Acute Chest Syndrome- When Vosyn is wrong

A 18 year old African American male with history of sickle cell disease presents to the ED with severe chest pain. He is a student at the Juilliard school and was playing the clarinet -- but unfortunately the opera house they were performing in had the airconditioning break. He was sweating a lot and didn't drink much water. By the end of the show, he was exhausted and began having severe chest pain and shortness of breath. He presented to the ED where he was tachycardic to 110, tachypnea, hypertensive to 145/90 and a temp to 101.4. You ask him how he feels and says in broken sentences and in varying levels of consciousness, “palms sweaty, knees weak, arms are heavy” and his saturation is 75%. Which of the following is correct?

A. Aggressive fluid hydration is indicated in these scenarios due to risk of systemic infection

B. Acute chest syndrome is the second most common cause of death in sickle cell disease patients behind splenic rupture.

C. Atypical bacteria are the most common bacterial infection in acute chest syndrome.

D. In severe acute chest syndrome, exchange transfusions are always performed after simple blood transfusions

E. Acute chest syndrome is defined as chest pain in a patient with sickle cell disease

Resources:

Field JJ, DeBaun MR. Acute chest syndrome in adults with sickle cell disease. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2018

Howard, Jo, Hart, Nicholas, Roberts-Harewood, Marilyn, Cummins, Michelle, Awogbade, Moji, Davis, Bernard; “Guideline on the management of acute chest syndrome in sickle cell disease”. BCSH Committee, 30 March 2015. https://doi.org/10.1111/bjh.13348

Vichinsky E, Neumayr L, Earles A, Williams R, Lennette E, et al. Causes and outcomes of the acute chest syndrome in sickle cell disease. N Engl J Med. 2000; 342:1855-1865.


Blake Briggs
Piano Man causing Vtach

You are working with EMS at a Billy Joel concert. It’s a pretty tame evening and you resort to standing in behind stage and eyeing the crowd. As Billy Joel plays Piano Man. One man clutches his chest and looks up to the sky as if to break out in song with the famed Piano Man. However he doesn’t, and instead drops to the ground and does not move. His girlfriend is super impressed and thinks he was overwhelmed with emotion, and makes an instagram story out of the incident.  Fortunately, one of her “live followers”, is a nurse and urgently called her to intervene and call for help. You rush to the patient with your team and find him with thready pulses and unresponsive. Rhythm strip shows a wide complex, regular tachycardia. Which of the following is true?

A. In patients with ischemic cardiac history, procainamide has displayed fastest rate of conversion

B. SVT with aberrancy can be mistaken for VT in up to 20% of adult patients

C. Nonsustained VT is a predictor of sudden cardiac death

D. Faster rate VT should suggest toxicologic cause

——- References:

Brugada P et al. A new approach to the diagnosis of regular wide complex tachycardia. Circulation 1991; 83: 1649-59. PMID: 2022022

Hollowell H et al. Wide-complex tachycardia: beyond the traditional differential diagnosis of ventricular tachycardia vs supra ventricular tachycardia with aberrant conduction. Am J Emerg Med 2005; 23: 876-89. PMID: 16291445

Ortiz M et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J 2016. PMID: 23754046

Yealy D, Kosowsky JM: Dysrhythmias, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 79: p 1034-63.

Blake Briggs
How to stop zombie hand

You are examining a 15 year old who presents to the ED with his Mother after developing hand pain 2 hours prior. He is a proud member of the local paintball team “SLY Slytherins”. You observe an uninterested teenager texting on his phone and sweeping his long hair of his face every so often to see his text messages. Suddenly he starts waving his phone at you in sweeping motions -- when you ask him why, he states, “It’s for my SNAP story brah”. His Mother states she thinks he was cleaning his paintball gun a few hours earlier today. On exam there is full range of motion and local, exquisite pain in the palmar aspect of the hand near the hypothenar eminence. No swelling, warmth, or exudate is noted. Which of the following is true?

A. X-ray is very poor at showing foreign body material

B. Physical exam plays an integral role in identifying extent of injury

C. Amputation risk on average is less than 50% in these patients

D. QT prolongation is a useful marker in hydrofluoric acid exposure

——-References:

Hart, R. et.al. (2001). Emergency and Primary Care of The Hand. American College of Emergency Physicians.

Loveday, I. (2007). High-pressure injection injuries. Emergency Nurse. PMID: 18065043

Locker, J. & Carstens, A. (2010). High-pressure injection of silica-based paint into a finger. The New Zealand Medical Journal. PMID: 20648104

Kohli, N. (2009). High-pressure injection injury in a furniture repairman -an outwardly minor in jury with the potential for a devastating outcome. Journal of Occupational and Environmental Medicine. PMID: 19741372


Blake Briggs
Fried snickers and gallstones

A 36 year old female from Wisconsin presents to the ED for abdominal pain. It's late summer and she is really excited to take her 2 children to the Minnesota State Fair (the 2nd largest state fair in the country) over memorial day weekend to enjoy favorites like turkey legs, Sweet Martha's Cookies and battered deep-fried snickers on a stick. Like the other 2 million people there, she attends the fair and chows down. 30 minutes after eating her deep-fried snickers on a stick, she begins having some cramping abdominal pain on her right side. It has happened before, but usually goes away. After 2 days or so of this pain, she decides to go to an urgent care because it has made her real nauseous and caused her to vomit. On exam, she is febrile and BP 90/70. She is extremely uncomfortable. A RUQ US is performed but the report states it is limited due to “overlying bowel gas”. Which of the following is correct?

A) Elevations in ALT and AST are common in cholecystitis

B) This patient should undergo emergent cholecystectomy
C) Patients with biliary colic should be made NPO and treated with IVF and IV Abx
D) Piperacillin-tazobactam is the Antibiotic of choice for biliary pathology requiring surgery

E) Physical exam findings are sufficient to establish the diagnosis of cholecystitis

——-References:

Williams, D. Gallbladder. Retrieved September 16, 2018, from https://onlinemeded.org/spa/gastroenterology/gallbladder/

Zakko, SF, Afdhal, NH. Acute Cholecystitis: Pathogenesis, clinical features, and diagnosis. UpToDate.Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/acute-cholecystitis-pathogenesis-clinical-features-and-diagnosis (Accessed on September 17, 2018.)
Zakko, SF. Overview of gallstone disease in adults. UpToDate.Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/overview-of-gallstone-disease-in-adults (Accessed on September 17, 2018.)

Blake Briggs
Doxycycline for all, #blessed

A 37 year old woman presents with concern for a bite. She collects caterpillars for her hobby and takes a particular liking to pink fuzzy ones. She was hiking in near her lake house and when she returned home she noticed a rash on her RLQ of her abdomen. She posted the photo to instagram as #trueblood and #oncebitten, however it was too painful to touch and none of her followers offered any medical advice so she presented to the ED for further evaluation. She also added #blessed, but still no advice.

Which of the following is true?

A. Acute prophylactic management does not effectively prevent cardiac manifestations

B. The majority of patients recall being bite by a tick

C. Lyme disease manifests as arthritis within the first 2 weeks of infection

D. Amoxicillin and Doxycycline have equal efficacy for early localized disease

E. Serologic testing is often false positive during the first two weeks

——-References:

Hu LT. In the clinic. Lyme disease. Ann Intern Med 2012; 157:ITC2.

Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med 1990; 323:1438.

Nadelman RB, Nowakowski J, Forseter G, et al. The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans. Am J Med 1996; 100:502.

Steere, A C (1987). "The clinical evolution of Lyme arthritis.". Annals of internal medicine, 107 (5), p. 725.

Steere, A. C., M.D. (1989). Lyme disease. The New England Journal of Medicine, 321(9), 586-596. doi:http://dx.doi.org.go.libproxy.wakehealth.edu/10.1056/NEJM198908313210906

Steere AC, McHugh G, Damle N, Sikand VK. Prospective study of serologic tests for lyme disease. Clin Infect Dis 2008; 47:188.

Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.


Blake Briggs
LR vs Normal saline

A 22 yo male presents septic to the ED 2 hours ago. He has been out of insulin for a few days now because he has been playing fortnite and after making a bunch of in-app purchases, he optimized his avatar and went on a crazy battle royale spree.  His battle royale spree ended when he was found by EMS surrounded by vomit at home.

His blood pressure on arrival is 85/60, and he is tachycardic at 110. ABG shows pH of 7.25, pCO2 of 26 mmHg and lactate of 3.5. You want to give the patient fluids, what would you like to give?

A) 2 more liters of normal saline

B) D5 to raise his glucose level

C) Lactated Ringers

D) Free water


Blake Briggs
Pediatric EKGs

The parents of a 11 year old are bringing in their son due to tremors. He was watching videos of the popular youtuber, PewDiePie(pronounced Puudeepie), when he stumbled upon some sort of Monster Energy drink challenge video.  He subsequently ingested 4 cans of Monster in one hour after he watched the video and is now in your ER.. The parents state he has no medical history other than ADHD for which he is on 2 different medications for. His vitals are within normal range yet he states he is jittery. Further, he is now dancing and doing the Drake, "In My Feelings" challenge and recording it for his VLOG. A 12-lead EKG is performed in between his gyrations. Which of the following is true?

A. T wave inversion implies myocarditis in children in the precordial leads

B. Right axis deviation in infants is an expected finding

C. All conduction intervals are longer in children due to immature neural connections

D. R wave dominance in infancy carries an ominous prognosis

E. The most common cause of wide complex tachycardia in children is ventricular tachycardia

Blake Briggs
Layups and dislocations all day

A 21 year old male presents to the ED after he fell playing basketball. He states he was reenacting the final game of Kobe Bryant’s NBA career, and after shooting so many times (because this is after all Kobe Bryant), he was attempting his 26th layup when he felt sudden pain and fell, getting dirt from the side court all over his recently signed Kobe Bryant Lakers jersey. He arrives to the ED in extreme right shoulder pain with stable vitals and right arm abrasions. Which of the following is true?

A. Posterior dislocations have a higher risk of neurological deficit

B. Axillary nerve deficit is most commonly found in posterior dislocations

C. Posterior dislocation can be effectively ruled out if the patient can perform external rotation

D. The ability to touch the opposite shoulder does not rule out anterior dislocation

Blake Briggs
Super fast FAST exam

EMS arrives with a 29 year old male who was involved in a head on collision on the interstate. He was in a high speed car chase in which he was running from the law after what he said was a “misunderstanding” at a bank. He states aliens told him they needed to borrow money, and he was simply trying to help them out. The misunderstanding involved the stealing of $5,000 dollars in gold Gringotts Galleons coins. He states he is a collector of memorabilia and wanted to add to his coin counts. He crashed into a semi in oncoming traffic.

On initial evaluation the patient was alert, talking, and had bilateral breath sounds. 2 IV’s are placed. His initial blood pressure is 87/57. Which the following is true?

A. Sensitivity decreases with Trendelenburg with the FAST exam

B. The FAST exam has higher specificity than sensitivity

C. Performing the FAST increases time it takes to go to the OR

D. In penetrating trauma, RUQ view should be obtained first

E. Direct peritoneal lavage is less sensitive than the FAST exam

Blake Briggs
There's a snake in my boot!

A 58 year old survivalist is patrolling his property when he decided to take a lunch break for his MRE which he packed in his bunker. He recently purchased the fully-furnished bunker in the Mojave desert after he was watching Youtube Videos of Alex Jones yelling on his Drudge Report sponsored InfoWars show.  He is also a frequently reader of Drudge Report and participates actively on commenting on their linked sites. After sitting down on his lunch break to type another comment on a blog, he he states he was bitten by a snake. He does not recall what it looked like. He arrives to your ED via ranger patrol with stable vital signs, redness and swelling are present at the site. Which of the following is true?

A. Dosing of immune fab is same as in adults as in children

B. The immune fab used has a significant risk of anaphylaxis

C. Prophylactic antibiotics are indicated upon discharge

D. Immune Fab has no effect on coral snake envenomation

E. Envenomation is much less common than dry bites

Blake Briggs
Meningititis prophylaxis? Hakuna Matata

A nervous 14 year old male presents to the ED with his mother. The patient has been secretly dating a girl at his high school and they met under the bleachers last week where he received his first kiss to the hit tune, “Can you feel the love tonight” (Lion King version). His girlfriend, who he refers to affectionately as Nala, requested that particular song play and she wore a t-shirt that said “Hakuna Matata”. They have been pecking each other daily since then. They are not sexually active. His girlfriend was diagnosed with seropositive streptococcal meningitis 2 days ago and was admitted to your hospital for further management. On exam the patient has facial acne, thick eyeglasses, wears a shirt that says “I never recieved my acceptance letter to Hogwarts”, but otherwise appears healthy. He is afebrile with normal vital signs. Which of the following is true regarding chemoprophylaxis?

A. Chemoprophylaxis is indicated in this case

B. Rifampicin is preferred in those on birth control

C. All healthcare workers meet criteria for chemoprophylaxis if involved in the patient’s care

D. Ceftriaxone is preferred in pregnant patients

Blake Briggs
Lightning strikes more than once

A 27 year old male was reading a Benjamin Franklin biography and watching the famous Movie Jackass as well. Unfortunately, he became inspired by both at the same time -- and recreated Benjamin Franklin’s famous kite experiment. In the process of recreating the experiment, he was struck by lightning -- he had a significant amount of metal earrings on that EMS suspects might have contributed to this. Which of the following is true?

A. Blood is the path of least resistance for electricity to move through

B.  Ventricular fibrillation is the most common cause of cardiac arrest

C. Keraunoparalysis is most often transient and does not require treatment

D. Troponins have prognostic utility for determining admission

E. Victims can benefit from prolonged CPR

Cheap Turkish Cigarettes and COPD exacerbation

A 67 year old male presents with dyspnea to the ED. He has an increased work of breathing, his O2 sats are in the mid 80s.

He states he was at a Wheezer concert 2 days prior with his wife, having a good time, and then developed cough, congestion. He subsequently developed shortness of breathing.

When you ask him if he has a history of smoking, he states, “nope”. When you notice his Camel Red cigarettes in his front shirt pocket, he states, “oh you mean those? Yea, I only smoke a pack a day, so not that much”.

Which of the following is true?

A. Pulmonary embolism occurs in as many as 20% of suspected COPD exacerbations

B. High risk COPD patients include those who have been hospitalized >2 times per year

C. Prednisone dose should be tapered if a patient is given a prescription

D. Steroids have been found to reduce relapses but not readmissions

E. The most common cause of COPD exacerbation is medication noncompliance