodeficiency virus (HIV). It is the most common AIDS-associated tumor in homosexual patients, but other at-risk populations include intravenous drug users, blood-transfusion recipients, hemophiliacs and children born to HIV-positive mothers. Lesions are classically multifocal and are in different stages of development: papules, nodules, macules. Small violaceous macules may merge to form large plaques. Extracutaneous sites are frequently involved, including the oral mucosa, gastrointestinal tract, lungs and lymph nodes. Despite its viral oncogenesis, it responds well to chemotherapy and radiation.
Patients infected with Rubella (A) often have a self-limited disease course with morbilliform rash, whereas congenital rubella has a higher mortality and can cause the “blueberry muffin” rash with purpuric lesions. Meningococcemia from Neisseria meningitidis (C) most commonly causes a petechial or purpuric rash. Additionally, patients with this condition are systemically ill and often exhibiting altered mental status, hemodynamic instability and rapid clinical deterioration. Tinea versicolor (D) is caused by the Malassezia fungal genus and characteristically causes a hypopigmented papular rash that is more notable in darker-skinned individuals.
Question 6 of 10
6. Question
Which one of the following Tinea infections in children always requires systemic antifungal therapy?
Correct
Tinea infections are caused by dermatophytes and are classified by the involved site. The most common infections in prepubertal children are tinea corporis and tinea capitis, whereas adolescents and adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium (onychomycosis). In the United States, tinea capitis (scalp) most commonly affects children of African heritage between three and nine years of age. Early disease can be limited to itching and scaling, but the more classic presentation involves scaly patches of alopecia with hairs broken at the skin line and crusting. Tinea capitis may progress to kerion, which is characterized by boggy tender plaques and pustules. Tinea capitis must be treated with systemic antifungal agents because topical agents do not penetrate the hair shaft. However, adjunct treatment with selenium sulfide shampoo or 2% ketoconazole shampoo should be used for the first two weeks because it may reduce transmission. For many years, the first-line treatment for Tinea capitis was griseofulvin because it has a long track record of safety and effectiveness. However, randomized clinical trials have confirmed that newer agents, such as terbinafine and fluconazole, have equal effectiveness and safety and shorter treatment course. Note that these agents are rarely initiated in the ED, as they require prolonged treatment courses and long-term monitoring by a PCP due to potential fluctuations in AST/ALT.
Tinea corporis, Tinea cruris, and Tinea pedis are generally responsive to topical creams such as terbinafine and butenafine, but oral antifungal agents may be indicated for extensive disease, failed topical treatment or immunocompromised patients. Tinea cruris (C), also known as jock itch, most commonly affects adolescent and young adult males, and involves the portion of the upper thigh. The scrotum itself is usually spared in Tinea cruris, but involved in candidiasis. Tinea corporis (B), also known as ringworm, typically presents as a red, annular, scaly, pruritic patch with central clearing and an active border. Lesions may be single or multiple and the size generally ranges from 1 to 5 cm, but larger lesions and confluence of lesions can also occur. Tinea corporis may be mistaken for many other skin disorders, especially eczema, psoriasis, and seborrheic dermatitis. A potassium hydroxide (KOH) preparation is often helpful when the diagnosis is uncertain based on history and visual inspection. Tinea pedis (D), athletes foot, typically involves the skin between the toes, but can spread to the sole, sides, and dorsum of the involved foot .The acute form presents with erythema and maceration between the toes, sometimes accompanied by painful vesicles.
Incorrect
Tinea infections are caused by dermatophytes and are classified by the involved site. The most common infections in prepubertal children are tinea corporis and tinea capitis, whereas adolescents and adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium (onychomycosis). In the United States, tinea capitis (scalp) most commonly affects children of African heritage between three and nine years of age. Early disease can be limited to itching and scaling, but the more classic presentation involves scaly patches of alopecia with hairs broken at the skin line and crusting. Tinea capitis may progress to kerion, which is characterized by boggy tender plaques and pustules. Tinea capitis must be treated with systemic antifungal agents because topical agents do not penetrate the hair shaft. However, adjunct treatment with selenium sulfide shampoo or 2% ketoconazole shampoo should be used for the first two weeks because it may reduce transmission. For many years, the first-line treatment for Tinea capitis was griseofulvin because it has a long track record of safety and effectiveness. However, randomized clinical trials have confirmed that newer agents, such as terbinafine and fluconazole, have equal effectiveness and safety and shorter treatment course. Note that these agents are rarely initiated in the ED, as they require prolonged treatment courses and long-term monitoring by a PCP due to potential fluctuations in AST/ALT.
Tinea corporis, Tinea cruris, and Tinea pedis are generally responsive to topical creams such as terbinafine and butenafine, but oral antifungal agents may be indicated for extensive disease, failed topical treatment or immunocompromised patients. Tinea cruris (C), also known as jock itch, most commonly affects adolescent and young adult males, and involves the portion of the upper thigh. The scrotum itself is usually spared in Tinea cruris, but involved in candidiasis. Tinea corporis (B), also known as ringworm, typically presents as a red, annular, scaly, pruritic patch with central clearing and an active border. Lesions may be single or multiple and the size generally ranges from 1 to 5 cm, but larger lesions and confluence of lesions can also occur. Tinea corporis may be mistaken for many other skin disorders, especially eczema, psoriasis, and seborrheic dermatitis. A potassium hydroxide (KOH) preparation is often helpful when the diagnosis is uncertain based on history and visual inspection. Tinea pedis (D), athletes foot, typically involves the skin between the toes, but can spread to the sole, sides, and dorsum of the involved foot .The acute form presents with erythema and maceration between the toes, sometimes accompanied by painful vesicles.
Question 7 of 10
7. Question
A healthy 7-year-old girl presents with the rash seen. What management is indicated?
Correct
This child presents with a mild case of impetigo and can be treated with topical mupirocin. The rash is characterized by a slowly progressing pustular eruption and is commonly seen in preschool age children. The most common causative agent is Staphylococcus aureus with group A streptococcus as a less common etiology. It most commonly presents on the face and other exposed areas and typically begins with a single pustule that develops into multiple lesions over time. The original erythematous vesicle will break leaving red erosions covered in a golden yellow crust. The lesions should not be painful but may be pruritic. The lesions are contagious. First line treatment for limited extent of lesions is with topical antibiotics including mupirocin 2% ointment. Mupirocin should not be used if methicillin-resistant strains are suspected.
Incorrect
This child presents with a mild case of impetigo and can be treated with topical mupirocin. The rash is characterized by a slowly progressing pustular eruption and is commonly seen in preschool age children. The most common causative agent is Staphylococcus aureus with group A streptococcus as a less common etiology. It most commonly presents on the face and other exposed areas and typically begins with a single pustule that develops into multiple lesions over time. The original erythematous vesicle will break leaving red erosions covered in a golden yellow crust. The lesions should not be painful but may be pruritic. The lesions are contagious. First line treatment for limited extent of lesions is with topical antibiotics including mupirocin 2% ointment. Mupirocin should not be used if methicillin-resistant strains are suspected.
Question 8 of 10
8. Question
A 43-year-old man presents with pain, swelling, and redness to his left leg for 2 days. He denies fever or history of similar presentations in the past. He was hospitalized a month ago for 3 days. Vital signs are unremarkable. Physical examination reveals a 3 cm area of erythema, warmth, and purulence on the left shin. What treatment is recommended?
Correct
This patient presents with signs and symptoms of cellulitis requiring antibiotic treatment covering the most likely pathogens. Cellulitis is a soft tissue infection involving the skin and subcutaneous tissue. It is characterized by erythema, swelling, local warmth and tenderness. Cellulitis can occur anywhere on the body but usually presents on the lower extremities, upper extremities and face. Staphylococcus aureus and Streptococcus pyogenes are the most commonly isolated organisms and antibiotics should be directed against these pathogens. The diagnosis is made clinically and there is no specific test that aides in diagnosis. Standard treatment is with immobilization, elevation, warm compresses and antibiotics. In the last 10-15 years, community acquired methicillin resistant S. aureus (CA-MRSA) has become a common causative organism. Cephalexin is a first generation cephalosporin with activity against manystreptococcus and staphylococcus species but not against MRSA. TMP-SMX is added to cephalexin when the cellulitis is associated with purulence. TMP-SMX is active against most strains of MRSA but does not have adequate activity against S. pyogenes. Per IDSA guidelines, for outpatients with purulent cellulitis (e.g., cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess), empirical therapy (e.g. TMP-SMX) for CA-MRSA is recommended pending culture results. Empirical therapy for infection due to β-hemolytic streptococci is likely to be unnecessary.
Incorrect
This patient presents with signs and symptoms of cellulitis requiring antibiotic treatment covering the most likely pathogens. Cellulitis is a soft tissue infection involving the skin and subcutaneous tissue. It is characterized by erythema, swelling, local warmth and tenderness. Cellulitis can occur anywhere on the body but usually presents on the lower extremities, upper extremities and face. Staphylococcus aureus and Streptococcus pyogenes are the most commonly isolated organisms and antibiotics should be directed against these pathogens. The diagnosis is made clinically and there is no specific test that aides in diagnosis. Standard treatment is with immobilization, elevation, warm compresses and antibiotics. In the last 10-15 years, community acquired methicillin resistant S. aureus (CA-MRSA) has become a common causative organism. Cephalexin is a first generation cephalosporin with activity against manystreptococcus and staphylococcus species but not against MRSA. TMP-SMX is added to cephalexin when the cellulitis is associated with purulence. TMP-SMX is active against most strains of MRSA but does not have adequate activity against S. pyogenes. Per IDSA guidelines, for outpatients with purulent cellulitis (e.g., cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess), empirical therapy (e.g. TMP-SMX) for CA-MRSA is recommended pending culture results. Empirical therapy for infection due to β-hemolytic streptococci is likely to be unnecessary.
Question 9 of 10
9. Question
A 54-year-old man with diabetes presents with severe leg pain. The pain has worsened over the last 2 days with increased swelling of the calf. He has no chest pain or shortness of breath. Vital signs are: T 101.8°F, BP 98/62, HR 118, RR 18. Physical examination is notable for erythema of the calf, severe tenderness, and crepitus. You initiate IV fluids and broad-spectrum antibiotics. Which of the following is the most appropriate next step?
Correct
Necrotizing fasciitis is an infection of the subcutaneous tissue that spreads rapidly across the fascial planes and is often fatal even with aggressive treatment. Risk factors for necrotizing infections include diabetes, vascular insufficiency, and immunosuppression. Classically patients have pain out of proportion to examination. Later findings include diffuse swelling, erythema, induration, and crepitus. The gold standard for diagnosis is direct visualization in the operating room by a surgeon. Surgeons may elect to perform a bedside biopsy prior to full exploration. Management includes aggressive IV hydration, broad-spectrumantibiotics, and surgical debridement.
Incorrect
Necrotizing fasciitis is an infection of the subcutaneous tissue that spreads rapidly across the fascial planes and is often fatal even with aggressive treatment. Risk factors for necrotizing infections include diabetes, vascular insufficiency, and immunosuppression. Classically patients have pain out of proportion to examination. Later findings include diffuse swelling, erythema, induration, and crepitus. The gold standard for diagnosis is direct visualization in the operating room by a surgeon. Surgeons may elect to perform a bedside biopsy prior to full exploration. Management includes aggressive IV hydration, broad-spectrumantibiotics, and surgical debridement.
Question 10 of 10
10. Question
A 55-year old male presents to the Emergency Department with a painful rash to his face. Vital signs on presentation are: heart rate 105, blood pressure 145/90, respiratory rate 18, oxygen saturation 99% on room air, and temperature 100.4 degrees F (38 degrees C). Physical exam reveals an erythematous rash along the right side of the patient’s face with a sharply demarcated and raised border. Which of the following pathogens is most likely to have caused this patient’s infection?
Correct
The correct answer is strep pyogenes (group A strep). This patient’s presentation, particularly the sharply raised border, is classic for erysipelas which is typically caused by group A strep. The rash itself is caused by a streptococcal exotoxin. Treatment involves parenteral or oral antibiotics depending on the extent of the infection.
Close
Incorrect
The correct answer is strep pyogenes (group A strep). This patient’s presentation, particularly the sharply raised border, is classic for erysipelas which is typically caused by group A strep. The rash itself is caused by a streptococcal exotoxin. Treatment involves parenteral or oral antibiotics depending on the extent of the infection.
Close
This week will mark part 1 of our 2 part series on dermatology. This week we will focus on all things infectious. This block will have a lot of cross talk between previous conferences as there are many sources of skin/soft tissue infections we’ve previously covered (ticks, other parasites, bacteria, fungi). Drs. Franckowiak and Inman will be hosting FLIPS on common infections as well as scratching the surface of some zebras
We will also be starting a new series of deep dives. We will have a “Think Pair & Share” station hosted by Dr. Messman and VandenBerg. This will be a true FLIP, and you have required readings posted below. You MUST do the readings for this station.
This week we have a very special conference, SONOCUP! There will be no quiz, but below are some good US review resources so that we can all bring our A game. And for those of you wanting a quick review of the basics without getting too fancy you can also look at the “Ultrasound Rotation” portion of the resident handbook which has a great breakdown provided by the amazing Dr. Baker. There is also a list of great US texts at the bottom of the handbook page if you have not found one that you prefer yet.
There are many, many more videos on the website (shoulder dislocations, nerve blocks, SBO, etc) so be sure to look around if you have any topics you’ve been interested in learning about!
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Question 1 of 10
1. Question
An 18-year-old man presents to the Emergency Department with his parents who are concerned about his behavior. They say he has few social relationships and prefers to work on his model aircrafts. He has never dated anyone and generally prefers to be left alone. He appears calm but withdrawn. He denies homicidality, suicidality or hallucinations. His parents do not feel he is fixated on any odd beliefs or magical thinking. What is the most likely diagnosis?
Correct
Schizoid personality disorder is classified as a cluster A personality disorder. This cluster describes patients with odd and eccentric behavior and includes paranoid personality disorder and schizotypal personality disorder. Patients with schizoid personality disorder generally prefer to be left alone. They do not enjoy engaging in social or sexual relationships or interactions. They are markedly detached from society, introverted, and primarily choose solitary activities or hobbies. They may be indifferent to praise or criticism and appear withdrawn or aloof. Schizoid patients are rarely seen in clinical practice. Patients with cluster A disorders may be difficult to treat because of an intrinsic distrust or suspicion of others. They may express resistance in engaging, but it is important to be clear in explaining management intentions without becoming overly involved in their personal lives. It is also important to remain professional, direct, and empathetic toward them and not to react emotionally to their odd, inappropriate or dramatic behavior.
Antisocial personality disorder (A) is a cluster B disorder characterized by selfishness, impulsivity, promiscuity, callousness, disregard for rules or other people, pervasive deception and lying, lack of remorse, and difficulty learning from prior experiences. Patients are commonly in trouble with the law. Borderline personality disorder (B) is also a cluster B disorder and is characterized by a lack of self-control, violence, aggression, and having unstable relationships (e.g., frequent break ups). Drug abuse and suicide attempts are very common in borderline individuals. Schizoaffective disorder (C) is not a personality disorder, but rather a condition on the spectrum schizophrenia-like disorders. It is characterized by the presence of delusions, hallucinations, disorganized speech, catatonia or grossly disorganized behavior, along with mood disturbance such as mania or major depression.
Incorrect
Schizoid personality disorder is classified as a cluster A personality disorder. This cluster describes patients with odd and eccentric behavior and includes paranoid personality disorder and schizotypal personality disorder. Patients with schizoid personality disorder generally prefer to be left alone. They do not enjoy engaging in social or sexual relationships or interactions. They are markedly detached from society, introverted, and primarily choose solitary activities or hobbies. They may be indifferent to praise or criticism and appear withdrawn or aloof. Schizoid patients are rarely seen in clinical practice. Patients with cluster A disorders may be difficult to treat because of an intrinsic distrust or suspicion of others. They may express resistance in engaging, but it is important to be clear in explaining management intentions without becoming overly involved in their personal lives. It is also important to remain professional, direct, and empathetic toward them and not to react emotionally to their odd, inappropriate or dramatic behavior.
Antisocial personality disorder (A) is a cluster B disorder characterized by selfishness, impulsivity, promiscuity, callousness, disregard for rules or other people, pervasive deception and lying, lack of remorse, and difficulty learning from prior experiences. Patients are commonly in trouble with the law. Borderline personality disorder (B) is also a cluster B disorder and is characterized by a lack of self-control, violence, aggression, and having unstable relationships (e.g., frequent break ups). Drug abuse and suicide attempts are very common in borderline individuals. Schizoaffective disorder (C) is not a personality disorder, but rather a condition on the spectrum schizophrenia-like disorders. It is characterized by the presence of delusions, hallucinations, disorganized speech, catatonia or grossly disorganized behavior, along with mood disturbance such as mania or major depression.
Question 2 of 10
2. Question
A 30 year old male is brought to the emergency department by EMS and police with disruptive behavior. EMS reports that he was evicted from his apartment today because he was shouting loudly and behaving violently. He has medical history of schizophrenia. He has no known drug allergies. On examination his vital signs are within the normal limits and he is agitated, unable to focus on commands, is muffling his ears while yelling at “the voices,” and is pacing. What is the most appropriate initial management plan of this patient?
Correct
IM haloperidol
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In an uncooperative patient unable to follow commands, rapid sedation is indicated. Once the patient is calm, a focused medical assessment can be safely performed.
A. CT head, basic blood work, urine toxicology screen
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In an uncooperative patient, verbal deescalation and, if necessary, rapid sedation with an antipsychotic may be necessary. Verbal deescalation has failed in this patient, and blood testing and imaging are unlikely to be successful at this time.
C. Sublingual olanzapine
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. While sublingual olanzapine is a great option in a cooperative patient, this patient is not following commands. In an acutely agitated and unncooperative patient without IV access, intramuscular administration is the safest and most effective.
D. IV midazolam
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In this uncooperative patient where verbal deescalation has failed, rapid sedation is most appropriate. Benzodiazepines would be an option, but starting a peripheral IV would be difficult in this aggressive patient.
Incorrect
IM haloperidol
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In an uncooperative patient unable to follow commands, rapid sedation is indicated. Once the patient is calm, a focused medical assessment can be safely performed.
A. CT head, basic blood work, urine toxicology screen
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In an uncooperative patient, verbal deescalation and, if necessary, rapid sedation with an antipsychotic may be necessary. Verbal deescalation has failed in this patient, and blood testing and imaging are unlikely to be successful at this time.
C. Sublingual olanzapine
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. While sublingual olanzapine is a great option in a cooperative patient, this patient is not following commands. In an acutely agitated and unncooperative patient without IV access, intramuscular administration is the safest and most effective.
D. IV midazolam
This presentation is consistent with acute psychosis. The safety of the health care staff and patient are paramount. In this uncooperative patient where verbal deescalation has failed, rapid sedation is most appropriate. Benzodiazepines would be an option, but starting a peripheral IV would be difficult in this aggressive patient.
Question 3 of 10
3. Question
A 23-year-old male presents to the ED by ambulance after being found yelling at cars on a nearby highway. On interview, the patient is disheveled and endorsing beliefs that the staff is trying to poison his water. After threatening the staff, the patient is chemically sedated with haloperidol and lorazepam. Two hours later, the patient appears to be in distress stating that he cannot move his eyes. On exam, both eyes are deviated upwards bilaterally. What is the next most appropriate action?
Correct
Diphenhydramine IM
The patient in the above question is demonstrating signs of an acute dystonic reaction. Acute dystonic reactions can occur at any point during long-term or short-term antipsychotic therapy. They are more common with typical antipsychotics such as haloperidol. Symptoms include involuntary contraction of muscle groups commonly seen in the neck (torticollis), tongue (buccolingual crisis), and eyes (oculogyric crisis). Treatment of acute dystonic reaction includes IM diphenhydramine or IM benztropine. After receiving one of these muscular agents, patient should receive the same medication in oral form for 48-72 hours to prevent recurrence. Source
Pringsheim T, Doja A, Belanger S, Patten S. Treatment recommendations for extrapyramidal side effects associated with second-generation antipsychotic use in children and youth. Paediatr Child Health. 2011;16(9):590-8.
PMC3223903
A. Benztropine PO (incorrect)
Benztropine can also be used to treat dystonic reactions; however, the appropriate route of administration is IM followed by subsequent PO dosing for 48-72 hours
B. Dantrolene IV (incorrect)
Dantrolene would be more appropriate for the treatment of malignant hyperthermia or neuroleptic malignant syndrome
D. Lorazepam IM (incorrect)
Ativan is an agent that can be effectively used to treat mild agitation or akithesia. It is not the appropriate therapy for dystonic reactions
Incorrect
Diphenhydramine IM
The patient in the above question is demonstrating signs of an acute dystonic reaction. Acute dystonic reactions can occur at any point during long-term or short-term antipsychotic therapy. They are more common with typical antipsychotics such as haloperidol. Symptoms include involuntary contraction of muscle groups commonly seen in the neck (torticollis), tongue (buccolingual crisis), and eyes (oculogyric crisis). Treatment of acute dystonic reaction includes IM diphenhydramine or IM benztropine. After receiving one of these muscular agents, patient should receive the same medication in oral form for 48-72 hours to prevent recurrence. Source
Pringsheim T, Doja A, Belanger S, Patten S. Treatment recommendations for extrapyramidal side effects associated with second-generation antipsychotic use in children and youth. Paediatr Child Health. 2011;16(9):590-8.
PMC3223903
A. Benztropine PO (incorrect)
Benztropine can also be used to treat dystonic reactions; however, the appropriate route of administration is IM followed by subsequent PO dosing for 48-72 hours
B. Dantrolene IV (incorrect)
Dantrolene would be more appropriate for the treatment of malignant hyperthermia or neuroleptic malignant syndrome
D. Lorazepam IM (incorrect)
Ativan is an agent that can be effectively used to treat mild agitation or akithesia. It is not the appropriate therapy for dystonic reactions
Question 4 of 10
4. Question
A homeless teenage girl presents to the ED and is found to be pregnant. You suspect she is a victim of human trafficking. Which of the following supports your suspicion?
Correct
Certain risk factors have been identified for trafficking. A tattoo that the patient is reluctant to discuss is a potential red flag. Some traffickers brand their victims.
Trafficking should be considered if the individual is traveling with an older companion (B) who is not a guardian. Those trafficked into commercial sex are overly familiar with sexual language and practices (D). Physicians should be suspicious when the accompanying person tries to answer all the questions and insists on being present at all times (C).
Incorrect
Certain risk factors have been identified for trafficking. A tattoo that the patient is reluctant to discuss is a potential red flag. Some traffickers brand their victims.
Trafficking should be considered if the individual is traveling with an older companion (B) who is not a guardian. Those trafficked into commercial sex are overly familiar with sexual language and practices (D). Physicians should be suspicious when the accompanying person tries to answer all the questions and insists on being present at all times (C).
Question 5 of 10
5. Question
A 33-year old male is brought to the emergency department for altered mental status. Toxicology screen is positive for cocaine. Heart rate is 133, blood pressure is 220/160, respiratory rate is 18, oxygen saturation is 100% on room air, and temperature is 102.4 degrees F (39.1 degrees C). What is the most appropriate initial treatment of this patient?
Correct
Lorazepam
The correct answer is benzodiazepines. For sympathomimetic toxidromes, the most efficacious medicines to reduce blood pressure/tachycardia/hyperthermia are benzos. Beta blockers are contraindicated as they lead to unopposed alpha activity. Phentolamine is a difficult medicine to titrate.
B. Clonidine
This patient likely has a sympathomimetic toxidrome. Treatment of choice is a benzodiazepine, not clonidine.
C. Labetolol
Beta blockers are contraindicated in cocaine toxicity
D. Phentolamine
Rarely used and difficult to titrate
Incorrect
Lorazepam
The correct answer is benzodiazepines. For sympathomimetic toxidromes, the most efficacious medicines to reduce blood pressure/tachycardia/hyperthermia are benzos. Beta blockers are contraindicated as they lead to unopposed alpha activity. Phentolamine is a difficult medicine to titrate.
B. Clonidine
This patient likely has a sympathomimetic toxidrome. Treatment of choice is a benzodiazepine, not clonidine.
C. Labetolol
Beta blockers are contraindicated in cocaine toxicity
D. Phentolamine
Rarely used and difficult to titrate
Question 6 of 10
6. Question
A 32-year-old man is brought in for evaluation after police found him agitated and violent. It takes multiple staff members to restrain him. On physical examination, rotary nystagmus is noted. Which of the following is the most likely ingestion?
Correct
Phencyclidine (PCP) was initially developed for use as a general anesthetic. However, frequent emergent reactions led to its discontinuation in the therapeutic setting. PCP is well absorbed from any mucous membrane and can also be smoked. The drug affects many receptors and therefore causes a broad spectrum of clinical findings. In most cases, the sympathomimetic effects predominate and patients are agitated, exhibiting both bizarre and violent behavior. Patients may, however, demonstrate catatonic features. Nystagmus is often present and may be horizontal, vertical or rotatory. The patient’s hemodynamic status is most often consistent with a sympathomimetic picture with hypertension, tachycardia and possibly hyperthermia.
Crystal methamphetamine (A) is an amphetamine causing release of presynaptic catecholamines. Most commonly amphetamines are ingested, but can be crushed and injected as well. Patients develop typical sympathomimetic effects. With crystal methamphetamine, patients may also become paranoid with delusions. Its use has also been associated with engaging in high-risk behavior, specifically sexual in the men who have sex with men community. Gamma hydroxybutyrate (GHB) (B) is a popular recreational drug classified as a sedative/hypnotic. When ingested it produces a euphoria that is popular at rave parties. Particularly when mixed with ethanol, GHB has a marked CNS depressive effect often leading to respiratory depression requiring transient intubation. It has also been implicated as a date rape drug due to its sedative and amnestic effects. Lysergic acid diethylamine (LSD) (C) is a potent psychoactive drug taken orally as a tablet, liquid, powder, gelatin square or on a sheet of blotter paper. The medication is a hallucinogen with serotonin-like characteristics. Patients go on a “trip” during which perception between the user and environment are distorted. Patients may have an acute panic reaction after taking LSD.
Incorrect
Phencyclidine (PCP) was initially developed for use as a general anesthetic. However, frequent emergent reactions led to its discontinuation in the therapeutic setting. PCP is well absorbed from any mucous membrane and can also be smoked. The drug affects many receptors and therefore causes a broad spectrum of clinical findings. In most cases, the sympathomimetic effects predominate and patients are agitated, exhibiting both bizarre and violent behavior. Patients may, however, demonstrate catatonic features. Nystagmus is often present and may be horizontal, vertical or rotatory. The patient’s hemodynamic status is most often consistent with a sympathomimetic picture with hypertension, tachycardia and possibly hyperthermia.
Crystal methamphetamine (A) is an amphetamine causing release of presynaptic catecholamines. Most commonly amphetamines are ingested, but can be crushed and injected as well. Patients develop typical sympathomimetic effects. With crystal methamphetamine, patients may also become paranoid with delusions. Its use has also been associated with engaging in high-risk behavior, specifically sexual in the men who have sex with men community. Gamma hydroxybutyrate (GHB) (B) is a popular recreational drug classified as a sedative/hypnotic. When ingested it produces a euphoria that is popular at rave parties. Particularly when mixed with ethanol, GHB has a marked CNS depressive effect often leading to respiratory depression requiring transient intubation. It has also been implicated as a date rape drug due to its sedative and amnestic effects. Lysergic acid diethylamine (LSD) (C) is a potent psychoactive drug taken orally as a tablet, liquid, powder, gelatin square or on a sheet of blotter paper. The medication is a hallucinogen with serotonin-like characteristics. Patients go on a “trip” during which perception between the user and environment are distorted. Patients may have an acute panic reaction after taking LSD.
Question 7 of 10
7. Question
A 17-year-old man is found unresponsive in his bedroom and brought to the emergency department. His parents report that he has been recently weight training and taking large quantities of bodybuilding supplements. Upon arrival, his vital signs are temperature 35.6°C, heart rate 68 beats per minute, blood pressure 100/70 mm Hg, respirations 10 breaths per minute. His pupils are small and minimally responsive to light. He is unresponsive to painful stimuli. Naloxone is administered without improvement. The patient is subsequently intubated for airway protection. About six hours later, the patient rapidly awakes and self-extubates. Which of the following is the most likely etiology of this patient’s symptoms?
Correct
This patient has gamma-hydroxybutyric acid (GHB) intoxication. GHB is an analogue of the inhibitory neurotransmitter GABA. It has been commonly used and abused by bodybuilders because of its anabolic effects. GHB also has euphoric effects, which has caused it to gain popularity as a club drug. Its sedative and amnestic effects have caused GHB to be implicated in cases of drug-facilitated sexual assault (“date rape”). Clinically, GHB overdose can range from euphoria to depressed mental status with or without coma. Vital sign abnormalities such as hypothermia, bradycardia, and hypotension may be present. U waves can be seen on ECG. Pupils are small and minimally responsive to light. Respiratory depression may occur, but—despite a comatose appearance—most GHB intoxicated patients maintain adequate ventilation. Effects of GHB overdose generally resolve within six to eight hours. The classic presentation of GHB overdose is a comatose patient who requires intubation then has an abrupt awakening. Care for GHB intoxication is largely supportive and includes benzodiazepines for agitation, fluid resuscitation, and keeping the patient in a safe environment.
Midazolam (B) is a short-acting benzodiazepine. Benzodiazepines are generally not found in bodybuilding supplements and rarely cause hypotension or bradycardia when ingested alone. The patient in this scenario has slow respirations, coma, and small pupils but does not respond to naloxone, making opioid intoxication (C) less likely. Opioids are also generally not found in bodybuilding supplements. Phenobarbital (D) is a long-acting barbiturate. Barbiturates can cause significant cardiovascular and central nervous system depression; however, given its long duration of action, it is unlikely that the patient would abruptly regain consciousness after six hours.
Incorrect
This patient has gamma-hydroxybutyric acid (GHB) intoxication. GHB is an analogue of the inhibitory neurotransmitter GABA. It has been commonly used and abused by bodybuilders because of its anabolic effects. GHB also has euphoric effects, which has caused it to gain popularity as a club drug. Its sedative and amnestic effects have caused GHB to be implicated in cases of drug-facilitated sexual assault (“date rape”). Clinically, GHB overdose can range from euphoria to depressed mental status with or without coma. Vital sign abnormalities such as hypothermia, bradycardia, and hypotension may be present. U waves can be seen on ECG. Pupils are small and minimally responsive to light. Respiratory depression may occur, but—despite a comatose appearance—most GHB intoxicated patients maintain adequate ventilation. Effects of GHB overdose generally resolve within six to eight hours. The classic presentation of GHB overdose is a comatose patient who requires intubation then has an abrupt awakening. Care for GHB intoxication is largely supportive and includes benzodiazepines for agitation, fluid resuscitation, and keeping the patient in a safe environment.
Midazolam (B) is a short-acting benzodiazepine. Benzodiazepines are generally not found in bodybuilding supplements and rarely cause hypotension or bradycardia when ingested alone. The patient in this scenario has slow respirations, coma, and small pupils but does not respond to naloxone, making opioid intoxication (C) less likely. Opioids are also generally not found in bodybuilding supplements. Phenobarbital (D) is a long-acting barbiturate. Barbiturates can cause significant cardiovascular and central nervous system depression; however, given its long duration of action, it is unlikely that the patient would abruptly regain consciousness after six hours.
Question 8 of 10
8. Question
A five-year-old boy is brought to the emergency department after being found unresponsive at home. He was found lying on the floor in his mother’s room with prescription medications scattered all over. His mother called 911, and he was immediately rushed to the hospital by ambulance. On examination, the boy is sedated with a heart rate of 69 beats per minute, respiratory rate of 15 per minute, blood pressure 70/50 mm Hg, pulse oximetry of 99 percent, pupils 1-2 mm reactive to light, and 1+ reflexes on all extremities. Blood sugar is 200 and ECG shows QTc interval prolongation. Which of the following is the most likely medication ingested?
Correct
The boy has signs and symptoms consistent with opioid ingestion. Methadone ingestion can manifest with the classic opioid toxidrome of respiratory depression, sedation, and miosis. Signs of more severe toxicity can include bradycardia, hypotension, and hypothermia. Methadone has been associated with a prolonged QTc interval and risk of torsades de pointes. Patients with significant respiratory or CNS depression should be treated with naloxone, which is a mu receptor antagonist. Because the half-life of methadone is longer than naloxone, patients can require multiple doses of naloxone. Also, serial ECGs are needed to monitor for the development of a prolonged QTc interval. If a patient does develop a prolonged QTc, management includes close cardiac monitoring, repletion of electrolytes, and having magnesium readily available should the patient develop torsades de pointes.
Clonidine (A) toxicity manifests as lethargy, miosis, and bradycardia. Although, findings may be similar to opioid overdose, QTc interval prolongation and torsades de pointes are typically only seen with opioid overdose. Propanolol (C) toxicity causes bradycardia and hypotension that typically develops within six hours of ingestion. Heart block and hypoglycemia may also be seen. Clinical manifestations of salicylate (D) toxicity include nausea, vomiting, diaphoresis, and tinnitus. Moderate cases can manifest as tachypnea, tachycardia, and altered mental status.
Incorrect
The boy has signs and symptoms consistent with opioid ingestion. Methadone ingestion can manifest with the classic opioid toxidrome of respiratory depression, sedation, and miosis. Signs of more severe toxicity can include bradycardia, hypotension, and hypothermia. Methadone has been associated with a prolonged QTc interval and risk of torsades de pointes. Patients with significant respiratory or CNS depression should be treated with naloxone, which is a mu receptor antagonist. Because the half-life of methadone is longer than naloxone, patients can require multiple doses of naloxone. Also, serial ECGs are needed to monitor for the development of a prolonged QTc interval. If a patient does develop a prolonged QTc, management includes close cardiac monitoring, repletion of electrolytes, and having magnesium readily available should the patient develop torsades de pointes.
Clonidine (A) toxicity manifests as lethargy, miosis, and bradycardia. Although, findings may be similar to opioid overdose, QTc interval prolongation and torsades de pointes are typically only seen with opioid overdose. Propanolol (C) toxicity causes bradycardia and hypotension that typically develops within six hours of ingestion. Heart block and hypoglycemia may also be seen. Clinical manifestations of salicylate (D) toxicity include nausea, vomiting, diaphoresis, and tinnitus. Moderate cases can manifest as tachypnea, tachycardia, and altered mental status.
Question 9 of 10
9. Question
A 35-year-old woman with a history of depression presents to the ED with altered mental status. Her medication was changed from fluoxetine to phenelzine two days ago. Upon arrival, her vital signs are temperature 39.5°C, heart rate 110 beats per minute, blood pressure 170/110 mm Hg, and respirations 16 breaths per minute. Her exam is notable for lower extremity myoclonus. What is the most likely etiology of this patient’s symptoms?
Correct
Serotonin syndrome occurs when there is an excess of systemic serotonin, usually due to a combination of medications, in this case fluoxetine and phenelzine. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that has a long half-life and active metabolites. Phenelzine is a monamine oxidase inhibitor (MAOI) that inhibits serotonin breakdown. Because of fluoxetine’s long half-life and the consequent risk of serotonin syndrome, a 6-week washout period is recommended postdiscontinuation before starting an MAOI. Serotonin syndrome is characterized by altered mental status, hyperreflexia, clonus, rigidity, and autonomic instability. Treatment includes removing the offending drugs, cooling measures, benzodiazepines, fluid resuscitation, and cyproheptadine, a serotonin antagonist.
Acute dystonic reactions (A) result from administration of dopaminergic-blocking agents (especially antipsychotics and some antiemetics) and include torticollis, akathisia, and pseudoparkinsonism. Unlike serotonin syndrome, altered mental status and autonomic instability do not occur with acute dystonic reactions. Hypertensive crisis (B) can occur in patients taking MAOIs, usually in the context of eating foods that are high in tyramine; however, altered mental status, hyperthermia, and movement disorders are not as common in this setting. Neuroleptic malignant syndrome (NMS) (C) occurs in the setting of antipsychotic medication administration. The onset is often more insidious then serotonin syndrome but can be difficult to distinguish because both can present with autonomic instability, hyperthermia, altered consciousness, and movement disorders. NMS is more commonly associated with bradykinesia and lead pipe rigidity. Patients with serotonin syndrome tend to have more agitation and myoclonus/hyperreflexia. A careful medication history can also help to distinguish the etiology.
Incorrect
Serotonin syndrome occurs when there is an excess of systemic serotonin, usually due to a combination of medications, in this case fluoxetine and phenelzine. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that has a long half-life and active metabolites. Phenelzine is a monamine oxidase inhibitor (MAOI) that inhibits serotonin breakdown. Because of fluoxetine’s long half-life and the consequent risk of serotonin syndrome, a 6-week washout period is recommended postdiscontinuation before starting an MAOI. Serotonin syndrome is characterized by altered mental status, hyperreflexia, clonus, rigidity, and autonomic instability. Treatment includes removing the offending drugs, cooling measures, benzodiazepines, fluid resuscitation, and cyproheptadine, a serotonin antagonist.
Acute dystonic reactions (A) result from administration of dopaminergic-blocking agents (especially antipsychotics and some antiemetics) and include torticollis, akathisia, and pseudoparkinsonism. Unlike serotonin syndrome, altered mental status and autonomic instability do not occur with acute dystonic reactions. Hypertensive crisis (B) can occur in patients taking MAOIs, usually in the context of eating foods that are high in tyramine; however, altered mental status, hyperthermia, and movement disorders are not as common in this setting. Neuroleptic malignant syndrome (NMS) (C) occurs in the setting of antipsychotic medication administration. The onset is often more insidious then serotonin syndrome but can be difficult to distinguish because both can present with autonomic instability, hyperthermia, altered consciousness, and movement disorders. NMS is more commonly associated with bradykinesia and lead pipe rigidity. Patients with serotonin syndrome tend to have more agitation and myoclonus/hyperreflexia. A careful medication history can also help to distinguish the etiology.
Question 10 of 10
10. Question
A 22 year-old woman presents to the emergency department by ambulance due to suspected ingestion. She has a history of depression and is on amitriptyline. She was found unresponsive next to an empty bottle of amitriptyline. She is intubated, tachycardic, hypotensive and an ECG reveals the following QRS prolongation > 100msec. What is the most appropriate initial treatment?
Correct
Tricyclic antidepressant (TCA) overdose initially manifests with anticholinergic symptoms such as sinus tachycardia and hypertension and can progress to seizures, coma and cardiovascular collapse. A dose greater than 10 mg/kg or 1000 mg in an adult should be considered life threatening. Severe lactic acidosis impairs myocardial sodium conduction leading to hypotension, dysrhythmias and ultimately cardiac arrest. Changes on ECG include QRS prolongation (greater than 100 msec), PR prolongation and rightward shift of the terminal 40-msec QRS vector. Treatment begins with assessment of airway and breathing. If intubated, hyperventilation will aid in reversing the acidosis. If the QRS is greater than 100 msec and the patient is symptomatic with hypotension or a dysrhythmia, or if the patient is acidemic, then intravenous sodium bicarbonate should be administered. Sodium bicarbonate produces an alkaline pH and provides a sodium load to aid conductance through the myocardial sodium fast channels that are blocked by the TCA. Sodium bicarbonate is administered by IV boluses of 1 to 2 mEq/kg until the QRS narrows or until the pH increases to 7.50-7.55. Once this is achieved, then a continuous infusion can be maintained by adding three ampules of 8.4% sodium bicarbonate (50 mEq/ampule) to one liter of 5% dextrose in water. The initial infusion rate mirrors that of the patient’s usual maintenance rate of intravenous fluids and should be maintained for 4 to 6 hours.
Hypertonic sodium chloride (A) is considered treatment of hypotension, acidemia and widened QRS interval that is refractory to treatment with sodium bicarbonate and fluid resuscitation. Intralipid (B) may be considered for refractory hypotension due lipophilic drug overdose, including TCA overdose, but is not first line. Vasopressors, such as norepinephrine (C) or dopamine, may be considered in persistently unstable patients after sodium bicarbonate therapy is maximized or no longer being tolerated.
Incorrect
Tricyclic antidepressant (TCA) overdose initially manifests with anticholinergic symptoms such as sinus tachycardia and hypertension and can progress to seizures, coma and cardiovascular collapse. A dose greater than 10 mg/kg or 1000 mg in an adult should be considered life threatening. Severe lactic acidosis impairs myocardial sodium conduction leading to hypotension, dysrhythmias and ultimately cardiac arrest. Changes on ECG include QRS prolongation (greater than 100 msec), PR prolongation and rightward shift of the terminal 40-msec QRS vector. Treatment begins with assessment of airway and breathing. If intubated, hyperventilation will aid in reversing the acidosis. If the QRS is greater than 100 msec and the patient is symptomatic with hypotension or a dysrhythmia, or if the patient is acidemic, then intravenous sodium bicarbonate should be administered. Sodium bicarbonate produces an alkaline pH and provides a sodium load to aid conductance through the myocardial sodium fast channels that are blocked by the TCA. Sodium bicarbonate is administered by IV boluses of 1 to 2 mEq/kg until the QRS narrows or until the pH increases to 7.50-7.55. Once this is achieved, then a continuous infusion can be maintained by adding three ampules of 8.4% sodium bicarbonate (50 mEq/ampule) to one liter of 5% dextrose in water. The initial infusion rate mirrors that of the patient’s usual maintenance rate of intravenous fluids and should be maintained for 4 to 6 hours.
Hypertonic sodium chloride (A) is considered treatment of hypotension, acidemia and widened QRS interval that is refractory to treatment with sodium bicarbonate and fluid resuscitation. Intralipid (B) may be considered for refractory hypotension due lipophilic drug overdose, including TCA overdose, but is not first line. Vasopressors, such as norepinephrine (C) or dopamine, may be considered in persistently unstable patients after sodium bicarbonate therapy is maximized or no longer being tolerated.
Welcome back everybody! This week we will be covering substance abuse and their psychiatric manifestations, so it’s time to get down with the DTs, brush off those bugs crawling on your skin, wave hello to that friendly pink elephant in the corner, and remember the answer is ALWAYS benzos. FLIP will be hosted this week by Drs. Koripella and Wilson. There are a lot of small topics to cover, we will focus on ETOH/withdrawal, stimulants, hallucinogens, opioids, and antichol/cholinergics, so choose one source and do your best to hit the highlights. We have recruited the tox. folk to help out with the stations so bring your A game!