Answer: quizzer Vol 1.7

quizzER Winners:

Sam Lee                       Brian Junnila                Daniel Seitz

Shereaf Walid             Bindu Vanapalli            Richard Gordon

Katie Ohlendorf          Marjan Siadat               Brian Kern

Kyle Perry                    Claire Jensen                 Maria Pak

Bao Dang                     Devon Moore                 Rob Klever

Last Week’s Question

Answer

The answer is c

The treatment for sepsis has evolved considerably over the past 10 years. Early recognition and early aggressive therapy for patients with sepsis have a significant impact on mortality. Dr Emanuel Rivers et al, brought this issue to the forefront with their landmark article in the New England Journal of Medicine in 2001, where they instituted a treatment protocol for patients with septic shock, termed Early-Goal-Directed Therapy (EGDT). EGDT emphasizes early recognition of patients with potential sepsis in the ED, early broad-spectrum antibiotics, and a rapid crystalloid fluid bolus, followed by goal-directed therapy for those patients who remain hypotensive or severely ill after this initial therapy. Those patients who did not respond to an initial fluid bolus and antibiotics received a central venous catheter in the internal jugular or subclavian vein to measure central venous pressure (CVP) and an arterial catheter to directly measure arterial blood pressure.

EGDT is basically a three-step process, aimed at optimizing tissue perfusion:

  • The first step involves titrating crystalloid fluid administration to CVP, or administering 500 mL boluses of fluid until the CVP measures between 8 and 12 mm Hg. CVP is a surrogate for intravascular volume, as excess circulating blood volume is contained within the venous system.
  • The second step, if the patient has not improved with fluid alone, is to administer vasopressors to attain a mean arterial pressure (MAP) greater than 65 mm Hg.
  • The third step is to evaluate the central venous oxygen saturation (SvO2). This is obtained from the central venous line, which, in turn, is a surrogate for peripheral tissue oxygenation and cardiac output. A central venous saturation of less than 70% is considered abnormal and indicative of suboptimal therapy. In this case, the hematocrit is checked and blood is transfused until a hematocrit greater than 30% is attained. Once this is attained and the central venous saturation is still low, dobutamine is initiated to increase cardiac output.

Systemic Inflammatory Response Syndrome (SIRS)

Sepsis

Severe Sepsis

Septic Shock

Two or more of the following criteria:

  • HR > 90
  • Temperature > 100.4ºF or < 96.8ºF
  • RR > 20, or PaCO2 < 32
  • WBC > 12,000 cells/mm3, or < 4,000 cells/mm3, or > 10% band forms

SIRS

+

Suspected or proven infections

Sepsis

+

Acute organ dysfunction

Sepsis

+

Refractory hypotension

(a) Vasopressor therapy should not be started until the patient receives at least normal saline fluid boluses to achieve a CVP between 8-12 mm Hg or to maintain a mean arterial pressure of at least 65 mm Hg. (b) Packed red blood cells can be transfused if the central venous oxygen saturation (ScvO2) is less than 70 percent, and the hematocrit is less than 30%. However, this occurs after fluid administration. (d) A CVP of 8-12 mm Hg is the goal. Fluid should be administered when the CVP is less than 8 mm Hg. (e) The femoral vein is not a suitable location to place a central line in early goal directed therapy because it does not accurately measure the central venous pressure.

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

quizzER Vol 1.7

An 81-year-old woman is brought to the ED by her children who state that the patient is acting more tired than usual, has had fever for the last two days, and is more confused. Ordinarily, the patient is high functioning: she is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day. Her vital signs are BP 85/60 mm Hg, heart rate 125, respiratory rate 20, temperature 101.3°F, and pulse oxygenation 97% on room air. On examination, the patient has dry mucous membranes, but is otherwise unremarkable. She is oriented to person and place, but states that the year is 1925. Her lab results show a WBC 14,300/µL, hematocrit 31%, and platelets 350/µL. Her electrolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radiograph does not show any infiltrates. Urinalysis reveals 2+ protein, trace ketones, WBC >100/hpf, RBC 5-10/hpf, nitrite positive, and leukocyte esterase positive.  After administering a 500 cc normal saline fluid bolus and broad-spectrum antibiotics through her peripheral intravenous line, the patient’s blood pressure is 82/60 mm Hg. You suspect that the patient is in septic shock. Which of the following is the next most appropriate course of action to manage this patient with early-goal-directed therapy?

a.    Start vasopressor therapy, repeat blood pressure, if below a systolic of 90 mm Hg, increase the dose
b.    Check the hematocrit and if it is less than 30% prepare to transfuse packed red blood cells
c.    Place a central venous line into the right internal jugular vein, measure a central venous pressure (CVP), administer normal saline boluses if the CVP is less than 8 mm Hg
d.    Place a central venous line into the left subclavian vein, measure a central venous pressure (CVP), administer normal saline boluses if the CVP is less than 12 mm Hg
e.    Place a central venous line into the right femoral vein, measure a central venous pressure (CVP), administer normal saline boluses if the CVP is less than 8 mm Hg

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Answer quizzER Vol 2.1

quizzER Winners:

David Mishkin           Marjan Siadat           Ryan Phillips             Allison Loynd

Julie Nguyen              Maria Pak                  HVSH CRNAs           Devon Moore

Maria Pak                   Brian Kern                 Richard Gordon        Rob Klever

Last Week’s Question

The answer is c.

Spinal abscesses are most commonly found in immunocompromised patients, IV drug users, and the elderly.Signs and symptoms of epidural abscess usually develop over a week or two and include fever, localized pain, and progressive weakness. An elevated WBC count is also commonly seen. MRI is the most useful diagnostic test. S. aureus is the most common causative organism, followed by gram-negative bacilli and tuberculosis bacillus.

___________________________________________________________
(a) A lung abscess is a cavitation of lung parenchyma resulting from local suppuration and central necrosis. It is often precipitated by aspiration of oropharyngeal secretions. (b) Inflammatory conditions, including ankylosing spondylitis, may cause back pain. The key findings in this disease include gradual onset of morning stiffness improved with exercise in a patient less than age 40 years. On physical examination, these patients may have limited back flexion, reduced chest expansion, and sacroiliac joint tenderness, all of which are nonspecific. Fever and weakness would not be expected. (d) Back pain may result from vertebral compression fractures. These may be secondary to trauma or may be atraumatic in a patient with osteoporosis. Osteoporotic compression fractures usually involve patients over 70 years or patients with acquired bone weakness (e.g., prolonged steroid use). (e) Metastatic lesions invade the spinal bone marrow, leading to compression of the spinal cord. Most common primary tumors include breast, lung, thyroid, kidney, prostate (BLT with Kosher Pickles), as well as lymphoma and multiple myeloma. Maintain a high level of suspicion for any cancer patient who develops back pain; these patients must be investigated for spinal metastases.

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

quizzER Vol 2.1

A 43-year-old man, who currently uses drugs intravenously, presents to the emergency department (ED) with 2 weeks of fever, back pain, and progressive weakness in his arms bilaterally. He reports having a cough with whitish sputum.  He denies any history of recent trauma. His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory rate (RR) is 16 breaths per minute. On physical exam, he has tenderness to palpation in the midthoracic spine, and decreased strength in the upper extremities bilaterally, with normal range of motion. Laboratory results reveal a white blood cell (WBC) count of 15,500/μL, hematocrit 40%, and platelets 225/μL. Which of the following is the most likely diagnosis?
a. Lung Abscess
b. Ankylosing spondylitis
c. Spinal epidural abscess
d. Vertebral compression fracture
e. Spinal metastatic lesion

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Answer quizzER 1.5

quizzER Winners:

Eric Tosh                Allison Loynd             Marjan Siadat

Julie Nguyen          Maria Pak                   Gloria Kuhn

Brian Kern              Richard Gordon        Rob Klever

Last Week’s Question

The answer is d.

The most useful diagnostic test obtainable in a suspected CO poisoning is a COHb level. Normal levels range from 0 to 5%, as CO is a natural by-product of the metabolism of porphyrins. COHb levels average 6% in one-pack-per-day smokers. CO poisoning should be suspected when multiple patients, usually in the same family, present with flu-like symptoms, and were exposed to products of combustion (e.g., home heaters/generators). This most commonly occurs in colder, winter months. The mainstay of treatment is the delivery of O2. Hyperbaric O2 is usually used for patients with COHb levels greater than 25%.

______________________
(a) Lead toxicity is mainly a disease of children resulting from ingestion of lead-based paints. Adults can be exposed to lead in a variety of occupational circumstances such as welders, glassmakers and scrap metal workers. There is no classic presentation of lead toxicity. Therefore, high suspicion and a thorough history are critical. The diagnosis is made by an elevated whole blood lead level. (b) CO poisoning is often confused for a viral syndrome. Patients with influenza usually present to the ED with high fever. (c) Malingering is the intentional production of false or exaggerated symptoms motivated by external incentives. (e) A lumbar puncture is used to diagnose meningitis, which may present with headache, nausea, and fatigue.

Here is an excellent review article from the New England Journal of Medicine on carbon monoxide poisoning

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

quizzER Vol 1.5

A 43-year-old woman presents to the ED in the state of Michigan with a 1-week history of intermittent headache, nausea, and fatigue. She was seen at her private doctor’s office 1-week ago along with her husband and children, who also have similar symptoms. They were diagnosed with a viral syndrome and told to increase their fluid intake. She states that the symptoms began approximately one week after Thanksgiving. The symptoms are worse in the morning and improve while she is at work. Her BP is 123/75 mm Hg, HR is 83 beats per minute, temperature is 98.9°F, and O2 saturation is 98% on room air. Physical exam is unremarkable. You suspect her first diagnosis was incorrect. Which of the following is the most appropriate next step to confirm your suspicion?
a. Order a mono spot test
b. Perform a nasal pharyngeal swab to test for influenza
c. Consult psychiatry to evaluate for malingering
d. Order a carboxyhemoglobin (COHb) level
e. Order a lead level

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Answer quizzER 1.4

quizzER Winners:

Sam Lee                Bindu Vanapali         Rob Klever

Marjan Siadat        Devon Moore            Chris Guyer

Brian Kern             Dave Mishkin

Julie Nguyen          Dave Daigle

Last Week’s Question

The answer is D.

This is a case of erythema infectiosum or Fifth’s Disease. Infection by Parvovirus B19 produces this pattern of a “slapped cheek” appearance. It is characterized by an eruption that presents initially as an erythematous malar blush followed by an erythematous maculopapular eruption on the extensor surfaces of extremities that evolves into a reticulated, lacy, mottled appearance. Fever and other symptoms may be present but are uncommon. In patients with chronic hemolytic anemias like sickle cell disease, aplastic anemia is a serious complication.  Pregnant women should avoid exposure to this virus, since it may cause fetal hydrops in 10% of cases.
The article by Kellermayer, R. “Clinical presentation of parvovirus B19 infection in children with aplastic crisis”. The Pediatric infectious disease journal. 22 (12), p. 1100.
_________________
Sickle cell patients can develop osteomyelitis (a), however, the clinical presentation is inconsistent. Patients with osteomyelitis caused by Salmonella species are generally those with sickle cell disease.  However, the most common organism that causes osteomyelitis in patients with sickle cell disease is Staphylococcus aureus.  Encephalitis (b) is an inflammation of the brain parenchyma and is not commonly caused by Parvovirus. Common etiologic agents include herpes simplex, herpes zoster, varicella-zoster, West Nile virus, and toxoplasmosis. Pneumonia (c) is a common diagnosis in patients of all ages. In children, the most common causative agents are viral. The most commonly found bacterial agent is S. pneumonia. Meningitis (e) is an infection of the meninges that surround the brain. It is caused by viral and bacterial entities. The most common bacterial agents include: E. coli, Group B streptococcus, and L. monocytogenes in very young infants and S pneumonia, N meningitides, and H influenza in older children.

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.